Palliative Chemotherapy: When is it appropriate? - PowerPoint Presentation

Slide1

Palliative Chemotherapy: When is it appropriate?

Mariela Macias, M.D.

Slide2

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

Slide3

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.

Slide4

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

Slide5

What’s

palliative chemotherapy

?

Palliative Care:

Improve symptoms:

PainQuality of Life

Prolonged life

Not Curative

Oncology’s Perspective:Control DiseaseProlonged LifeTumor control/ shrinkageImprove Pain and QoLNot Curative

Improve Understanding of Disease, Options and Prognosis

Slide6

Palliative care vs. Hospice

Palliative

Hospice

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

Slide7

Models of Palliative Care:

_____ __ _________ ___

Slide8

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

Slide9

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 bedridden4 20-30 Bedridden

Slide10

80 year old male with metastatic NSCLC, ECOG 3-4, on 3th

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:

Slide11

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):426-9

Slide12

Scenario Changed: Palliative Care Appropriateness

If

Performance Status

0-2,

regardless of age

more likely to benefit in the NSCLC settingAble to keep oral intake, carry light activity, likely appropriate

If heavily pre-treated and PS 0-1

Phase I-II clinical trials

Slide13

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

Slide14

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

Slide15

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

Slide16

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

Slide17

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

Slide18

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. 2011 Sep 21;10:14.

Slide19

Overall Survival in Metastatic Cancer

Colorectal Cancer and Non Small Cell Lung Cancer

Bottom line:

Metastatic Cancer is heterogeneous

Slide20

Why the hesitancy for early referral?

Healthcare Provider barriers:

Eliminating hope

Difficulty in delivering “bad news”

Hesitancy in the name “palliative” vs. “supportive”

Slide21

Eliminating MD Preconceptions:

Eliminating Patients Hope:

Remain Honest with patients:

An informed decision is the best decision

End of life planning:

Finances, family, future treatmentsHope 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

Slide22

Other Physician Fears:

Hospice will reduce patient survival

Slide23

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

Slide24

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 prognosisMack, 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

Slide25

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

Slide26

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

Slide27

Certain Cancers Can Resemble Chronic Disease: Metastatic Breast Cancer

Slide28

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

Slide29

Palliative Care in Case 2:

Indicated? YES

patient may be having symptoms related to therapy

Anxiety of disease progression

Family dynamics

Slide30

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

Slide31

Barriers:

Lack of

interdisciplinary care:

Oncology & Palliative Approach in the Outpatient Setting

Outpatient Palliative Care Expansion- Needed

Late Referrals by OncologyMisunderstanding of Palliative Care roles by some providers

Slide32

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: 217-2243. 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

.

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

Slide33

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) 429-35  

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.

 

 

13. Siegel, Rebecca

et al.

Cancer Statistics 2012.

CA Cancer J

Clin

.

2012 Jan-Feb; 62(1):10-29.