Posts tagged cancer
America, your bluff has been called…the verdict is in, and the old adage remains true: you cannot have your cake and eat it too (shocking news, I know). Clichéd as it may sound, that message rang true this morning as the annual assembly opened in a blaze of introspection and criticism of the status quo. The target? Rising healthcare costs. Even current levels of U.S. healthcare spending are unsustainable, yet we continue on a path of rising costs without adequate thought regarding the value of care provided.
The panel discussion featured Thomas Smith, Brad Stuart, and Rebecca Kirch, each presenting perspectives on the problem and fielding questions. Smith hit the nail on the head, pointing out that “value is missing, care is not optimal, and costs are rising unsustainably.” He highlighted some staggering statistics from a sample of cancer patients at a major academic medical center (Dy, et al, 2011). Roughly 1/3rd received chemotherapy within 2 weeks of death, ~25% ended up on a ventilator, less than 1/4th were discharged to hospice care, and ~1/3rd died in the hospital. Quite a sad state of affairs! Yet insurance premiums are rising quickly, having doubled between 2000 and 2010; herein lies the “missing value.” What are we buying with all this money spent? What’s a society to do?
At this point someone usually drops the “R-bomb,” which can curtail any meaningful debate. Imposing limits on healthcare is such a charged and seemingly un-American idea. Must rationing be the only solution though? Per Brad Stuart, the answer to this question is a resounding “no!” Stuart described a program called AIM (Advanced Illness Management), which effectively turns this debate on its head. Rather than focusing on imposing limits, AIM emphasizes the importance of eliciting and defining patient preferences early (and often), and facilitates doing this in the community rather than just the hospital. AIM data show how this approach can yield improved outcomes, higher quality of care, and even decreased costs!
This sounds like what many of us in palliative care already think we do; we’re communicators, goals elicitors, and compassionate caregivers. But we are handcuffed by a system that often views us as the alternative to aggressive treatments, especially in cancer care, and we’re often involved too late in the process. Thankfully, this too is changing. A recent guideline from the American Society of Clinical Oncology recommends early palliative care for all patients with advanced cancers (link). Palliative care is increasingly viewed as a part of the solution and a part of quality cancer care, rather than an adversary.
In this climate, 2012 is a time of enormous excitement for our field! How we brand and conduct ourselves though, is crucial. We must be partners in cancer care, not antagonists. As Kirch taught us in reviewing the CAPC report, how we talk about palliative care truly matters; if we do it “correctly,” patients are overwhelmingly interested in what we do, and would want it for their loved ones (link).
As a trainee in both oncology and palliative medicine, I cannot imagine a more exciting time to be working at the intersection of these fields. Let’s continue to work together to blaze a trail towards increasing quality of life and quality of cancer care. In line with the AIM program, and those like it, let’s be champions of patient choice, rather than reapers of grim. Palliate early, and often!Thomas W. LeBlanc, MD, MA Fellow, Medical Oncology and Palliative Medicine Duke University
by Porter Storey, MD, AAHPM Executive Vice President
Palliative care teams should be consulted more often for cancer patients in active treatment.
I know, I am “preaching to the choir” on this blog, but it may be important how we explain this to our various “stakeholders.”
The Public – Palliative care can help align patient wishes with their treatments and make sure patients and families are comfortable and supported.
Patients – Palliative care can help with symptom management, care coordination, psychosocial support so that you can continue your treatment and continue to do so after it is completed.
Hospice Programs – Palliative care can provide support before they qualify for hospice and refer patients to hospices sooner, for longer lengths of stay.
Payors and Program Administrators – Palliative care consultations can reduce costs and improve quality for the sickest (and most expensive) patients we care for. It can reduce hospital readmissions and save thousands of dollars per hospitalized patients (for the latest of many articles see Nelson C, et al. Inpatient Palliative Care Consults and the Probability of Hospital Readmission. Permanente J. 2011, 15(2):48-51.)
Referring Oncologists – Palliative care can act as an extension of the oncology care team so oncologists can focus on giving treatment. And as Tom Smith and Bruce Hilner argue in the May 26 NEJM, “bend the cost curve” so that we can afford to offer expensive new treatments to patients who can benefit from them (N Engl J Med 2011; 364:2060-2065).
Let’s not apply the wrong argument to the wrong class of stakeholders.
What do we say to the politicians?
Join the discussion when AAHPM offers the webinar “Changing the Mindset: Integrating Palliative Care into Cancer Treatment” lead by Tom Smith on Tuesday July 14 at 3pm ET.
Most of you have already seen the study released yesterday in the New England Journal of Medicine and I suspect that those of you who work in palliative medicine were not at all surprised by the results: patients who received palliative care along with standard oncology treatment for advanced lung cancer not only had a higher quality of life, but lived three months longer, as well. Isn’t that what we’ve been saying all along?
I have personal experience that supports their conclusions. When I was diagnosed with advanced ovarian cancer in 2008, I relied on a program of palliative care to enable me to tolerate the toxic intraperitoneal chemotherapy that was recommended. I was determined to get ALL of my treatments, WHEN they were scheduled, in order to give myself the best chance of responding. I sought out aggressive symptom management, controlling the pain and nausea so that I could be ready for the next round of treatment. I saw an oncology counselor and set up a website to coordinate meals for my family and me. I prayed. My friends prayed. Friends of friends prayed. I used acupuncture, initially to help with the nausea but later, just because it made me feel better. Three Reiki masters came to my home weekly to keep my energy positive.
And I stayed on schedule! I had chemotherapy the day before Thanksgiving (only because they were closed on Thanksgiving and Thursday was my “usual” day). I finished my last treatment on Christmas Eve. I was determined to do this and palliative care made it possible. With an “n” of one, I’m not a randomized trial, but I did better than those around me. And, I’m still here two years later to marvel at my survival.
But now there IS a randomized trial!
151 patients with newly diagnosed, metastatic non-small-cell lung cancer were randomly assigned to receive either early palliative care integrated with standard oncology care or standard oncology care alone. The primary outcome was the change in quality of life at 12 weeks, assessed by the Functional Assessment of Cancer Therapy-Lung (FACT-L) and the Hospital Anxiety and Depression Scale. Data on end-of-life care were collected from electronic medical records.
Patients who received concurrent palliative care had a better quality of life than did patients who received standard care alone (P = 0.03). They also had fewer depressive symptoms (P = 0.01). At the end-of-life, the palliative care group had fewer aggressive treatments (aggressive care was defined as receiving any of the following: chemotherapy within 14 days of death, no hospice care, or admission to hospice less than 3 days before death) (P = 0.05). Despite this, the patients who received concurrent palliative care from the time of diagnosis lived longer – almost 3 months longer (ll.6 months vs. 8.9 months, P = 0.02).
This study confirms the importance of palliative care begun at the time a serious illness is diagnosed, enabling patients to live better AND to live longer. Great news for patients and for the field of palliative care.