The Evidence for Palliative Care in Oncology, An Introduction for the American Cancer Society Southeastern Division Palliative Roundtable Discussion

1. Palliative Care in Oncology:
Literature Update and the
Pennsylvania Plan for
Palliative Oncology Care
Kristina Newport, MD FAAHPM
June 22nd
, 2017

2. Objectives
Discuss the paradigm shift of palliative care in oncology
Recognize benefits of palliative care in cancer care
Identify challenges, opportunities and potential
solutions to expand palliative care in Pennsylvania.

3. The presenter has no
relevant conflict of
interest to disclose

4. Community Collaboration:

5. Palliative Care, defined
“Palliative care means patient and family-centered
care that optimizes quality of life by anticipating,
preventing and treating suffering. Palliative care
throughout the continuum of illness involves
addressing physical, intellectual, emotional, social and
spiritual needs and to facilitate patient autonomy,
access to information and choice.”
~as defined by United States Department of health and Human Services (HHS)
Centers for Medicare & Medicaid Services (CMS), the National Quality
Forum(NQF) and National Consensus Project

6. Palliative care Consultation
Serious illness with any Prognosis
Goals can be curative or palliative
Interdisciplinary team
In hospital consultation, outpatient
clinics
Covered by insurance like other
specialists, may include copay
Required physician or NP visit
Rare in-home visits
Palliative Care via Hospice
Serious illness with 6 month or less
prognosis
Palliative goals only (not life-
prolonging)
Interdisciplinary team
Majority in home care, some inpatient
hospice
100% covered by most insurances when
prognosis certified
Physician/NP visit not required but
involved in plan of care

7. “All hospice is palliative care but palliative care is not all hospice”
“Palliative care is both a philosophy and a method of delivery”

8. Palliative Care Is
Excellent, evidence-
based
medical treatment
Vigorous care of
pain and symptoms
throughout illness
Care that patients
want at the same time
as efforts to cure or
prolong life
Palliative Care Is NOTNOT
 Not “giving up” on aNot “giving up” on a
patientpatient
 Not in place ofNot in place of
curative or life-curative or life-
prolonging careprolonging care
 Not the same asNot the same as
hospicehospice
Slide courtesy of Kathy Selvaggi, MS MD Butler Health

9. Benefits of PC in Serious Illness
Kavalieratos et al, JAMA 2016: Systematic review
and meta-analysis of 43 RCTs in palliative care vs
usual care: inpatient and outpatient (14)
Improved quality of life and symptom burden
No change in survival
Improvements in advance care planning, patient and
caregiver satisfaction, and lower health care utilization
Kavalieratos, Dio, Jennifer Corbelli, Di Zhang, J. Nicholas Dionne-Odom, Natalie C. Ernecoff, Janel
Hanmer, and others, ‘Association Between Palliative Care and Patient and Caregiver Outcomes: A
Systematic Review and Meta-Analysis’, JAMA, 316 (2016), 2104–14 Nov 2016

10. Benefits of Outpt PC in Serious Illness
Davis, et al A of Pall Med 2015: Review of 62 studies on
PC in ambulatory and home care (28 RCTs, )
Improvements in Depression, patient/caregiver
Quality of life, patient and family satisfaction, caregiver
burden
Reduced aggressive care at EOL, Increased advanced
directives,
Reduced hospital length of stay and hospitalizations,
reduction in overall cost of care
Davis, Mellar P., Jennifer S. Temel, Tracy Balboni, and Paul Glare, ‘A Review of the Trials Which Examine Early Integration
of Outpatient and Home Palliative Care for Patients with Serious Illnesses’, Annals of Palliative Medicine, 4 (2015), 99–121

11. Benefits of PC in Cancer Care
Symptom improvement: Depression
Patient reported outcomes: Improved Quality of life
and patient satisfaction
Resource allocation: Less Chemo at EOL, Increased
enrollment and length of use of hospice at EOL
Survival: Improved (in two studies)
No adverse outcomes noted.
Ferrell, Betty R., Jennifer S. Temel, Sarah Temin, Erin R. Alesi, Tracy A. Balboni, Ethan M. Basch, and
others, ‘Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology
Clinical Practice Guideline Update’, Journal of Clinical Oncology, 2016, JCO.2016.70.1474

