1. Supportive/Palliative Care For
The Woman With Cancer
Michael L. Pearl, MD, FACOG, FACS
Professor and Director, Division of Gynecologic Oncology
Director, Women’s Cancer Services
Stony Brook Medicine

2. Objectives
At the completion of this presentation, the participant
will be able to:
– Define palliative care
– Describe the role of palliative care in contemporary
management of the woman with cancer
– Provide several examples of palliative care
– Distinguish between palliative care and hospice care
– Appraise the New York Palliative Care Information Act
Occasionally, I am a surgical consultant for Ethicon

3. WHY?
Introduction
• It seems appropriate to have a talk about
palliative care at the END…
• In reality, this talk should be one of the FIRST
talks!

4. Palliative Care
“If you’ve never heard of palliative care, you’re not alone.
In a recent survey, only 24% of people said they were
familiar with the term. Palliative care isn’t nearly as well
known as, say, hospice care; in fact, people often confuse
the two. Its use is growing fast, however, and 59% of
hospitals with more than 50 beds now have palliative-care
programs. Hospitals like this type of care because it
appears to be cost-effective and may improve health
outcomes. Patients — once they know about it — like it
because it can make them feel better.”
The Washington Post, 3/28/11

5. Definition of “Palliative”
pal·li·a·tive
• adjective /’palē,ātiv/ /’palēətiv/
– (of a treatment or medicine) Relieving pain or
alleviating a problem without dealing with the
underlying cause
• short-term, palliative measures had been taken
• noun /’palē,ātiv/ /’palēətiv/
palliatives, plural
– A remedy, medicine, etc., of such a kind

6. Palliative Care:
Traditional View
“Active
Treatment”
Palliative
Care
D
E
A
T
H

7. Palliative Care:
Traditional View
“Recurrent ovarian cancer is seldom curable.
Second-, third-, or even fourth-line chemotherapy
is often administered in a palliative fashion, as a
means of diminishing symptoms and prolonging
life.”
http://emedicine.medscape.com/article/270646-overview

8. Palliative Care:
Traditional View
•Ms. Jones has Stage IIIC EOC
– Cytoreductive surgery, followed by Taxol/Carboplatin
– Recurrence # 1 treated with Topotecan
– Progression # 1 treated with Doxil
– Progression # 2 treated with Gemzar/CDDP
– SBO, surgery unsuccessful
– Pain, progressive weakness, altered mental status
– Admitted to Hospice for 9 days before dying
•Survival: 43 months from diagnosis

9. Palliative Care:
Contemporary View
Cure/Life-prolonging
Intent
Palliative/
Comfort Intent
D
E
A
T
H

10. CMS Definition Of Palliative Care:
Contemporary View
“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.”
73 FR 32204, June 5, 2008
Medicare Hospice Conditions of Participation
– Final Rule

11. Palliative Care:
Contemporary View
•Ms. Jones has Stage IIIC EOC
– Cytoreductive surgery, followed by Taxol/Carboplatin
• Referred to Palliative Care Team before discharge
– Palliative care physician, clinical pharmacist, social worker,
attorney, occupational therapist, beautician, nutritionist, chaplain
– Recurrence # 1 treated with Topotecan
• Referred to Palliative Care Team before starting chemotherapy
– Progression # 1 treated with Doxil
• Palliative Care Team actively involved
– Progression # 2, chemotherapy stopped
• Palliative Care Team actively involved
– SBO, no surgery, G-tube placed, Hospice Care instituted
– Pain and other symptoms well-controlled, died at home 5 weeks later
•Survival: 49 months from diagnosis

12. How Does Palliative Care Differ From
Hospice Care*?
• Palliative Care is appropriate at any time during management
of a serious illness. It can be provided at the same time as, and
in addition to, life-prolonging treatment. There are no prognostic
requirements and no need to choose between management
approaches (palliative care vs. curative/life-prolonging care).
• Hospice Care is a form of palliative care that provides care for
those at the end of their life. According to CMS rules, patients
must have a 2 MD-certified prognosis of <6 months and give up
insurance coverage for curative/life prolonging treatment in
order to be eligible.
*Hospice and Palliative Medicine is a nationally-recognized subspecialty
with Board Certification available through the American Board of Medical
Specialties.
http://www.aahpm.org

13. Evolving Model Of Palliative Care

14. Palliative Care Team
• Usually a team of experts, including palliative care
physicians, nurses and social workers. Chaplains,
massage therapists, pharmacists, nutritionists and
others may also be part of the palliative care team.
Working together with the attending physician, the
palliative care team provides:
– Close communication
– Expert management of pain and other symptoms
– Help navigating the healthcare system
– Guidance with difficult and complex treatment choices
– Emotional and spiritual support for the patient and family

15. Palliative Care Goals
• While palliative care may seem to offer a broad range
of services, the goals of palliative treatment are
concrete:
– relief from suffering,
– treatment of pain and other distressing symptoms
– psychological and spiritual care
– a support system to help the patient live as actively as
possible
– and a support system to sustain and rehabilitate the patient's
family
Walsh D, et al. J Pain Symptom Manage 1994;9(2): 109-.

