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Oncology group issues new policy, patient guide
The American Society of Clinical Oncology (ASCO) has called on physicians, medical schools, insurers, and others to help improve quality of life for people with advanced cancer. In a new policy statement, ASCO recommends steps to ensure that physicians initiate candid discussions about the full range of palliative care and treatment options soon after patients' diagnosis with advanced cancer (defined as incurable disease).
"While improving survival is the oncologist's primary goal, helping individuals live their final days in comfort and dignity is one of the most important responsibilities of our profession," said ASCO President George W. Sledge Jr., MD. "Patients have a right to make informed choices about their care. Oncologists must lead the way in discussing the full range of curative and palliative therapies to ensure that patients' choices are honored."
Because doctor/patient communication is critical to optimal patient care, ASCO also released a guide to help patients with advanced cancer broach difficult conversations about their prognosis, treatment, and palliative care options with their physicians. Later this year, ASCO will issue its first clinical guidance to help oncologists initiate these conversations and better integrate palliative therapy into oncology practice.
"Studies show that palliative therapies not only improve patient quality of life, but can even extend life," said Sledge. "Yet for many with advanced cancer, conversations about palliative and hospice options do not occur until the patients' final weeks or days of life, if they happen at all. This not only hurts patients, but their caregivers as well. ASCO's new patient booklet and upcoming clinical guidance will help patients and physicians broach these topics early in the course of care."
a.randomized trial sponsored by The ASCO Cancer Foundation recently found that patients with advanced lung cancer who received chemotherapy and palliative care immediately after their diagnosis lived almost three months longer than those who received chemotherapy alone. Another study published in the Journal of Clinical Oncology showed that caregivers of terminally ill patients who receive palliative therapy suffer less emotional stress. ICU and hospital deaths were associated with more psychiatric illness among bereaved caregivers compared with home hospice deaths.
In addition, a new, preliminary analysis of 5,500 patient records from ASCO's Quality Oncology Practice Initiative (QOPI), a quality improvement program involving about 600 oncology practices nationwide, indicates that less than half (45%) of cancer patients are enrolled in hospice care before death. Of those enrolled, one-third were enrolled in the last week of life. The analysis also found that a significant number of patients did not receive appropriate management of their pain (one-in-five patients) or shortness of breath (two-in-three patients) in their last two medical visits.
a.CO's policy statement was published online ahead of print in ASCO's Journal of Clinical Oncology. To access, go to http://jco.ascopubs.org. Click on early release. Under "January 24, 2011," select "American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer." It outlines essential elements of care for patients with advanced cancer and identifies barriers that prevent advance cancer care planning conversations between physicians and patients. The statement enumerates critical steps to ensure that care is individualized to address each patient's needs, goals and preferences throughout the course of their illness. The key elements identified by ASCO to individualize advanced cancer care include:
Physicians should initiate candid discussions about prognosis with their patients soon after an advanced cancer diagnosis. Such conversations occur with less than 40% of patients with advanced cancer.
Quality of life should be an explicit priority throughout the course of advanced cancer care. Physicians must help their patients fully understand their prognosis, the potential risks and benefits of available cancer treatments, and quality-of-life considerations. In cases in which active treatment is unlikely to extend survival, palliative care should be discussed as a concurrent or alternate therapy.
Clinical trial opportunities should be increased. Few patients with advanced cancer participate in trials due to strict eligibility criteria, a dearth of trials that address quality-of-life issues, and other barriers. Increasing opportunities for these patients to potentially benefit from trials and to contribute to improving cancer care should be a high priority.
a.CO CEO Allen S. Lichter, MD, said many barriers prevent physicians and patients from engaging in optimal advanced cancer care planning. "Oncologists recognize the importance of palliative therapy and other quality-of-life measures in advanced cancer, but physician education and training programs historically have provided little guidance in this area," Lichter said. "Although patients are entitled to make informed choices about their palliative care and treatment options, our nation's health care system currently places no value on conversations that can guide these decisions."
To address barriers to advanced cancer care planning, ASCO recommends:
Advanced cancer care planning should be emphasized in physician education and training programs.
Communication skills for discussing prognosis and care options should be emphasized in oncologists' initial training and in continuing medical education (CME).
For oncologists in practice, advanced cancer care planning should be a key part of ongoing quality improvement programs.
Palliative care should be incorporated into American Board of Internal Medicine oncology training and certification, and into oncology fellowship programs.
Provide insurance coverage for advanced cancer care planning discussions. Most public and private insurance plans provide little or no compensation for discussions with patients about palliative care options, despite their demonstrated value. To address these issues, ASCO's statement calls for:
public and private insurers to provide direct reimbursement for advanced cancer care planning discussions;
private insurers to expand pilot programs that maximize palliative care (e.g., hospice) without requiring patients to abandon cancer-focused treatment. By requiring patients to end their cancer treatment in order to receive palliative care, many plans currently reinforce the false choice between fighting the cancer and maximizing quality of life;
increase opportunities for advanced cancer patients to participate in clinical research. ASCO calls for researchers and research sponsors to prioritize studies that:
evaluate strategies to maximize quality of life for patients with advanced cancer;
examine potential ways to improve communication between oncologists and patients to ensure patients' care reflects their individual goals and preferences;
assess which patients with advanced cancer are most likely to benefit from novel treatments, and study how to overcome biological mechanisms that make their cancer resistant to available treatments;
increase educational resources for patients with advanced cancer. To help guide patients through difficult yet important doctor-patient discussions, ASCO has a free comprehensive educational booklet for patients with advanced cancer. For copies of the booklet, go to www.Cancer.net. Select "order cancer.net materials" and then "Advanced Cancer Care Planning."