The Integration of Palliative Care into Standard Oncology

Care: American Society of Clinical Oncology Clinical

Practice Guideline Update

www.asco.org/palliative-care-guideline ©American Society of Clinical Oncology 2016. All rights reserved.

 Introduction
• The purpose of this version of the American Society of Clinical Oncology (ASCO)
guideline is to update the ASCO Provisional Clinical Opinion (PCO) (2012) on the
integration of palliative care into standard oncology care, and transition the
content into a guideline.

• Patients with advanced cancer are defined as those with distant metastases, with
late-stage disease, cancer that is life-limiting and/or with prognosis of 6-24
months.

• This update includes nine RCTs, as well as one quasi-experimental study, and five
secondary publications from previously reviewed RCTs.

• It reviews and analyzes new and updated evidence on early palliative care,
including for patients in both inpatient and outpatient settings, the components
and triggers for offering patients palliative care, palliative care services for family
caregivers, and how oncology professionals and other clinicians can provide
palliative care, in addition to palliative care specialists.
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 ASCO Guideline
Development Methodology
The ASCO Clinical Practice Guidelines Committee guideline process includes:
• a systematic literature review by ASCO guidelines staff
• an expert panel provides critical review and evidence interpretation to
inform guideline recommendations
• final guideline approval by ASCO CPGC

The full ASCO Guideline methodology supplement can be found at:

www.asco.org/palliative-care-guideline

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 Clinical Questions
This clinical practice guideline addresses six overarching clinical questions:

(1) What is the most effective way to care for patients with advanced cancers’
symptoms?

(2) What are the most practical models of palliative care?

(3) How is palliative care in oncology defined or conceptualized?

(4) How can palliative care services relate in practice to other existing/emerging
services?

(5) Which interventions are helpful for Family Caregivers?

(6) Which patients should be offered/or referred to palliative care services, when in
their disease trajectory, and are there triggers that should be employed to prompt
specialty palliative care referrals?

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 Target Population and Audience
Target Population
Patients with advanced cancer and their caregivers

Target Audience
Oncology clinicians, patients, caregivers, palliative care
specialists

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 Summary of Recommendations
CLINICAL QUESTION 1
What is the most effective way to care for patients with
advanced cancers’ symptoms (palliative care services in addition
to usual care, compared with usual care alone)?

Recommendation 1
Patients with advanced cancer should be referred to
interdisciplinary palliative care teams (consultation) that provide
inpatient and outpatient care early in the course of disease,
alongside active treatment of their cancer (Type: evidence
based, benefits outweighs harms; Evidence quality:
intermediate; Strength of recommendation: strong).

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 Summary of Recommendations
CLINICAL QUESTION 2
What are the most practical models of palliative care? Who
should deliver palliative care (external consultation, internal
consultations with palliative care practitioners in the oncology
practice, or performed by the oncologist her/himself) ?

Recommendation 2
Palliative care for patients with advanced cancer should be
delivered through interdisciplinary palliative care teams, with
consultation available in both outpatient and inpatient settings
(Type: evidence based, benefits outweigh harms; Evidence
quality: intermediate; Strength of recommendation: moderate).

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 Summary of Recommendations
CLINICAL QUESTION 3
How is palliative care in oncology defined or conceptualized?

Recommendation 3
Patients with advanced cancer should receive palliative care services, which may include a
referral to a palliative care provider. Essential components of palliative care include:
• rapport and relationship building with patient and family caregiver(s)
• symptom, distress, and functional status management (i.e. pain, dyspnea, fatigue, sleep
disturbance, mood, nausea, or constipation)
• exploration of understanding and education about illness and prognosis
• clarification of treatment goals
• assessment and support of coping needs (e.g., provision of dignity therapy)
• assistance with medical decision making
• coordination with other care providers
• provision of referrals to other care providers as indicated.
For newly diagnosed patients with advanced cancer, the Expert Panel suggests early palliative
care involvement, starting early in the diagnosis process and ideally within 8 weeks of diagnosis
(Type: informal consensus; Evidence quality: intermediate; Strength of recommendation:
moderate).
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 Summary of Recommendations
CLINICAL QUESTION 4
How can palliative care services relate in practice to other existing or emerging
supportive care services (including nurse navigation, lay navigation, community and
home health care, geriatric oncology, psycho-oncology, and pain services)?

