1. Supportive Oncology 2011: Living Better and Longer with Integrated Palliative Care Jason R. Beckrow, DO Hospice and Palliative Care Specialist Board Certified Medical Oncologist

2. Disclosure Conflicts of interest-None I am employed by: – Hospice at Home, St. Joe & South Haven, Michigan – Lighthouse Oncology - South Haven, Michigan

3. Objectives At the completion of this lecture the learner will understand: – Integrated palliative care is synonymous with quality cancer care. – Recent research demonstrates that cancer patients receiving early/integrated palliative care experience greater quality of life and improved survivorship over patients with late or no palliative care interventions.

4. Case Study Alvern B. – 78 yo male – Metastatic NSCLCA James B – 69 yo male – Metastaic NSCLCA

5. Palliative Care Defined Person centered care for patients of all ages who are experiencing a debilitating or life threatening illness, condition or injury. The goal of palliative care is to prevent and relieve suffering, including pain and psychosocial distress. Palliative care is both a philosophy and an organized structure of health care delivery.

6. Supportive Oncology The goal of supportive oncology is to alleviate the suffering associated with: – Cancer Diagnosis Emotional/Psychological Spiritual/Existential Physical – Cancer Treatment Side Effects Sustain and improve quality of life Duke Cancer Care Research Program Duke University Health System

7. Conceptual model for integration of palliative and supportive care in oncology. Bruera E, Hui D JCO 2010;28:4013-4017 ©2010 by American Society of Clinical Oncology

8. Conventional Care PresentationPresentationDeathDeath Anti-disease Therapy Bereavement Care 6m6m Hospice Care

9. Palliative Care Therapies to modify disease Hospice Medicare Benefit Presentation Therapies to relieve suffering and/or improve quality of life Bereavement Care 6mDeath

10. Model of palliative cancer care. Ferris F D et al. JCO 2009;27:3052-3058 ©2009 by American Society of Clinical Oncology

11. The use of a car is an analogy for setting goals of care. Bruera E, Hui D JCO 2010;28:4013-4017 ©2010 by American Society of Clinical Oncology

12. (A) A hopeful and unrealistic patient focuses on cancer cure and life-prolongation measures, without paying attention to her symptoms and advance care needs. Bruera E, Hui D JCO 2010;28:4013-4017 ©2010 by American Society of Clinical Oncology

14. 150 patients with newly diagnosed metastatic NSCLC Early palliative care integrated with standard oncology care Standard oncology care Baseline Data Collection RANDOMIZEDRANDOMIZED Study Design Meet with palliative care within 3 weeks of signing consent and at least monthly thereafter Meet with palliative care only when requested by patient, family or oncology clinician.

15. Early Palliative Care Study Procedures Palliative Care Guidelines Illness understanding and education Inquire about illness and prognostic understanding Offer clarification regarding treatment goals Distress Management Symptom management Pain Pulmonary symptoms Fatigue and sleep disturbance Mood Gastrointestinal Decision-making Assess mode of decision-making Assist with treatment decision-making Coping with life-threatening illness Patient Family/family caregivers www.nationalconsensusproject.org

16. Distress Management Are We Missing Something Here?

17. Patients Reported Oncology Teams Often Do Not Consider psychosocial care as a part of their patients’ cancer care Understand their psychosocial needs, know about resources, or refer when needed President’s Cancer Panel 2003, 2004

20. Community Oncology Offices Cancer-Free Survival Managed Chronic or Intermittent Disease Treatment Failure Treatment with Intent to Cure Palliative Care Diagnosis and Staging Death Where majority of cancer care is given today Where fewest psychological and social services available

21. What patients want to know about their disease Patients say they want to know the truth…. – Of 126 terminally ill patients, 98% said they wanted their oncologists to be realistic. (Hagerty 2005) – Honesty associated with compassion and caring. – Patients want oncologists to be compassionate, stay the course, and be truthful. (Kirk 2004) About 5-10% will not want to know. Reviewed in Matsuyama R, Reddy S, Smith T. JCO 2006; Harrington & Smith JAMA 2008