12. Benefits of PC in Cancer Care, cont.
Temel et al:
Pts with newly diagnosed Stage IV NSCLCa at MGH
with standard monthly outpatient pall care
Improved QOL, survival(2.7mo) & mood by 8 weeks 1
 2.5mo = median benefit of new solid tumor txs introduced 2002-144
Less aggressive EOL care (4th
line chemo), hospice referral earlier
and longer duration 1
Improved prognostic awareness  less chemo at EOL2
Less chemotherapy at EOL(within 60 days), more time without
chemo before death, more enrollment in hospice > 1 week3
1. Temel, et al‘Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer’, The New England Journal of Medicine, 363 (2010), 733–42
2. Temel, et al ‘Longitudinal Perceptions of Prognosis and Goals of Therapy in Patients with Metastatic Non-Small-Cell Lung Cancer: Results of a
Randomized Study of Early Palliative Care’, Journal of Clinical Oncology(2011), 2319–26
3. Greer, et al ‘Effect of Early Palliative Care on Chemotherapy Use and End-of-Life Care in Patients with Metastatic Non-Small-Cell Lung Cancer’, Journal
of Clinical Oncology (2012),
4. Fojo, Tito, Sham Mailankody, and Andrew Lo, ‘Unintended Consequences of Expensive Cancer Therapeutics—The Pursuit of Marginal Indications and a
Me-Too Mentality That Stifles Innovation and Creativity: The John Conley Lecture’, JAMA Otolaryngology–Head & Neck Surgery, 140 (2014),

13. Benefits of PC in Cancer Care, cont.
Bakitas et al ENABLE I-III trials:
 In person & phone nurse-led PC support for patients
with advanced cancer of various types, prognosis 6-24
mo, in New Hampshire
II: Less depression, improved QOL
III: 15% difference in one-year survival when pall care was started
three months earlier
Bakitas, Marie A., Tor D. Tosteson, Zhigang Li, Kathleen D. Lyons, Jay G. Hull, Zhongze Li, and others,
‘Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE
III Randomized Controlled Trial’, Journal of Clinical Oncology, 2015, JCO.2014.58.6362

14. Palliative Care in Private Oncology Clinic
Palliative care clinic integrated into an office-
based oncology practice
Measurement of symptom burden- ESAS scale
21% decrease in symptom burden (ESAS 49.3 39)
Oncology Provider satisfaction: 9/10
Oncologists time saved in 1 year: 4 weeks (162
hours)
Muir, J. C et al “Integrating Palliative Care into the Outpatient, Private Practice Oncology Setting.” Journal of Pain and
Symptom Management 40, no. 1 (July 2010)
Modification of Original Slide by Dr. K Selvaggi

15. Meisenberg et al:
340 visits were recorded for 330 unique patients
during 11 months of a NP Supportive Care Clinic
Same day / next day appointments with NP were
arranged for 62% / 25% of patients
Admissions for symptoms decreased by 31%
66 ED visits avoided
Symptom management in Oncology Clinic
Meisenberg, Barry R., Lynn Graze, and Catherine J. Brady-Copertino. “A Supportive Care Clinic for Cancer
Patients Embedded within an Oncology Practice.” The Journal of Community and Supportive Oncology 12, no. 6
(June 2014): 205–8.

16. Benefit of Patient Reported
Outcomes Management
Basch et. al
766 adults with metastatic cancers receiving chemotherapy
randomized to report symptoms through a computerized
patient reporting portal or usual care
Patients using the PRO portal had:
 5 mo longer survival(26 vs 31.2)
 2 mo longer tolerance of chemo (8.2 vs 6.3)
Less decline in quality of life
Less ED and hospitalization
Basch, E et.al “Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer
Treatment.” JAMA, June 4, 2017.
Basch, E, et al. “Symptom Monitoring With Patient-Reported Outcomes During Routine Cancer Treatment: A Randomized Controlled Trial.”
Journal of Clinical Oncology 34, no. 6 (February 20, 2016):

17. PC in Stem Cell Transplant
El-Jawahri, et al JAMA 2016
Patients undergoing hematopoietic stem cell
transplantation had standard inpatient PC consultation
during transplant hospitalization at Duke
PC patients received 2+ idt visits per week
 Patients receiving PC had significant difference in QOL,
depression, anxiety, symptom burden at 2 weeks.
 QOL improvement durable at 3 months
 Caregivers had significant difference in depression
El-Jawahri, Areej, Thomas LeBlanc, Harry VanDusen, Lara Traeger, Joseph A. Greer, William F. Pirl, and
others, ‘Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell
Transplantation: A Randomized Clinical Trial’, JAMA, 316 (2016), 2094–2103
<https://doi.org/10.1001/jama.2016.16786>

18. “What’s in the serum?”
Interdisciplinary consultation team
Inpatient and outpatient presence, possibly telephonic
Specialty trained clinicians in addition to primary
palliative care
3-4 months minimum involvement
Prognostic awareness- understanding of illness,
prognosis and potential benefits of treatment
Comprehensive & ongoing assessment of distress
QOL, Physical, psychological, spiritual & social
Integration with oncologic care

