Models of multidisciplinary management

Background

The World Health Organization’s definition of palliative care states that:

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.

While the goals of any medical management are to make patients live longer and better, it is clear that palliative radiotherapy needs to integrate multidisciplinary management in order to achieve optimal palliative care. Radiotherapy when given with palliative intent is often used for bone metastases, brain metastases, and for primary and other metastatic sites to alleviate symptoms. The therapeutic landscape for stage IV cancer patients has evolved to include focused radiation techniques such as stereotactic radiation. Molecular targeted therapy and immunotherapy have also improved survival for many stage IV cancers.

Multidisciplinary cancer clinics were pioneered at Stanford University by Doctors Henry Kaplan and Saul Rosenberg in the early 1960s. Since that time, multidisciplinary cancer clinics have become ubiquitous across cancer centers around the globe. Management of incurable cancer is complex with evolving therapies that span across the disciplines of radiation oncology, medical oncology, and surgical oncology. Other than physical management, psychosocial and spiritual aspects also weigh heavily in the overall management of palliative cancer patients.

Early palliative care

A systematic review of trials was reported examining the use of early palliative care in adult patients with advanced cancer. There were 7 included randomized trials which recruited 1614 participants. The studies compared early palliative care (beginning at the time or shortly after the diagnosis of advanced cancer). Early palliative care involved combining anticancer treatment (e.g., systemic therapy, radiation) with prognosis discussions, advance care planning, symptom assessment and control. Early palliative care was compared with usual cancer care (systemic therapy, radiation) alone. The authors discovered that early palliative care significantly improved quality of life (QoL) with a small effect size (standardized mean difference [SMD] 0.27, 95% CI 0.15 to 0.38). Significantly lower symptom intensity in early palliative care (SMD −0.23, 95% CI −0.35 to −0.10) with small effect size was also reported. Effects on survival and depression were uncertain.

A randomized controlled trial was conducted by advanced practice nurses on 322 patients with advanced cancer. Patients were randomized to a psychoeducational intervention consisting of 4 weekly educational sessions versus usual oncology care (anti-cancer and symptom control treatment). The estimated treatment effect (intervention minus usual care) was a mean (standard error) 4.6 (2) for QoL ( P = .02), −27.8 (15) for symptom intensity ( P = .06), and −1.8 (0.81) for depressed mood ( P = .02). The authors concluded that those who received nurse-led, palliative care sessions dealing with physical and psychosocial issues scored higher for QoL and mood.

Another randomized trial consisting of 207 patients examined the use of in-person palliative care consultation, and structured palliative care telehealth nurse sessions. Patients were randomized to early palliative intervention (as described above) versus delayed palliative intervention. Early intervention was defined as within 60 days of the patient being informed of an advanced cancer diagnosis. Delayed intervention was defined as 3 months after being informed of an advanced cancer diagnosis. QoL, symptoms, and mood were no different between early versus delayed palliative intervention. However, 1 year survival was 63% in the early group versus 48% in the delayed group, P = .038.

Maltoni and colleagues randomized 207 outpatients with metastatic pancreatic cancer to either on-demand palliative care (palliative care consultation requested by oncologists when symptoms are reported by patients) versus systematic early palliative care (palliative care consultation given at the beginning of chemotherapy). Those who had earlier palliative care had a higher median and mean period of hospice care ( P = .025) and a significantly higher number of hospice admissions ( P < .010). Less chemotherapy was given to those who had early palliative care in the last 30 days of life (18.7% versus 27.8%, P = .036).

A clustered randomized trial was also reported on 146 patients with newly diagnosed late-stage cancers. Patients with lung and gynecological cancers were allocated to a 10-week standardized intervention involving symptom management, clarifying the illness experience, and goals of care discussions. Patients with head and neck or gastrointestinal cancers were assigned to usual cancer care. There was no difference in symptoms, health distress, depression, functional status, or self-reported health between the two randomized groups.

In another randomized trial, patients with newly diagnosed metastatic cancer with an estimated prognosis of 12 months or less were randomized to usual oncologic care plus palliative care nursing intervention versus usual oncologic care alone. The authors could not detect a difference in symptoms, QoL, or survival between the two groups.

In patients with newly diagnosed stage IV non-small cell lung cancer (NSCLC), Temel and colleagues randomized 151 patients to early palliative care with usual oncologic care versus usual oncologic care alone. Median survival was longer for those who received early palliative care (11.6 vs. 8.9 months, P = .02). Fewer patients in the early palliative care reported depressive symptoms (16% vs. 38%, P = .01). As well, the early palliative care group had better QoL, P = .03.

Zimmermann and colleagues also randomized 461 patients to early palliative care and usual cancer care versus usual cancer care alone. At 3 months, there was no difference in Functional Assessment of Chronic Illness Therapy- Spiritual Well-Being (FACIT-Sp) scores between the two groups. However, at 4 months, there were significant differences in FACIT-Sp ( P = .006), Quality of Life at the End of Life (QUAL-E) ( P = .003), and Edmonton Symptom Assessment System (ESAS) scores ( P = .05).

In summary, the data suggest that early palliative care may improve QoL and possibly survival. As such, palliative care consultation remains an important component in the care of non-curable cancer patients. Palliative care specialists may be fully integrated into multidisciplinary cancer clinics, and they remain a valuable source of care for inpatient and outpatient cancer patients.

Palliative care delivery models

Many cancer centers have dedicated palliative radiation clinics. The impetus for these specialized palliative radiation clinics was largely based on limiting wait times for symptomatic cancer patients with short life expectancy. ^, Wait times from referral to radiation consultation to radiation simulation and treatment are significantly reduced with specialty palliative radiation clinics. Some programs see new patients, plan radiation, and deliver radiotherapy to palliative patients on the same day.

The most common indications for palliative radiation are bone metastases and brain metastases. Patients with advanced cancers may also be treated with palliative radiation to symptomatic primary sites such as lung cancer. Many radiation palliative care clinics integrate numerous specialties such as medical oncology, surgical oncology, palliative specialty physicians, nurses, dedicated palliative radiation therapists, social workers, psychologists, occupational therapists, physiotherapists, and nutritionists.