16. Examples of Palliative Care
• Clinical pharmacist helps control chemotherapy-
induced symptoms (e.g., nausea/vomiting, fatigue,
mouth sores)
• Social worker assists with advance directives and
accessing community resources (e.g., transportation)
• Weekly spiritual visits (e.g., chaplain, minister, rabbi,
imam….)
• Massage therapist, cosmetician, physical therapist,
nutritionist

17. Why Palliative Care?

18. Palliative Care Is Beneficial
• Overall, patient satisfaction is markedly superior with
palliative care compared to usual care
• Palliative care superior for:
– Care/setting concordant with patient preference
– Emotional/spiritual support
– Information/communication
– Care at time of death
– Access to community services
– Well-being/dignity
– Pain control
– PTSD symptoms
Casareti et al. J Am Geriatr Soc 2008;56:593-99

19. Palliative Care Is Beneficial
• Recall of a conversation regarding goals
and prognostication was associated with:
– Better quality of dying and death
– Lower risk of complicated grief and
bereavement
– Less “aggressive” care
– Lower costs of care
Zhang et al. Arch Int Med 2009;169:480-488
Wright et al. JAMA 2008;300:1665-1673
Prospective, multicenter study of 332 seriously ill cancer patients

20. Temel et al. N Engl J Med 2010;363:733-742
Palliative Care Improves Survival
• Randomized, prospective, controlled study of patients with newly
diagnosed non-small cell lung cancer
• Integrated palliative care consult team (PCCT) with standard
oncologic care vs. standard oncologic care:
– PCCT met with patient & family within 3 wks, then at least every 6 wks
• Pain and symptom management
• Psychosocial and spiritual support
• Assistance with treatment choices
• Help in planning for care in the community
• Bereavement support and referral
• Early palliative care led to significantly:
– Improved quality of life and mood in pts. with metastatic disease
– Less aggressive care but significantly longer median survival
• 11.6 vs. 8.9 months

21. Palliative Care Reduces Cost
• Substantial data demonstrates decreased cost
across settings, regions, institutional and delivery
models
• Why?
– Talking openly and realistically with patients, families
and treating physicians leads to more conservative
choices
– Allows provision of higher quality and more satisfactory
care in more appropriate and, often, less costly settings

22. And, Yes, Palliative Care
Includes Hospice Care
•Home
•Comfort
•Sense of completion
•Saying goodbye
•Life-review
Themes for a “good” death
“Hey, great death!”

23. Palliative Care Allows People
To Die at Home
85
57
91
87
0
20
40
60
80
100
% satisfied with services % died at home
Usual Medicare home care Palliative care intervention
Brumley et al. The Permanente Journal 2003;7:7-12
Outcomes among patients who died from CHF/COPD/Cancer
Palliative Care vs. Usual Care, 1999-2000

24. New York Palliative Care
Information Act
“If a patient is diagnosed with a terminal illness or condition, the patient's attending health
care practitioner shall offer to provide the patient with information and counseling regarding
palliative care and end-of-life options appropriate to the patient, including but not limited to:
the range of options appropriate to the patient; the prognosis, risks and benefits of the
various options; and the patient's legal rights to comprehensive pain and symptom
management at the end of life. The information and counseling may be provided orally or
in writing. Where the patient lacks capacity to reasonably understand and make informed
choices relating to palliative care, the attending health care practitioner shall provide
information and counseling under this section to a person with authority to make health
care decisions for the patient. The attending health care practitioner may arrange for
information and counseling under this section to be provided by another professionally
qualified individual.”
NY Public Health Law, Section 2997-C

25. New York Palliative Care
Information Act
“If a patient is diagnosed
with a terminal illness
or condition, the
patient's attending health
care practitioner shall
offer to provide the
patient with information
and counseling regarding
palliative care and end-
of-life options appropriate
to the patient…”
•Specific for patients who are
predicted to have less than 6
months to live (“terminal”)
•Requires that a physician be
able and willing to make that
prediction (prognosticate)
•Wording suggests palliative
care and hospice care are
identical
Potential Pitfalls

26. New York Palliative Care
Information Act
•The presence of chronic disease(s) or
symptoms or functional impairments that
persist but may also fluctuate
•The symptoms or impairments resulting
from the underlying irreversible disease
require formal or informal care and can lead
to death
•Does not have a time component
Components of “End Of Life”
NIH State-of-the-Science Conference Statement on Improving End-of-Life Care; http://consensus.nih.gov

27. New York Palliative Care
Information Act
• Population-based cohort of 233 cancer
patients at onset of terminal phase
• Prospective evaluation of clinical
estimate of survival
• Treating physicians overestimated
duration of survival
– 25% accurate within 1 month
– 23% underestimated survival
– 52% overestimated survival (2/3 of incorrect
estimates)
Cancer 1999:86(1);170-176
No crystal ball!

28. New York Palliative Care
Information Act
Cure/Life-prolonging
Intent
Palliative/
Comfort Intent
D
E
A
T
H
“Active
Treatment”
Palliative
Care
D
E
A
T
H
Palliative care is more than just hospice care

29. New York Palliative Care
Information Act
“The attending health care practitioner may arrange for
information and counseling under this section to be
provided by another professionally qualified individual.”

30. New York Palliative Care
Information Act

31. How Can You Get Palliative Care?
• Ask your doctor
• Call your hospital
• Speak to other patients
• Internet resources

32. Palliative Care Resources
• American Association of Hospice and
Palliative Medicine. www.aahpm.org
• Center to Advance Palliative Care.
www.capc.org
• National Hospice and Palliative Care
Organization. www.nhpco.org
• www.palliativedoctors.org
• www.getpalliativecare.org
• Many, many others…….

33. Thank You