19. ASCO Clinical Practice Guideline
Update
Ferrell, et al J of Clinical Oncology October, 2016
All patients with advanced cancer should receive
concurrent, dedicated palliative care services
 Essentials: relationship building, distress management,
prognostic awareness, goals, coping, decision making,
collaboration
PC available early (within 8 weeks of dx) inpt/outpt
Palliative Care should include interdisciplinary team
Caregivers should also be considered for support
Ferrell, Betty R., Jennifer S. Temel, Sarah Temin, Erin R. Alesi, Tracy A. Balboni, Ethan M. Basch, and others, ‘Integration of Palliative Care Into Standard
Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update’, Journal of Clinical Oncology, 2016, JCO.2016.70.1474
<https://doi.org/10.1200/JCO.2016.70.1474>

20. PA Plan for Oncology Palliative Care
No certifying agency governing palliative care
Quality measures coming from other specialties
Therefore in 2014-2015,
Survivorship and Palliative Care Stakeholder
Leadership Team (SLT) of the Pennsylvania (PA)
Comprehensive Cancer Control Coalition, a working
committee of the Pennsylvania Cancer Advisory Board
(CAB), prioritized Objective 3.3 of the PA
Comprehensive Cancer Control Plan (2013-2018)
“Facilitate collaboration to increase attention to
appropriate use of palliative care and improve quality of

21. PA Standard for Essential
Elements and Accessibility of
Palliative Care Services
Patients with cancer and their designated family
members or caregivers should have access to palliative
care across clinical settings including inpatient,
outpatient, long term care facilities and home. Services
may be provided within the cancer organization or
through community partnerships to provide all of the
following:

22. PA Standard for Essential Elements and
Accessibility of Palliative Care Services
Interdisciplinary team collaborates on plan of care
Attention to patient goals for treatment and communication preferences
Evidence based screening & management of symptoms & distress
Specialty Level palliative care by board certified clinician
Care of patient at the End of life and post-death care
Grief and Bereavement support
Quality improvement plan
Staff support to prevent compassion fatigue
Education for clinicians & trainees
Palliative care representation in leadership

23. Palliative Care in Practice
“When you’ve seen one palliative care program…”
Certification for palliative care programs
JCAHO inpatient certification
No outpatient/home based certification:
standards/recommendations only
Hospital, Clinic Based
Home Health/Hospice based
Health system versus community partnerships
We must hold ourselves accountable & ensure quality
care is delivered- avoid undermining

24. Completed by
primary oncologist
at diagnosis,
updated at decision
points

25. Serious Illness
Conversation
Guide
https://www.ariadnelabs.org/areas-of-
work/serious-illness-care/

26. Palliative Related Quality Measures
Oncology Care Model
Completion of Oncology (Patient centered)Care plan
Hospitalizations, ED Visits, Hospice > 3 days (median 18!)
Pain, depression, patient experience
American Society of Clinical Oncology (ASCO) Quality Oncology
Practice Initiative (QOPI) measures
Evaluation of pain by the 2nd
visit Emotional well-being
assessment and management Dyspnea assessment and
management
Documentation of palliative versus curative, intent discussion
with patient documented
We need to demonstrate our quality, not just decreased cost!

27. Next frontiers: Research & Care
PC for non-advanced cancers: Data emerging- not yet
strong enough to support guidelines but Ferrell et all
found improved QOL in early stage lung cancer1
Evaluating and considering “Quality of Death”2:
QOD is
not improved, and can be harmed, by chemotherapy use
near death, even in patients with good performance
status.
Caregiver needs: well documented distress, increased
mortality but how to intervene?3
1. Ferrell, et al ‘Interdisciplinary Palliative Care for Patients With Lung Cancer’, JPSM, 50 (2015), 758–67
2. Prigerson et al, ‘CHemotherapy Use, Performance Status, and Quality of Life at the End of Life’, JAMA Oncology, 2015
3. McDonald, et al ‘Impact of Early Palliative Care on Caregivers of Patients with Advanced Cancer: Cluster Randomised
Trial’, Annals of Oncology 2016

28. Where do we start?
Needs assessment: Clinicians, Patients, Health
systems, Insurers, quality measures
Partnerships: Champions in system, community
organizations
Education& Advocacy: ASCO Pall Onc, AAHPM,
PHPCN, Pediatric Palliative Care Coalition
Program Development
Center to Advance Palliative Care (CAPC)
National Quality Forum

29. Take-aways:
PC is meant to supplement, not detract, from oncology care
with evidence-based improvement in symptoms, quality,
satisfaction and possibly mortality with decreased cost so…
Don’t equate PC with hospice
Do recognize the need for disease specific palliative
education and consult the literature (or at least look at Fast
Facts!)
Do offer specialty palliative care consultation to all patients
with advanced cancer, within 3 months of diagnosis
Do discuss prognosis and expected outcomes, to facilitate
shared decision making, improve appropriate care choices
Do assess whole-person distress early and regularly
Consider assessing and supporting caregiver needs

30. Questions/Comments
Kristina Newport, MD FAAHPM
Palliative Medicine Consultants
knewport@supportivecare.org

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