22. What patients know about their disease Matsuyama R, Reddy S, Smith T. JCO 2006 35 small cell lung cancer patients learned more about their prognosis from other patients than their doctors (The et al, WJM 2001) – Doctors did not want to give a death sentence – Patients did not want to hear it

23. What patients know about their disease Perspective of those facing death… Matsuyama R, Reddy S, Smith T. JCO 2006 We routinely overestimate prognosis to patients with serious illness – Meta- analysis: 30-40% overestimate of time left (Glare 2003) – Best study of hospice: doctors overestimated to patients by 5.1: 1 (Christakis and Lamont) – We don’t like to give bad news (Lamont 2002)

24. Panagopoulou, E. et al. J Clin Oncol; 26:1175-1177 2008 Why don't we bring up the "D" word? It hurts…us. Task: Tell a 26 year old woman she has inoperable brain tumor, live less than 2 years. Randomized to 3 options: 1. Disclose complete information about diagnosis, prognosis, and treatment. 2. Conceal the true diagnosis, but still refer the patient for treatment. 3. Interview about dietary habits. (control)

25. What patients know about their disease Perspective of those facing death… Matsuyama R, Reddy S, Smith T. JCO 2006 Solid tumor patients who are over (falsely or un- realistically)-optimistic don’t live any longer (Weeks et al, JAMA 1998; Smith & Swisher JAMA 1998) But are more likely to – Die in ER – Die in ICU – Die on vent – Be readmitted with complications

26. Hope is maintained even with truthful discussions that teach RR, PFS, OS, chance of cure, and transitions. Smith TJ, et al. Oncology, 2010. Herth Hope Index Values Before and After Educational Intervention 0 5 10 15 20 25 30 35 40 45 50 BeforeAfter

27. Study Objectives Primary Objective: Measure the difference in QOL between the two study arms at 12 weeks. Secondary Objectives: 1.Psychological distress at 12 weeks 2.Quality of end-of-life care 3.Resource utilization at the end-of-life 4.Documentation of resuscitation preference in the medical record

28. Study Eligibility 1.Metastatic NSCLC diagnosed within the previous 8 weeks. 2.ECOG performance status 0-2. 3.Ability to read and respond to questions in English. 4.Planning to receive oncology care at the participating institution.

29. Effect of Early PC on 12-week Psychological Distress p=0.01 p=0.66 p=0.04

30. Standard care Survival Analysis Months Overall survival Median Survival Early palliative care 11.6 mo Standard care 8.9 mo p=0.02 Early palliative care Controlling for age, gender and PS, adjusted HR=0.59 (0.40-0.88), p=0.01

31. Summary Compared with standard oncology care, integrated palliative care led to: – Improvements in QOL – Lower rates of depression – Less aggressive care at the end-of-life – Greater documentation of resuscitation preferences – Higher survival rates

32. Lighthouse Oncology Supportive Oncology Consultation Initial Consultation: – Metastatic and Locally Advanced Patients – All Performance Status – Prior to initiation of Chemotherapy – Interventions per National Consensus Project Follow Up – Q 2-6 weeks – Interventions per National Consensus Project

33. Early Palliative Care Study Procedures Palliative Care Guidelines Illness understanding and education Inquire about illness and prognostic understanding Offer clarification regarding treatment goals Distress Management Symptom management Pain Pulmonary symptoms Fatigue and sleep disturbance Mood Gastrointestinal Decision-making Assess mode of decision-making Assist with treatment decision-making Coping with life-threatening illness Patient Family/family caregivers www.nationalconsensusproject.org

34. Case Study Alvern B. – 78 yo male – Metastatic NSCLCA – Chemotherapy – Supportive Care – Time with Family – ICU or Home James B – 69 yo male – Metastaic NSCLCA – Chemotherapy – Supportive Care – Long and Short term goal setting. – Garden

35. Thank You Eduardo Burrera, MD Charles van Gunten, MD Jimmie Holland, MD T. J. Smith, MD. Jennifer Temel, MD Lawrence Feldman, MD George Drake, MD Chris Strayhorn, M Div MD Steve Dupuis, DO Linda Beushausen, RN, PhD Eric Lester, MD Sean O’Neill, PhD Questions?