Recommendation 4
Among patients with cancer with high symptom burden and/or unmet physical or
psychosocial needs, outpatient programs of cancer care should provide and use
dedicated resources (palliative care clinicians) to deliver palliative care services to
complement existing program tools (Type: informal consensus, benefits outweigh
harms; Evidence quality: intermediate; Strength of recommendation: moderate).

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 Summary of Recommendations
CLINICAL QUESTION 5
Which interventions are helpful for family caregivers?

Recommendation 5
For patients with early or advanced cancer for whom family caregivers will
provide care in outpatient, home, or community settings, nurses, social
workers, or other providers may initiate caregiver-tailored palliative care
support, which could include telephone coaching, education, referrals, and
face-to-face meetings. For FCGs who may live in rural areas and/or unable to
travel to clinic and/or longer distances, telephone support may be offered
(Type: evidence-based; Evidence quality: low, Strength of recommendation:
weak).

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 Summary of Recommendations
CLINICAL QUESTION 6
Which patients should be offered/or referred to palliative care services, when
in their disease trajectory, and are there triggers that should be employed to
prompt specialty palliative care referrals?

Special Commentary
Interventional studies support early specialty palliative care referrals among
patients with cancer and their caregivers (FCGs) with advanced stage
malignancies. However, additional triggers should be considered among all
patients with cancer to ensure prompt referrals to specialty palliative care
services for patients at high risk for specialty palliative care needs.
Furthermore, oncologists should be educated in primary palliative care
competencies and regularly assess triggers for palliative care specialty
services as part of their care to patients with cancer and their FCGs. Further
studies are needed to better define triggers for meeting unmet specialty
palliative care needs in the population of patients with cancer.

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 Patient and Clinician Communication
• A key component in retrospective analyses has been the performance of a
“goals of care” discussion that entails asking about:
– Knowledge of the illness
– Realistic options for treatment
– Planning for the future

• If such discussions are held, care at the end of life improves, and is more
consonant with what most people want.

• The stage IV NSCLC guideline also suggests inquiry about psychological and
spiritual care, social support, assessing FCG needs, and physician self-care.
Please see the Palliative Care and Patient and Clinician Communications
sections of the 2015 guideline, as well as its Data Supplement, which
includes Sample Talking Points at www.asco.org/guidelines/nsclc
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 Health Disparities
• Clearly, further research involving people of color and/or with low
socio-economic status and/or participants from other
underrepresented groups is needed.

• It is not within the scope of this guideline to examine specific

factors contributing to disparities; however, given the relatively
recent publication of research and guidelines on palliative care, it is
likely that dissemination is occurring slowly, especially in
populations already experiencing health disparities and/or
populations with cultures differing from those in research to date.

• Awareness of the disparities in access to palliative care should be

considered in the context of this clinical practice guideline, and
health care providers should strive to deliver the highest level of
cancer care to these vulnerable populations.
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 Multiple Chronic Conditions
• It is important to note that elderly patients most often have multiple chronic
illnesses and with the aging population it is expected that this problem will
increase.

• In addition, the best available evidence for treating index conditions, such as
cancer, is often from clinical trials whose study selection criteria may exclude these
patients in order to avoid potential interaction effects or confounding of results
associated with MCC.

• As a result, the reliability of outcome data from these studies may be limited,
thereby creating constraints for expert groups to make recommendations for care
in this heterogeneous patient population.

• As many patients for whom guideline recommendations apply present with MCC,
any treatment plan needs to take into account the complexity and uncertainty
created by the presence of MCC and highlights the importance of shared decision
making regarding guideline use and implementation.

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 Cost Implications
How is palliative care reimbursed?
• Palliative care is reimbursed as a medical specialty comparable to oncology or
hematology. Hospice and Palliative Medicine was made an official medical sub-
specialty in the U.S. in 2006 and received a Medicare billing identifier in 2008. The
physician and advance nurse practitioner can bill for Medicare professional time
and palliative care services, but the other members of the inter-disciplinary team
such as the chaplain and social worker cannot bill for palliative care services
directly, so some other provision must be made for them.

What other resources are available to support palliative care, such as cost-avoidance
to the practice and health system? What is the business case for palliative care?
• The primary impetus for hospice and subsequently palliative care was to improve
quality of life and symptom management. Hospice has been proven over many
years to improve symptoms, reduce patient and caregiver distress, produce equal
or even better survival compared to those who do not use hospice, and improve
the chance of dying where one desires, usually at home.

