Get Adobe Flash player
Supportive Oncology Supportive and Palliative Oncology— A New Paradigm for Comprehensive Cancer Care David Hui, MD, MSc and Eduardo Bruera, MD Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center, Houston, TX, US. Abstract Patients with advanced cancer often experience symptoms related to increasing tumor burden, cancer treatments, and psychosocial stressors. They also have significant social, informational, and decision-making needs. Palliative care practitioners have developed expertise to address many of these supportive care concerns through interprofessional teamwork, validated assessments, multidimensional interventions, and frequent communication. In this article, we aim to provide an evidence-based update on several important palliative care topics, including management of pain, fatigue, anorexia–cachexia, depression, and anxiety, as well as patient–clinician communication and decision-making. Multiple randomized controlled trials have demonstrated that palliative care can improve symptom burden, quality of life, quality of care, satisfaction, and possibly survival and cost of care. To enhance the level of care for patients with advanced cancer, oncologists need to have a good working knowledge of the major palliative care principles, and to refer patients to palliative care programs often and early in the disease trajectory. Keywords Anorexia, cachexia, communication, decision-making, fatigue, healthcare systems, neoplasms, pain, palliative care, supportive care Disclosure: The authors have no conflicts of interest to declare. Acknowledgement(s): Eduardo Bruera is supported in part by National Institutes of Health grants RO1NR010162-01A1, RO1CA122292-01, and RO1CA124481-01. The authors are also supported by the MD Anderson Cancer Center Support Grant (CA 016672). Received: January 31, 2013 Accepted: February 11, 2013 Citation: Oncology & Hematology Review, 2013;9(1):68–74 Correspondence: David Hui, MD, MSc, Department of Palliative Care and Rehabilitation Medicine Unit 1414, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, USA 77030. E: Cancer is associated with significant morbidity and mortality. Patients with advanced cancer often experience multiple symptoms related to increasing tumor burden, cancer treatments, and psychosocial stressors (see Figure 1). Direct infiltration, compression, obstruction, inflammation, and various cancer-related complications, such as thrombosis and infections, may all contribute to symptom distress. Cancer treatments such as surgery, radiation, and systemic therapies are associated with multiple adverse effects. Cancer patients also frequently experience emotional distress as a result of changes to their health and functional status, social and financial stressors, existential concerns, comorbid psychiatric diagnoses, and decompensated coping mechanisms. Taken together, progressive cancer, cancer treatments, and psychosocial stressors can lead to multiple physical and emotional symptoms, ultimately decreasing patients’ quality of life and increasing caregiver burden. In several cross-sectional studies, cancer patients experience an average of eight to 12 symptoms. 1 In addition to symptom burden, patients often have significant social, informational, and decision-making needs, requiring significant expertise and time to provide optimal care. Over the past few decades, palliative care has evolved as a discipline to address the physical, psychologic, and spiritual needs for patients living with advanced illnesses and their families. Figure 2 shows a conceptual framework for the overlapping, yet distinct, roles of supportive care, palliative care, and hospice care. 2 In addition to symptom management, 68 palliative care focuses on patient–clinician communication, complex decision-making, caregiver care, and care for patients at the end-of-life. 3 Multiple studies have demonstrated that palliative care is associated with improved symptom control, quality of life, quality of care, and satisfaction, while at the same time reducing the cost of care. 4 Palliative care programs are typically situated in acute care facilities, and may include four types of services: inpatient consultation teams, acute palliative care units, outpatient clinics, and palliative home care. 5 Inpatient consultation services are most commonly available, which provide symptom management and transition of care for patients under the supervision of oncologists. Acute palliative care units are intensive symptom control units for patients with severe distress, facilitating discharge planning, and end-of-life care. 6 Outpatient clinics serve patients earlier in the disease trajectory, and are ideal settings for advance care planning and early symptom interventions. 7 Home care teams deliver healthcare services to the patients’ home for those who are not already enrolled onto hospice programs. Palliative care is, by nature, interdisciplinary and consists of nurses, physicians, social workers, counselors, chaplains, physical and occupational therapists, volunteers, and other professionals to address the multidimensional aspects of care for cancer patients and their families. Recognizing the importance of palliative care, multiple organizations including the American Society of Clinical Oncology (ASCO), 8,9 the National © Touch ME dica l ME dia 2013