Shelley Fuld Nasso
As more studies link aggressive end-of-life oncology care to problems such as suboptimal cost and quality outcomes, experts are increasingly proposing earlier, more comprehensive palliative care interventions. “There is absolutely clear-cut evidence that palliative care enhances clinical outcomes and quality of life for people with advanced malignancy,” said Michael Kolodziej, MD, Aetna’s national medical director for oncology solutions.
As far back as 2012, the evidence was compelling and sufficiently prolific to convince ASCO to issue a clinical opinion supporting the integration of palliative care with conventional oncology treatment.1
“There has been an increasing chorus of voices, in ASCO and outside of ASCO, saying that there really needs to be a better way,” said Lowell E. Schnipper, MD, chair of ASCO’s Value in Cancer Care Task Force and chief of hematology/oncology at Beth Israel Deaconess Medical Center.
Impact of Expanded Palliative Care on End-of-Life Outcomes
In a pivotal recent study, Jennifer Temel, MD, Massachusetts General Hospital, found that early palliative care among patients with metastatic non–small cell lung cancer led to increased survival.2
The palliative group achieved superior outcomes based on median survival and quality of life measures, the study found.
Shelley Fuld Nasso, CEO, National Coalition for Cancer Survivorship, described the Temel study as having initiated a “Big Bang” revolution, predicting that it would eventually “change the way people view palliative care.” Craig C. Earle, MD, director of the Ontario Institute for Cancer Research, said that such findings are taking the pressure off oncologists to go on fighting a patient’s cancer until the very end. “Studies showing that early involvement of palliative care can actually improve hard outcomes like survival are making it more acceptable for oncologists to not always be pushing the most aggressive approach,” he said.
Kolodziej said it’s important to carefully assess the type and value of end-of-life care that patients receive because that is where the costs can really add up. “Look at where the dollars are spent in patients who die of malignancy; the number one cost is not chemotherapy, it’s inpatient care,” Kolodziej said. His view is supported by a 2014 study in Cancer, which linked earlier palliative care referral (>3 months before death vs <3 months before death) with fewer emergency department (ED) visits, fewer hospitalizations, and fewer hospital deaths in the last 30 days of life.3
Even within the hospital setting, earlier palliative consultation has the potential to significantly lower costs. Research published in 2015 showed that in an adult population diagnosed with advanced cancer, palliative intervention within 6 days of admission reduced hospital stay costs by 14% ($1312 per patient)4
and within 2 days by roughly 24% ($2280 per patient).
Current Care: A Mixed Picture
There are strong believers in the value potential of palliative intervention, but there is no consensus on whether a paradigm shift is underway. “There is a mixed picture,” said David Hui, MD, of the Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center. “People generally have a greater awareness of inappropriate chemotherapy use. National data seem to show some decrease in acute care or hospital stays at the very end of life, but then some other trends show there are a bit more ICU stays.5 This is still evolving.”
The research results Hui mentioned, published in 2013, showed a sharp increase in the percentage of patients who were in hospice at the time of death: 21.6% in 2000 versus 42.2% in 2009.5
Conversely, a study of advanced cancer patient admissions in 2000 (n = 191) and 2010 (n = 141) found that despite poor median survival in both groups (4.7 months median survival post discharge in 2000 and 3.4 months in 2010), hospice was recommended to only 23% of patients in 2000 and 24% in 2010.7
“What we do know is there is plenty more work to do on this score,” Schnipper said.
Obstacles to Change
A range of complex factors continues to drive overzealous end-of-life oncology care. One of these is that the era of immunotherapy is generating excitement and contributing to the “focus-on-cure” mentality, Hui said. Similarly, the utility of precision therapies tempts physicians to continue treatment in patients well into advanced-stage cancer. “Targeted therapies, many of which are oral, have made it seem easier to keep treatment going very near end of life. In some situations, this is not unreasonable, but in others, these drugs can still be very toxic, not to mention incredibly expensive, for very modest potential benefits,” Earle said.