Craig D. Blinderman, MD, MA
A consensus has emerged among oncology practitioners that palliative care should not be seen as end-of-life care but is best deployed early to help patients and their caregivers manage symptoms throughout the cancer treatment trajectory.
OncLive discussed what this approach means for the future of palliative care with Craig D. Blinderman, MD, MA, the director of the Adult Palliative Medicine Service at Columbia University Medical Center/New-York Presbyterian Hospital and Co-Director of the Center for Supportive Care and Clinical Ethics in the Department of Medicine
There has been an emphasis on starting palliative care earlier on in treatment. What signals should practitioners be looking for to start palliative care?
In a study done in 2010 that I was a part of, we looked at randomizing early palliative care for patients with advanced lung cancer versus treating with standard oncologic therapy. There were some significant benefits associated with the randomization group who received palliative care early on. Benefits included improved quality of life, decreases in depression, and increased survival.
ASCO issued a statement recommending that clinicians who are treating patients with metastatic cancer, especially lung cancer, should consider palliative care at the moment of diagnosis. And so rather than thinking about waiting for the patient to really be suffering with symptoms or coping poorly as the disease progresses, physicians should think about integrating palliative care right off the bat. Just like we have nutrition services and other kinds of supportive services at the beginning of their cancer treatment, we should also be doing that with palliative care.
The main problem is concerns staffing—having enough well-trained specialists in palliative care and pain management to actually meet the needs of this large population. So there’s a balance between wanting to get all these patients in and see them and make sure they’re getting specialized palliative care, and at the same time, knowing that we can’t necessarily do that at all institutions. So, we need to bring up the generalist level of expertise of oncology and other practitioners to do some of this work, and then maybe refer back to us when they start to realize that their pain management or symptom management or some of their approaches are not sufficient or they need additional help or extra support.
There are a lot of terms used: palliative care, supportive care, hospice. What are the differences between all these terms?
A lot of patients, including physicians, are confused about the terms and sometimes equate palliative care with hospice care. Palliative came out of the oncology literature. Things are either considered curative or palliative when you think about a treatment approach. So palliative became equated with the idea of “I can’t be treated, so I must be going to hospice,” or something like that. And that’s not the case. We’re trying to rebrand the idea that palliative care is an integrative approach to care for patients with serious illnesses like cancer to provide an extra layer of support to them, to their families, to the oncologists, and the other treating physicians to manage pain, other symptoms, alleviate suffering, things like that.
Hospice is for patients at the very last stage of life. Typically within the last 6 months of life. They become eligible for hospice service, which is largely a home care program to keep patients comfortable at the end of life.
Palliative care can be integrated with disease modifying therapies such as chemotherapy, radiation therapy. So we’re trying to consider it more upstream as part of the whole comprehensive care of patients.
It’s true that the term supportive care and palliative care are equated, and in my mind it’s not so problematic. From my perspective, if it works to get patients incorporated into a care plan that includes a palliative care clinician and we call it supportive care, that’s what we’re really trying to do: wrap them with more support—the patients, the family and so forth, and that’s fine.
The program that we have here is under a center called “Supportive Care and Clinical Ethics,” where we work together with the head of ethics to try to provide a program both of education, clinical programming and starting to do some research to really foster this idea that we’re here to support patients, families, and the treating physicians themselves. And convey that we’re trained palliative care clinicians to do that, but it doesn’t matter so much to me if we call it palliative care or supportive care in that sense.
What kind of people should be part of a multidisciplinary team to carry out palliative care to cancer patients?
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