OncoLog

 

From OncoLog, February 2012, Vol. 57, No. 2

Palliative Care May Offer Survival Benefits

By Bryan Tutt

Recent studies indicate that palliative care, which has been shown to improve quality of life in patients with advanced cancer, may also help patients live longer.

Patients with cancer or any life-threatening disease face a broad array of physical, spiritual, emotional, and financial problems. “Palliative care has a body of knowledge that can help patients, families, and even the primary care physicians treating those patients cope with problems related to debilitating chronic disease,” said Eduardo Bruera, M.D., a professor in and chair of the Department of Palliative Care and Rehabilitation Medicine at The University of Texas MD Anderson Cancer Center.

Benefits of palliative care

For cancer patients, the most noticeable benefit of palliative care (also called supportive care) is the relief of physical symptoms such as pain, fatigue, lack of appetite, nausea and vomiting, or shortness of breath. “We have demonstrated consistently that when people are seen by the supportive care team in addition to their oncologist, they feel better,” Dr. Bruera said.

But palliative care is not limited to pain management; it includes counseling and other services that can ease the emotional and spiritual distress of patients and their families.

Palliative care may also offer a financial benefit to patients and their families. Dr. Bruera said that patients who receive palliative care concurrently with cancer treatment and continue to do so after treatment options have been exhausted are less likely than those not receiving palliative care to be given a costly and unnecessary escalation of care in emergency rooms or intensive care units at the end of life.

“Ours is a program in which patients’ overall physical and emotional care is integrated with their cancer treatment.”
— Dr. Eduardo Bruera

These benefits, plus a survival benefit, were documented in a 2010 study reported in the New England Journal of Medicine. In the study, patients with metastatic non–small cell lung cancer who received palliative care had better quality of life, were less likely to receive aggressive care at the end of life, and had a longer median survival duration than those who did not receive palliative care.

Similar studies to determine whether palliative care will lengthen survival for patients with other types of cancer are under way at MD Anderson and other centers, and Dr. Bruera said preliminary data from these studies are promising. He hypothesized that the survival benefits from palliative care likely result from a combination of factors. “If patients feel better emotionally and physically, they are able to continue their cancer treatment,” Dr. Bruera said. “Another point that has been shown very clearly for other diseases is that untreated physical and emotional distress can shorten lives. If a patient has untreated pain, fatigue, depression, and nausea, there is a chance that he or she will die of complications from that continued stress.”

For these reasons, Dr. Bruera encourages oncologists to refer patients to a palliative care center at the first sign of physical or emotional distress.

Outpatient care

A referral for palliative care can take place at any point in the disease or treatment process because palliative care can be given in conjunction with chemotherapy or radiation therapy. To ensure that all patients have access to palliative care services, MD Anderson has both inpatient and outpatient palliative care centers.

Outpatient palliative care is important because many cancer patients—even those with incurable disease—continue living at home and working while undergoing treatment.

“Our model is based on collaborating closely with the primary oncologist early in the treatment of the disease,” Dr. Bruera said. “In fact, more than 80% of the patients seen at our palliative care center are receiving active cancer treatment. Ours is a program in which patients’ overall physical and emotional care is integrated with their cancer treatment.”

What’s in a name?

Dr. Bruera, who served on the committee that drafted the World Health Organization’s definition of palliative care in 1986, said that although palliative care has always been intended for any patient with a serious chronic or life-threatening illness, the misconception that palliative care is primarily a transition to end-of-life care persists.

In 2007, MD Anderson conducted a survey of its oncologists and mid-level providers and found that the name “palliative care” was a deterrent to their referring patients who had early stages of cancer or who were undergoing active treatment. To more accurately reflect its services, the Palliative Care and Rehabilitation Medicine Center changed its name to the Supportive Care Center.

Since the name change, the number of referrals has increased by about 40%, and patients arrive about a month and a half earlier in their treatment process than they did before. “We believe these improvements are because clinicians feel more comfortable referring their patients to a place called supportive care, which is not closely associated with the end of life,” Dr. Bruera said.

Patient-centered care

“Rapid and early access to supportive and palliative care might be a win-win situation in which patients benefit from reduced emotional, spiritual, symptom, and family distress as well as longer survival.”
— Dr. Eduardo Bruera

Patients being treated at MD Anderson can be referred to the Supportive Care Center by their oncologist. During a patient’s first visit to the outpatient clinic at the Supportive Care Center, the patient, usually accompanied by family members, goes directly to a comfortable hotel-style room; there is no waiting room. Together, the patient, the patient’s family, a nurse, and a palliative care physician identify any physical, emotional, spiritual, social, and financial problems and establish a personalized care plan that addresses these issues.

“No one comes to the center with just one problem,” Dr. Bruera said. “Patients usually come with seven or eight problems, and during the initial visit we establish a plan to deal with every one of them. Our care is multi-disciplinary. It includes doctors, nurses, counselors, social workers, chaplains, and in many cases physical and occupational therapists.” Several of these professionals typically see the patient during the initial visit.

The Supportive Care Center is organized so that the physicians, nurses, and other professionals come to the patient, who remains in the room where he or she can relax. “We try to minimize the number of places the patient has to visit,” Dr. Bruera said.

Follow-up visits to the Supportive Care Center are scheduled on days when the patient is coming to MD Anderson for other treatment or tests. The patient is encouraged to call the Supportive Care Center between visits if he or she has questions or needs support. “We get 30–40 phone calls every day from our patients to discuss how they’re feeling,” Dr. Bruera said.

A win-win situation

In addition to maintaining contact with the patient, the palliative care physician consults with the patient’s oncologists to ensure that supportive care services complement the patient’s cancer treatment.

“In the past, there was the thought that a referral for palliative care might be some sort of trade-off in which patients would have better quality of life but shorter survival, perhaps because their treatment would be less aggressive,” Dr. Bruera said. “But now we’ve seen that this is not true. Rapid and early access to supportive and palliative care might be a win-win situation in which patients benefit from reduced emotional, spiritual, symptom, and family distress as well as longer survival.”

What Is Palliative Care?

The field of palliative care has its roots in the hospice movement that began in the United Kingdom in the 1960s. Over the next two decades, palliative care grew into a multidisciplinary field. The following definition was adopted by the World Health Organization in 1986:

“Palliative care is an approach that improves the quality of life of patients and their families facing the problems 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. Palliative care:

  • provides relief from pain and other distressing symptoms;
  • affirms life and regards dying as a normal process;
  • intends neither to hasten or postpone death;
  • integrates the psychological and spiritual aspects of patient care;
  • offers a support system to help patients live as actively as possible until death;
  • offers a support system to help the family cope during the patient’s illness and in their own bereavement;
  • uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated;
  • will enhance quality of life and may also positively influence the course of illness;
  • is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.”

Source: World Health Organization.

For more information, contact Dr. Eduardo Bruera at 713-792-6084.

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