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.
ASCO's provisional clinical opinions (PCOs) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a PCO was submitted for publication. PCOs are not continually updated and may not reflect the most recent evidence. PCOs cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine the best course of treatment for the patient. Accordingly, adherence to any PCO is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO PCOs describe the use of procedures and therapies in clinical trials and cannot be assumed to apply to the use of these interventions in the context of clinical practice. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO's PCOs, or for any errors or omissions.
As palliative care specialists in oncology, we are used to the questions: Why palliative care? Shouldn't the palliative care types be doing the palliative care? As Abrahm points out, most oncologists think they already do palliative care, 1 although when measured, their performance needs significant improvement. 2 We have some good answers for these questions now. As defined by the Center to Advance Palliative Care, 2a palliative care is "specialized medical care for people with serious illnesses, focused on providing patients with relief from the symptoms, pain, and stress-whatever the diagnosis," with an explicit goal to "improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support, and can be provided together with curative treatment."Palliative care concurrent with usual oncology care is now endorsed by ASCO because it results in better quality of life, better quality of care, improved symptom management, and equal or better survival, at an affordable cost. 3 The enhanced survival of patients who receive palliative care 4,5 or hospice care 6,7 is an unexpected benefit. For years we have heard, "Hospice will just give them morphine to make them comfortable and they'll die sooner." But the data suggest otherwise.There are three types of palliative care. 8 Primary palliative care is delivered every day in the oncology office. Secondary palliative care is delivered by specialized teams at specific programs or inpatient units. And tertiary palliative care is delivered by specialized teams with expertise in advanced pain and symptom management, such as implantable drug delivery systems, palliative sedation, or advanced delirium management. In this article, we show what we have done in our oncology office that has effectively integrated palliative care into the treatment of patients with incurable cancer. Table 1 shows a list of components that must be in place for successful palliative care. As the table shows, much of our new learning is about communication. 9,10
How to Do Palliative Care in the Office
Panitumumab is an anti-EGF receptor (EGFR) antibody approved for use in treatment of chemotherapyrefractory colorectal cancers lacking K-RAS mutations. Despite overall response rates approximating 10%, no marker predictive of clinical benefit has been identified. We describe a chemotherapy-refractory patient whose clinical condition necessitated rapid identification of an effective agent in whom we used 18
Cancer patients experience multiple symptoms throughout their illness trajectory. Symptoms consistently occurring together, known as symptom clusters, share common pathophysiologic mechanisms. Understanding and targeting such symptom clusters may allow for more effective and efficient use of treatments for a variety of symptoms. Fatigue-anorexia-cachexia is one of the most prevalent symptom clusters and significantly impairs quality of life. In this review, we explore the fatigue-anorexia-cachexia symptom cluster and focus on current and emerging therapies with an emphasis on pharmacologic management.
Our quality improvement project demonstrated that the CASH assessment tool is useful in ascertaining existential concerns of patients with serious illness. It enhances patient care by the primary team as well as the palliative care team. As a brief set of questions with an easy-to-remember mnemonic, the CASH assessment tool is feasible for a busy palliative consult service. Furthermore, the positive results of this project merit more rigorous evaluation of the CASH assessment tool in the future.
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