1. Palliative Chemotherapy: When is it appropriate? Mariela Macias, M.D.

2. Goals and Objectives Role of Palliative care – Palliative Care’s Perspective – Oncologist perspective – Comparison with Hospice Cases Patient Preferences – Barriers Physician Barriers to Early Referrals Moving Forward

3. US Cancer Statistics: 2012 Estimated Cancer Deaths: 577K 1:4 individuals will die from CA Lung, Colon Cancer, Breast & Prostate cause most CA deaths Lifetime probability of Cancer ▫Male 45% ▫Female 38% Siegel, Rebecca et al. Cancer Statistics 2012. CA Cancer J Clin. 2012 Jan-Feb; 62(1):10-29.CA Cancer J Clin.

4. Bottom-line: There is a growing need to incorporate early palliative care into cancer care 90% of outpatient palliative referrals are from oncology services: – But when do they come? Johnson et al. JOURNAL OF PALLIATIVE MEDICINE. 2011. 14 (4) 429-35

5. What’s palliative chemotherapy? Palliative Care: ▫Improve symptoms:  Pain  Quality of Life  Prolonged life ▫Not Curative Oncology’s Perspective: ▫Control Disease  Prolonged Life  Tumor control/ shrinkage  Improve Pain and QoL ▫Not Curative Improve Understanding of Disease, Options and Prognosis

6. Palliative care vs. Hospice PalliativeHospice Can be implemented at all stages of disease Active concurrent cancer treatment can have a role Disease Modifying measures End of life care Usually active cancer treatment not appropriate Not disease modifying, natural progression

7. Models of Palliative Care: _____ __ _________ ___ _____ __ _________ ___

8. Core Values of Palliative Care: Based on Patient Values Symptom control Communication: ▫Physician Patient Family Explaining prognosis/expectations Acknowledging Patient Preferences ▫Autonomy Focusing on the whole person vs. disease

9. Performance Scales ECOG Karnofsky Definitions 0 100 Asymptomatic 1 80-90 Symptomatic, fully ambulatory 2 60-70 Symptomatic, in bed less than 50% of the day 3 40-50 Symptomatic, in bed more than 50% of the day, but not bedridden 4 20-30 Bedridden

10. 80 year old male with metastatic NSCLC, ECOG 3-4, on 3 th line chemotherapy, symptoms no longer improving with palliative chemotherapy. Cc: “ I just want to die” The family and oncologists are pressing forward with chemotherapy options, ….What do you do? CASE 1:

11. Understanding why this patient is inappropriate for Palliative Chemotherapy Performance status= ECOG 3-4 (unable to perform ADLS independently) Cachexia-Anorexia Syndrome (unable to eat or maintain weight) Received multiple prior chemotherapy treatments Short life expectancy without benefit of survival nor palliation of symptoms (more toxicities) Sanchez-Munoz, A et al. Limited Impact of palliative chemotherapy on survival in advanced solid tumours in patients with poor performance status. Clin Transl Oncol. 2011 Jun;13(6):426-9Clin Transl Oncol.

12. Scenario Changed: Palliative Care Appropriateness If Performance Status 0-2, regardless of age more likely to benefit in the NSCLC setting Able to keep oral intake, carry light activity, likely appropriate If heavily pre-treated and PS 0-1  Phase I-II clinical trials

13. FEW Exceptions to the rule of NOT giving Palliative chemotherapy on Patients with ECOG 3-4: Chemotherapy naïve (new diagnosis) and highly chemotherapy responsive tumor ▫Testicular Cancer ▫Small Cell Cancer ▫Most Aggressive Lymphomas

14. Case 1: Highlights Individual Less Likely to Utilize Palliative Services Characteristics Associated with less utilization: ▫Males ▫Lung Cancer Patients ▫Less Educated ▫Actively getting treatment Kumar et al. JOURNAL OF PALLIATIVE MEDICINE. 2012. Volume 15(8): 923-30

15. Patient Barriers to Incorporating Palliative Care Patient Reported Barriers: ▫No MD referral ▫No Awareness * Those two reasons accounted for almost 50% of the barriers Kumar et al. JOURNAL OF PALLIATIVE MEDICINE. 2012. Volume 15(8): 923-30

16. Aggressive Care at the End of Life: Younger Age Higher performance status Use of Surrogate decision makers Non-White patients Maida, Vincent et al. Preferences for active and aggressive interventions among patients with advanced cancer. 2010. BMC. 10:592

17. So how about the 80 year-old patient? Focus on understanding his comment ▫What is most bothersome? Expectations and Goals Is the treatment making his life better or worse? Advocate for what the patient wants: ▫Bring the key-players on board with patient’s goals

18. Our Patient: Case 1 No additional benefit of chemotherapy at the end of life ▫2 month improvement in overall survival when not initiated 2 wks before death ▫When initiated at end of life, median survival ≈ 30 days Chemotherapy at end of life 30% less likely to enter palliative care services Chemotherapy initiated at 14 days of death not reimbursed as incentive to decrease misuse BMC Palliat Care.BMC Palliat Care. 2011 Sep 21;10:14.

