1. Palliative Care as a Strategy For Improving Quality and Fostering System Reform
Jeffrey Peppercorn, MD, MPH
Associate Professor of Medicine
Duke Cancer Institute

2. Definition of palliative care – Diane Meier, MD, Director, Center to Advance Palliative Care, Mt Sinai Hospital
Palliative care is specialized medical care for people with serious illnesses focused on providing patients with relief from the symptoms, pain, and stress of disease and treatment.
The goal is to improve quality of life for both the patient and family.
Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.
Palliative care can be provided together with curative treatment.”
Slide Courtesy of Tom Smith

3. Why is Palliative Care Part of Cancer Care
Why is Palliative Care Part of Cancer Care? High Symptom Burden Symptoms in Advanced Lung Cancer
4-6 months before death
0-3 months before death
70 patients with advanced lung cancer
The majority of patients had metastatic NSCLC.
The Lung Cancer Symptom Scale was used to assess symptom frequency.
Another study assessed symptom prevalence in cancer patients at the time of palliative care or hospice referral.
Of the lung cancer patients, 74% reported pain, with 51% experiencing moderate to severe pain.
Additional symptoms included: 46% dyspnea, 32% constipation, 14% nausea.
Loss of Appetite
Chest Pain
Fatigue
Cough
Dyspnea
Hemoptysis
Lutz, J of Pall Med (4)

4. High Burden on Family/Caregivers
40-70% report depression
Depression gets worse as patients status declines and they lose ability to perform normal activities
Rhee JCO 26 (36) 2008

5. Staus Quo: Lack of Realistic Conversations Perceptions of chance for CURE among patients with incurable cancer…
CanCORS Study
1,200 patients
Stage IV Lung or Colorectal on chemo
Asked: “How likely is cure”
3/4 of patients with incurable disease believe they can be cured….
This might impact decisions about what toxicity patients endure, how they spend their time, whether they pursue hospice.
Weeks NEJM 367 (17) 2012

6. Late Discussion of Hospice
Survey of U S Oncologists: Keating, Cancer Feb 15;116(4):
WHEN DO YOU DISCUSS HOSPICE?
“when there are no more treatment options”
~ 60% of Med Oncologists
“at the time of diagnosis of incurable disease”
~18% of Med Oncologists
50% of patients with lung cancer in U.S. have no discussion of hospice 2 months prior to death Huskamp HA, et al. Arch Intern Med May 25;169(10):954-62

7. CONTEXT
62 yo man with incurable Stage IV lung cancer spread to his bone, lung, and his liver.
He doesn’t have mutation suggesting a role for targeted therapy
He is treated on 1st line Carboplatin + taxol with a partial response, but after 5 months has progression of disease.
He now has shortness of breath, worsening pain, and fatigue
What are my options?
2nd Line therapy
Standard Rx
Clinical Trial
Palliative Care
Hospice

8. “Ideal” Care will vary by patient
Performance Status
Disease Directed Therapy
Research Participation
Symptom Focused Palliative Care
Preferences
Prior Rx
Goals
Comorbidity
Biomarkers
Family Support
Symptoms
Research Options

9. Cancer Care: What are we good at?
Obtaining imaging, labs, biopsies to make a diagnosis
Developing and implementing a treatment plan for the disease
Often with toxic chemotherapy
Increasingly with molecularly targeted agents
Emerging immune mediated agents
Discussing and planning next treatment when the cancer gets worse

10. Cancer Care: What are we less good at?
Managing symptoms of disease
Identifying and managing side effects of treatment
Having realistic conversations about prognosis
Discussing the full range of options for care, including integration of palliative care and disease directed care, or of palliative care alone
Discussing end of life care and death

11. WHY?
We train cancer specialists in management of disease (breast cancer) not in management of symptoms (nausea, fatigue).
Financial incentives reward action: give chemo, perform surgery…. Not talking
Its hard to talk about treatments not working and its hard to talk about death

12. Just Because Something is hard, does not mean we shouldn’t do it…
Philae probe successfully lands on comet 300 million miles away
- Nov 12th, 2014
We can probably have honest conversations…..

13. The Rationale to Integrate Palliative Care with Cancer Care
Many cancers are incurable
Patients, and their families, suffer as a result of disease and treatment
Discussions of goals of care & focus on QOL often occur late, if ever
When asked, patients often want more focus on palliative care

14. Discussing Prognosis and Preferences impacts care and QOL
Coping With Cancer Study:
332 patients with advanced cancer, 7 clinical centers
ONLY 37% report discussing EOL preferences
Discussing EOL was NOT associated with depression or anxiety
Discussing EOL DID lead to less aggressive care, more hospice
Aggressive care (ED, ICU, chemo in last weeks) associated with:
Worse Quality of Life
Higher risk for depression among caregivers
Earlier hospice associated with better patient and caregiver QOL
Wright, JAMA 2010

15. + Societal Imperative…. Most spending on cancer in the U. S
+ Societal Imperative….Most spending on cancer in the U.S. occurs in the Last Year of Life
Age > 65 years
The bulk of cost falls within the first year and the last year of life
Huge cost in last year of life, points to opportunities for cost savings
Mariotto t Al. J Natl Cancer Inst 2011; 103:

16. Total Medicare Spending (patients >65):
We are spending a lot without giving some patients what they need, and giving others what they don’t want….
FACT 1: We spend too much on futile care
FACT 2: We often do this, without giving patients what they want
Many with incurable cancer never discuss their preferences
When they do, they often choose symptom management over disease directed care.
Opportunity to improve care AND reduce costs….
Total Medicare Spending (patients >65):
~ 500 Billion (2010…)
1/3 on Last Year of Life:
~ 165 billion
40% on Last 30 Days :
~ 66 billion
12% of US Budget
2% of US Budget!
~ 2x NIH Budget…
Ramsey et al, JNCI 2013

17. Potential Benefits of Early Palliative Care
Improve QOL
Improve understanding  Informed choices
Reduce futile care
Chemo within weeks of death, death in ICU/hospital
Improve allocation of healthcare resources
Spend $ on high value care, research to find cure?
Improve survival?

18. A better Model?: Integrating Palliative and Oncology Care
Slide Courtesy of Jennifer Temel

19. Palliative Care in Randomized Trials
Home PC vs. standard care in homebound terminally ill patients
Improved patient satisfaction and quality of life
Decreased use of ER and Hospital
Brumley J Am Ger Soc. 2007
PC vs. standard in patients with poor prognosis chronic illness
PC improved shortness of breath, anxiety, sleep, well-being
Rabow, Arch Int Med 2004
RCT: Hospital PC vs. standard in patients with terminal illness
Increased use of hospice, decreased ICU care
Gade, J Palliative Med 2008

20. Improved quality of life, fewer symptoms, and less depression
Project ENABLE:
Palliative Care Outreach + standard Oncology Care
“Educate, Nurture, Advise, Before Life Ends”
RCT in 322 rural patients with advanced cancer: intervention vs. standard care
4 weekly telephone educational sessions + monthly f/u by nurse
41% GI, 36% lung, 12% GU, 10% breast
Improved quality of life, fewer symptoms, and less depression
. Bakitas M, et al. Project ENABLE. JAMA 2009

21. Proof of Principle for Early Palliative Care
Temel, NEJM, 2010

22. Study Design RANDOMIZED
Meet with palliative care within 3 weeks of signing consent and at least monthly thereafter
RANDOMIZED
Early palliative care integrated with standard oncology care
150 patients with newly diagnosed metastatic NSCLC
Baseline Data Collection
Meet with palliative care only when requested by patient, family or oncology clinician.
Standard oncology care
Within 8 wks of diagnosis
ECOG PS 0-2
English speaking
Receiving care at MGH
Not already receiving palliative care
Patients who have an understanding of their life expectancy are participate in ACP are more likely to accept hospice at the EOL. Thus providing more comprehensive support for patients throughout the course of their disease may not only benefit their current health status but also allow for a more timely transition to hospice care. Integrated oncology and palliative care can bridge the gap between cancer-directed and comfort-oriented therapies in advanced cancer patients.
PC provided by MD or NP in Cancer Center on day of clinic visits with med onc, rad onc, or surgery
Patients admitted to hospital also followed by PC team
Temel, NEJM, 2010 22

23. Palliative Care Visits Early Palliative Care (N=77)
How many visits?
Palliative Care Visits by 12-weeks
Palliative Care Visits
Standard Care (N=74)
N (%)
Early Palliative Care (N=77)
None
64 (87%)
1 (1)* 1
7 (9%) 2
3 (4%)
8 (10%) 3
18 (23%) 4
26 (34%)
> 5
24 (31%)
* Died within 2 weeks of enrollment
88% 3 or more
11% 1-2 visits
Temel, NEJM, 2010

24. Early palliative care + standard oncology care improved survival by almost 3 months vs. usual oncology care! Temel J, et al. NEJM 2010; Greer J, et al. JCO 2011
Longer and better survival
Better understanding of prognosis
Less IV chemo in last 60 days
Less aggressive end of life care
More and longer use of hospice
Lower costs of care
AND improved QoL, Less Anxiety and Depression, - Temel JCO 2011

25. The American Society of Clinical Oncology now recommends “…combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”
Smith TJ, et al. J Clin Oncol Mar 10;30(8):880-7.

26. AAHPM Choosing Wisely Task Force and ASCO Choosing Wisely Converging on how to achieve HIGH VALUE CARE 2. Don’t delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment. 
Slide Courtesy of Tom Smith

27. Access to Palliative Care: Growing Rapidly
> 5,700 registered hospitals in U.S.

28. Access to Palliative Care?: Not Everywhere
Only 60% of Hospitals nationwide had palliative care programs as of 2012
Center to Advance Palliative Care, 2012 Report Card

29. Some Challenges Behavior Change SCIENCE
What are the most important aspects of palliative care?
Is the survival benefit reproducible? Seen in other cancers?
Need more research focused on symptom management
Care Delivery
How is it best delivered? Separate team? Oncology Office?
How do we offer this to all patients?
Reimbursement for symptom management and care planning?
Behavior Change
Are patients interested? Do they know what they are missing?
Are Physicians receptive to this?
How do we educate patients and oncologists regarding benefits