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 Guideline Implementation
• ASCO guidelines are developed for implementation across health settings.
• Barriers to implementation include the need to increase awareness of the
guideline recommendations among front-line practitioners and patients
with cancer and their caregivers, and also to provide adequate services in
the face of limited resources.
• In addition, there are not enough palliative care providers to do the
needed consultations, so oncologists will have to adopt the practices of
palliative care and implement primary palliative care in their offices.
• This guideline will be distributed widely through the ASCO Practice
Guideline Implementation Network. The guideline Bottom Line Box was
designed to facilitate implementation of recommendations.

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 Limitations of the Research
Research to date has made great strides, but some of the studies faced
limitations, for example:
• The field of palliative care research began relatively recently.
• Research funding for palliative care has been limited, therefore
outcome data are very limited (90% of hospitals have funding for
palliative care services, but few have funding for research).
• The majority of the research has been in patients with solid tumors
and more research is needed across tumor types and in
hematology.
• Research in health disparities in palliative care is lacking.
• Some studies were single site, which can limit generalizability,
and/or small sample size and/or short follow-up.

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 The acronym T-E-A-M describes the common
attributes of successful palliative care used in
the clinical trials.
• Time: at least an extra hour a month with the
patient and family.
• Education: about prognosis, options, advance
care planning, use of hospice.
• Assessments: formal symptom, spiritual, and
distress assessments.
• Management: by an interdisciplinary team.

Sources: Leong, Shah, and Smith, JOP 2017//TS PPT 23 May 2016, JHU
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Time: ≥ 1 hour/month. Does not have to be
oncologist, but with someone. Can be over the
phone.
Education: to address difficult issues.
Assessment Tools - Pain and Symptom
Management tools – Measure and Evaluation
Tools - National Palliative Care Research
Center - http://www.npcrc.org/content/25/Measurement-
and-Evaluation-Tools.aspx

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JHU clinicians may use this palliative care temporary tattoo to remember to
address the important issues that may not be covered by the oncologist in a
routine visit. This temporary tattoo is available from Tom Smith at a minimal cost
and lasts about 10 days.

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©American Society of Clinical Oncology 2016. All rights reserved.
 Limitations of the Literature and
Future Directions
To enhance and strengthen the evidence base on palliative care, the dissemination of
research results, and the quality and equity of palliative care, more research is
needed; specific areas include:
• Identifying the specific elements, such as skills and personnel that make the
difference seen in research
• Identifying triggers for palliative care
• Including patients with cancers of types not represented in earlier trials, especially
hematologic cancers
• More research on the role of palliative care for patients with early stage disease.
• Elucidating health disparities specific to palliative care, for purposes including to:
identify disparities, barriers, determinants in receipt and quality of palliative care,
and on evidence-based interventions to address disparities
• On family caregivers
• Including patients with advanced cancer in early phase clinical trials
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 Additional Resources
More information, including a Data Supplement, a
Methodology Supplement, slide sets, and clinical tools
and resources, is available at
www.asco.org/palliative-care-guideline

Patient information is available at www.cancer.net

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©American Society of Clinical Oncology 2016. All rights reserved.
 ASCO Guideline Panel Members
Member Affiliation
Betty R. Ferrell, PhD, Co-Chair City of Hope Medical Center, Duarte, CA
Thomas J. Smith, MD, FACP, FASCO, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University,
FAAHPM, Co-Chair Baltimore, MD
Erin R. Alesi, MD Virginia Commonwealth University Health System, Richmond, VA
Tracy A. Balboni, MD Dana-Farber Cancer Institute, Boston, MA
Ethan M. Basch, MD University of North Carolina, Chapel Hill, NC
Janice I. Firn, PhD, LMSW University of Michigan Health System, Ann Arbor, MA

Judith A. Paice, PhD, RN Northwestern University, Evanston, IL

Jeffrey M. Peppercorn, MD, MPH Massachusetts General Hospital, Boston, MA

Tanyanika Phillips, MD, MPH CHRISTUS St Frances Cabrini Hospital, Alexandria, LAS
Ellen L. Stovall, FASCO (Deceased), Patient
National Coalition for Cancer Survivorship, Silver Spring, MD
Representative
Florian Strasser, MD Cantonal Hospital, St. Gallen, Switzerland
Jennifer S. Temel, MD Massachusetts General Hospital, Boston, MA
Camilla Zimmermann, MD Princess Margaret Cancer Centre, Toronto, Canada
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 Disclaimer
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