Purpose To provide evidence-based recommendations to oncology clinicians, patients, family and friend caregivers, and palliative care specialists to update the 2012 American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) on the integration of palliative care into standard oncology care for all patients diagnosed with cancer. Methods ASCO convened an Expert Panel of members of the ASCO Ad Hoc Palliative Care Expert Panel to develop an update. The 2012 PCO was based on a review of a randomized controlled trial (RCT) by the National Cancer Institute Physicians Data Query and additional trials. The panel conducted an updated systematic review seeking randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of RCTs in the 2012 PCO, published from March 2010 to January 2016. Results The guideline update reflects changes in evidence since the previous guideline. Nine RCTs, one quasiexperimental trial, and five secondary analyses from RCTs in the 2012 PCO on providing palliative care services to patients with cancer and/or their caregivers, including family caregivers, were found to inform the update. Recommendations Inpatients and outpatients with advanced cancer should receive dedicated palliative care services, early in the disease course, concurrent with active treatment. Referral of patients to interdisciplinary palliative care teams is optimal, and services may complement existing programs. Providers may refer family and friend caregivers of patients with early or advanced cancer to palliative care services.
IMPORTANCEThe use of palliative care programs and the number of trials assessing their effectiveness have increased.OBJECTIVE To determine the association of palliative care with quality of life (QOL), symptom burden, survival, and other outcomes for people with life-limiting illness and for their caregivers.
Presence of palliative care inpatient consultation team Presence of palliative care outpatient clinic Presence of community based / home palliative care Clinical processes (*) Presence of multidisciplinary specialized palliative care team Routine symptom screening in the outpatient oncology clinic Administration of systemic cancer therapy (e.g. chemo and targeted agents) possible in patients admitted to PC service oncology-and palliative care as well as their cultures. Local variations in terms of resources and practices also probably play a role. By acknowledging integration of oncology and PC as a complex process including different parts of the health care system, both horizontally and vertically, and also involving the patient, we propose SCPs as a means for future efforts to promote integration. For the same reasons, this paper will address integration in different panels. Each panel will address different aspects of integration, ranging from how to focus on the patient, to societal changes and new research areas. Introduction of panels Policy-challenges and frameworks Societal challenges Prognostication Patient-centredness-content methodology and clinical implications Models of palliative care integration The role of education: challenges and recommendations Research The commission is an international collaboration between 30 experts in oncology, PC, public health and psycho-oncology. In October 2016 a kick-off meeting was held in Milan where panel leaders were appointed, the structure of the commission was decided, and a plan for the work was agreed upon. During the two following years each panel expanded with experts within the relevant field, conducted topical literature searches, and an interactive writing process was conducted. Both administrative and academic organization were run from Norway, by Stein Kaasa, Jon Håvard Loge and Tonje Lundeby. Policy-challenges and frameworks Questions to be addressed What type of recommendations is given for integration at the national and international level on policy and public health at present? What are the current examples of different practices in organization of palliative care in different national policies in European countries? What kind of policies and approaches are needed for integration of oncology and palliative care? Patient-centredness-content, methodology and clinical implications Questions to be addressed What is patient-centredness? What are the main elements of patient-centred care in practice? How do we involve the family? Communication-a necessary tool for patient-centred care What are the barriers and solutions to succeed? Research Questions to be addressed What are some opportunities and challenges for integrating oncology and palliative care teams to conduct research together? What are some key research priorities related to integration of palliative care and oncology? What are some key research priorities related to symptom assessment and treatment? What are some key research priorities related to psychosocial support, communication and dec...
The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise-from epidemiologists, psychologists, policy makers, and cancer specialists-has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to eff ect change are outlined. The strengths of primary care-its continuous, coordinated, and comprehensive care for individuals and families-are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.
Context Specialized palliative care teams are increasingly providing care for the terminally ill. However, the impact of such teams on quality of life, satisfaction with care, and economic cost has not been examined systematically using detailed criteria for study quality.Objective To systematically review the evidence for effectiveness of specialized palliative care. Data SourcesWe performed a keyword search of the following databases from their inception to January 2008: MEDLINE, Ovid Healthstar, CINAHL, EMBASE, and the Cochrane Central Register of Controlled Trials. Study SelectionWe included all randomized controlled trials in which specialized palliative care was the intervention and for which outcomes included quality of life, satisfaction with care, or economic cost. Data Extraction Data on population, intervention, outcome, methods, and methodological quality were extracted by 2 investigators using standardized criteria. ResultsOf 396 reports of randomized controlled trials, 22 met our inclusion criteria. There was most consistent evidence for effectiveness of specialized palliative care in improvement of family satisfaction with care (7 of 10 studies favored the intervention). Only 4 of 13 studies assessing quality of life and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power to report conclusive results, and quality-of-life measures were not specific for terminally ill patients. There was evidence of significant cost savings of specialized palliative care in only 1 of the 7 studies that assessed this outcome. Methodological limitations were identified in all trials, including contamination of the control group, failure to account for clustering in cluster randomization studies, and substantial problems with recruitment, attrition, and adherence. ConclusionsThe evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population, are needed.
Interpretation: There is a strong stigma attached to palliative care, which may persist even after positive experiences with an early palliative care intervention. Education of the public, patients and health care providers is paramount if early integration of palliative care is to be successful. AbstractCMAJ Podcasts: author interview at
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