A Conversation with Dr. Thomas Smith about Palliative Care for Patients with Cancer
In March 2012, the American Society of Clinical Oncology (ASCO) released a Provisional Clinical Opinion (PCO) recommending that palliative care be integrated with cancer treatment early in the course of illness for any patient who has metastatic cancer or is greatly burdened by symptoms. The ASCO authors based their recommendation on the results of seven randomized trials that tested the addition of palliative care to traditional cancer care. One of these studies showed that patients with advanced non-small cell lung cancer who received early palliative care not only had improved quality of life but lived longer than patients who received standard treatment alone. Dr. Thomas J. Smith, director of palliative care for the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center and lead author of the PCO, discussed the growing role of palliative care in oncology practice.
Is palliative care integrated into traditional oncology training?
Palliative care is becoming more integrated into oncology training, but if you trained more than 10 years ago, you probably didn't learn much about it. Many oncologists don't really know how to integrate palliative care directly into their practice. I am still learning.
I think we oncologists typically have very good working relationships with our surgeons and our radiation therapy colleagues, but not often with palliative care providers. In fact, we should have the same sort of preferred provider relationship with hospice as we do with other specialties. By that, I mean we should choose one or two providers that we work with closely, get to know them really well, get to know what they can do and what they can't do, and get feedback from those hospice programs on how we could do better [on referrals].
What could be done now to expand access to palliative care for cancer patients?
One of the things is to get hospice involved much sooner in the care of our patients. We're asking oncologists to schedule a hospice information visit when they expect that a patient has 3 to 6 months left to live, where you send a hospice team to meet the patient and the family.
It's often easier for patients and families to talk about some of these things with someone other than their oncologist. Having that palliative care team to help make sure the patient understands his or her prognosis, making sure the patient understands what the treatment options are, what the treatment goals are—to really break things down in black and white—can be very helpful for both the oncologist and the patient.
About a third of patients go into hospice with less than a week to live, and everyone is scurrying around trying to get the patient comfortable when the outcome for that patient was predictable 3 to 6 months before. Most of us choose not to have discussions about things like hospice, do-not-resuscitate [orders], and advanced medical directives until there are no more chemotherapy options left. That allows us to avoid a hard conversation, but it doesn't serve as well to prepare the patients and families for what's coming.
Can palliative care help people with less-advanced cancers?
Yes, palliative care can help people who have curable cancers, too. When someone's getting bludgeoned by cancer treatment, it's really helpful to have someone else co-manage their symptoms. As an oncologist, I may not have the skills or the time—particularly the time, with a patient scheduled every 20 minutes—to help a patient with all of his or her physical and psychological symptoms. But if I have a good working relationship with a palliative care provider, a referral can be very helpful for me and the patient. Some particular examples are neuropathic pain and distress.
If the doctor recommends it, or if the advanced-practice nurse recommends it, it's a rare patient who's going to say, "Oh, I don't want to see the palliative care team." But again, it's up to us, as the treating oncologists, to refer patients. It is not as effective if we ask the social worker to handle it.
Is there work under way in the United States to standardize how palliative care is given?
There are already some very good standards. The Clinical Practice Guidelines for Quality Palliative Care, from the National Consensus Project for Quality Palliative Care, first came out in 2004. They're not proscriptive in that they don't tell you exactly what you can and can't do, but they do give you some very good ideas about what a good palliative care consultation should include.
A consultation should definitely include a symptom assessment, a screen for depression, a screen for spiritual distress, and referrals to a chaplain and psychologist, if indicated. The team itself should have some multidisciplinary components to it—not just a nurse, not just a doctor. I am concentrating on asking patients "What's important to you?" as a way into core matters.
The Joint Commission also offers an accreditation program that was just established this past year. So, the Joint Commission now approves palliative care centers, just as it approves stroke centers or heart-disease centers.
What are the most urgent research priorities for palliative care in oncology?
One is to test palliative care in diseases other than lung cancer, to do randomized trials of what we know works in lung cancer—which is a multidisciplinary palliative care intervention—in other cancers. Just like we tested stem-cell transplantation in myeloma, lymphoma, and breast cancer, let's test palliative care.
The other priority would be to try to figure out what are the main components in an effective palliative care intervention—what's necessary, what's sufficient [to see an effect]. Those results would have important implications for funding, because getting reimbursed [for palliative care] in today's environment can be really difficult.
How do caregivers benefit from palliative care?
I think that's one of the biggest areas of benefit. In several studies we looked at for the PCO, caregivers did extraordinarily better when someone other than the treating oncologist was helping to take care of the patients. Part of that has to do with knowing the prognosis, knowing the treatment goals, and knowing what's going to happen.
Patients and families want this information; the problem is that patients and families won't bring these questions up—they're waiting for us. So if we choose not to talk about these things, we're making a choice that seems easier in the moment—easier for us, easier emotionally for the families at the time—but it's a choice that will make care more difficult down the road.
And that's where having a palliative care team involved early can be so useful.