19. Overall Survival in Metastatic Cancer Colorectal Cancer and Non Small Cell Lung Cancer Bottom line: Metastatic Cancer is heterogeneous

20. Why the hesitancy for early referral? Healthcare Provider barriers: ▫Eliminating hope ▫Difficulty in delivering “bad news” ▫Hesitancy in the name “palliative” vs. “supportive”

21. Eliminating MD Preconceptions: Eliminating Patients Hope: ▫Remain Honest with patients:  An informed decision is the best decision  End of life planning:  Finances, family, future treatments Hope is not eliminated when delivering bad news Mack, Jennifer et al. Reasons why Physicians Do not Have Discussions About Poor Prognosis, Why it matters and What Can Be Improved.2012. JCO. 30(22): 2715-2717

22. Other Physician Fears: Hospice will reduce patient survival

23. Benefits of Adding Palliative Care Services to Metastatic Cancer Care: Improved: ▫ Overall survival in NSCLC= 2.6 months (11.6 months vs. 8.9 months, P=0.02). ▫Depressive symptoms (16% vs. 38%, P=0.01) in NSCLC ▫Quality of Life ▫Patient satisfaction ▫Pain scores ▫Decreased utilization of Aggressive End of life Care Temel JS et al. Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer. N Engl J Med. 2010. 363(8)733-42

24. One Preconception is true: Delivering Bad News is hard! Stressful for MD: ▫67% of Oncologist prefer end of life care planning when all treatments have been exhausted ▫Bad news:  Does NOT:  Eliminate Hope  Shorten life  Improve patient satisfaction:  About 90% of patients want to know their prognosis Mack, Jennifer et al. Reasons why Physicians Do not Have Discussions About Poor Prognosis, Why it matters and What Can Be Improved.2012. JCO. 30(22): 2715-2717

25. Overcoming a Reputation: Palliative vs. Supportive Care Oncology Providers ▫57% preferred supportive vs. 29% ▫ 79% vs. 45% would consider referring metastatic oncology patients on active treatment if called: “Supportive” vs. “Palliative” Bottom-line: ▫Educating on the role of Palliative Care may improve patient’s access to care Fadul, Nada et al. Supportive versus Palliative Care: What’s in the Name? 2009. Cancer. 115:2013-21

26. CASE 2: 55 year old F diagnosed with stage III invasive ductal carcinoma ER/PR+ at age 44, received neo- adjuvant chemotherapy, 5 years of tamoxifen, at age 49 the patient was having shoulder pain and metastatic lesions were noted in shoulder blade  bx proven ER/PR IDC  started on fulvestrant until age 53  new lesion seen in the liver  stopped Fulvestrant  postmenopausal  bx ER/PR IDC  started on letrozole coming in for 6 month follow up

27. Certain Cancers Can Resemble Chronic Disease: Metastatic Breast Cancer

28. CASE 2: Progression 55 year old ECOG 0, highly functional, postmenopausal female living with known metastatic BCA for 6 years now with three liver lesions and increasing bone lesions Decision is made to start capecitabine until trial becomes available

29. Palliative Care in Case 2: Indicated? YES ▫patient may be having symptoms related to therapy ▫Anxiety of disease progression ▫Family dynamics

30. TAKE HOME POINTS: There is a role for Concurrent Active Cancer Treatment and Palliative Care Services improve: Understanding Physician/Patient Barriers can improve utilization of multidisciplinary care: Transitioning to Outpatient Palliative Care Services may improve early utilization Palliative Care Involvement in Tumor Boards may help improve a multidisciplinary approach

31. Barriers: Lack of interdisciplinary care: Oncology & Palliative Approach in the Outpatient Setting Outpatient Palliative Care Expansion- Needed Late Referrals by Oncology Misunderstanding of Palliative Care roles by some providers

32. References 1. Colla, CH et al. Impact of payment reform on chemotherapy at the end of life. J Oncol Pract. 2012. May 8 (3) e6s-e13s 2. Chen, Yiqun et al. Survival of metastatic colorectal cancer patients treated with chemotherapy in Alberta (1995-2004). Support Care Center (2010) 18: 217-224 3. Chew, Min Hou et al. Stage IV Colorectal Cancers: An Analysis of Factors Predicting Outcome and Survival in 728 Cases. J Gastrointestinal Surg (2012) 16:603-612. 4. Doyle, C et al. Does Palliative chemotherapy palliate? Evaluation of expectations, outcomes, and costs in women receiving chemotherapy for advanced ovarian cancer: J Clin Oncol. 2001 Mar 1;19(5):1266-74.J Clin Oncol. 5. Fadul,N et al. Supportive versus palliative care: what's in a name?: a survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer. 2009 May 1;115(9):2013-21 6. Kumar et al. Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access. J Palliat Med.. 2012. Volume 15(8): 923-30

33. References… 7. Temel JS et al. Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer. N Engl J Med. 2010. 363(8)733-42 8. Johnson, C et al. Australian general practitioners’ and oncology specialists’ perceptions of barriers and facilitators of access to specialist palliative care services. J Palliat Med. 2011. 14 (4) 429-35J Palliat Med. 9. Mack, Jennifer et al. Reasons why Physicians Do not Have Discussions About Poor Prognosis, Why it matters and What Can Be Improved.2012. JCO. 30(22): 2715-2717 10. Maida, Vincent et al. Preferences for active and aggressive interventions among patients with advanced cancer. 2010. BMC. 10:592 11. Saito, AM et al. The Effect on Survival of continuing chemotherapy to near death. BMC Palliat Care. 2011. Sep 21:10:14 12. Sanchez-Munoz, A et al. Limited Impact of palliative chemotherapy on survival in advanced solid tumors in patients with poor performance status. Clin Transl Oncol. 2011 Jun;13(6):426-9.Clin Transl Oncol. 13. Siegel, Rebecca et al. Cancer Statistics 2012. CA Cancer J Clin. 2012 Jan-Feb; 62(1):10-29.CA Cancer J Clin.