Integrating palliative care and oncology: towards a common understanding

Health care institutions such as the World Health Organization (WHO) pointed out years ago that palliative care is a vital part of caring for patients with life-threatening diseases and that it is applicable early in the course of the disease together with life-prolonging and disease-modifying therapies (1). Palliative care has been equated with end-of-life care by many physicians, the public, and policy makers for too long (2), even though for example in the field of cancer care, major societies and alliances such as the American Society of Clinical Oncology (ASCO) (3) and National Comprehensive Cancer Network (NCCN) (4) strongly advocate the early integration of palliative care and oncology.

Meanwhile, there is also growing evidence from a number of controlled studies that the integration of palliative care early in the disease trajectory improves cancer care. Such early integration leads to improvements in physical and psychosocial symptoms, quality of life, quality of end-of-life care, and costs of care, as well as increased survival for patients with advanced malignancies (5-9). Most of these trials have assessed the effect of the integration of specialist palliative care services into standard care, but it is indisputable that palliative care is a core duty of physicians and other health care professions regardless of their discipline (2,10). The latter is most commonly referred to as generalist or primary palliative care. Despite all efforts, such early integration of palliative care remains challenging (11). From other contexts, it is known, that terminological confusion is a major cause of misunderstandings concerning palliative care and impedes its widespread provision (12,13).

Therefore, the recently performed systematic review by Hui et al. (14) in close cooperation with members from ASCO, NCCN, European Association of Palliative Care (EAPC) and European Society of Medical Oncology (ESMO) is of great interest. The authors aimed to evaluate the view of other working groups about what encompasses the integration of palliative care and oncology. Of the 101 publications that met their inclusion criteria, the majority of which were reviews (57/101) and original articles (35/101), but editorials (5/101) and other publications (5/101) were also examined.

The authors found that among the most important infrastructural indicators of palliative care integration are the presence of palliative care outpatient clinics, inpatient consultation teams, and community-based palliative care. Notably, in their discussion, Hui et al. note that besides the mere availability of such specialist palliative care services, the comprehensiveness and expertise of the interdisciplinary team and the degree of collaboration between the palliative care team and other disciplines are of vital importance (14). The latter may be benchmarked by the degree of early referral to these services. Common rounds, tumor boards and case conferences may be pragmatic means for a closer integration and cooperation in the clinical level. It is of utmost importance that the integration of palliative care must not be misunderstood as the complete delegation of palliative care tasks to specialist palliative care services. The findings by Hui et al. (14) highlight the expectation that medical oncologists and providers across disciplines who care for patients with cancer must be equipped with core skills to deliver primary palliative care.

Most of the indicators for palliative care integration in oncology have been derived from publications originating from large academic centers, but basic measures of integration are also be feasible in other settings. While Hui et al. champion advanced palliative care for cancer patients (14), it must not be overlooked that both specialist and generalist palliative care are both critical to the successful integration of palliative care for our patients (15). This may be one of the limitations of the excellent work of Hui et al. (14), who limited their search to cancer patients (“neoplas$” or “cancer$” or “tumor$” or “tumour$”). The main challenge in cancer care and other clinical settings will be the implementation of early palliative care as a joint effort of all disciplines in close cooperation with specialist palliative care services (9). A comprehensive look at integration and early palliative care in oncology will be the subject of the upcoming April 2014 special issue of Annals of Palliative Medicine.

Acknowledgements

Disclosure: The authors declare no conflict of interest.

References

1. World Health Organization. Cancer control: Palliative care: WHO guide for effective programmes. Available online: http://www.who.int/cancer/publications/cancer_control_palliative/en/. [Accessed on Jan 21, 2015].
2. Peppercorn JM, Smith TJ, Helft PR, et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol 2011;29:755-60. [PubMed]
3. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol 2012;30:880-7. [PubMed]
4. Levy MH, Adolph MD, Back A, et al. Palliative care. J Natl Compr Canc Netw 2012;10:1284-309. [PubMed]
5. Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 2009;302:741-9. [PubMed]
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. [PubMed]
7. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. [PubMed]
8. Gaertner J, Siemens W, Antes G, et al. Specialist palliative care services for adults with advanced illness. Cochrane Database Syst Rev 2015;
9. Gaertner J, Wolf J. Smith TJ. Early Palliative Care. In: Nauck F, Alt-Epping B. eds. Palliative Care in Oncology. New York: Springer, 2015. (In press).
10. Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a more sustainable model. N Engl J Med 2013;368:1173-5. [PubMed]
11. van der Eerden M, Csikos A, Busa C, et al. Experiences of patients, family and professional caregivers with Integrated Palliative Care in Europe: protocol for an international, multicenter, prospective, mixed method study. BMC Palliat Care 2014;13:52. [PubMed]
12. Hui D, Nooruddin Z, Didwaniya N, et al. Concepts and definitions for "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care": a systematic review. J Pain Symptom Manage 2014;47:77-89. [PubMed]
13. von Gunten CF. Humpty-Dumpty Syndrome. Palliat Med 2007;21:461-2. [PubMed]
14. Hui D, Kim YJ, Park JC, et al. Integration of Oncology and Palliative Care: A Systematic Review. Oncologist 2015;20:77-83. [PubMed]
15. Radbruch L, Payne S, de Lima L, et al. The Lisbon Challenge: acknowledging palliative care as a human right. J Palliat Med 2013;16:301-4. [PubMed]