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September 2017 VOL 8, NO 9
Plea for Straight Talk and Early Palliative Care
“Collusion in communication is a big issue in oncology,” stated Mellar Davis, MD, Director of Palliative Care Services at the Geisinger Medical Center in Danville, PA. Dr Davis spoke at the 2017 Annual Meeting of the Multinational Association of Supportive Care in Cancer (MASCC). “It is the elephant in the room.”
For purposes of his talk, Dr Davis identified collusion as an unconscious agreement between the patient and clinician that provokes unreflective behavior and strong emotions and leads to a negative impact on cancer care. Elements of collusion include concealing the actual prognosis, having cancer-centered goals (as opposed to patient-centered goals), and using nonspecific terms that mislead the patient to suppose the treatment is curative. Collusion leads to a failure to address the future in terms of advanced directives and personal goals of the patient and leads to misuse of therapies beyond established benefits.
When collusion is present, communication is flawed, and patients with advanced cancer have unrealistic treatment expectations. Under these circumstances, patients have little autonomy and miss opportunities to plan for the future. Initiating early palliative care, which is one approach to avoiding collusion, can reduce the costs of treatment and lead to better patient-centered care.
“The trajectory of palliative oncology includes an existential crisis at diagnosis, then a focus on anticancer therapy, with peace of mind for the patient if the disease is stabilized. Another crisis occurs at relapse, and then there is the final crisis of facing a terminal illness,” explained Dr. Davis. Collusion minimizes the limits of antitumor therapy and the toxicity of treatments in discussions with patients and leads to continuing anticancer therapy when it will not extend life—just to provide false hope to the patient. This approach negates the patient and focuses only on the cancer.
“Watchful waiting is given little attention. Patients are offered treatment to make them think they will get better. This is fostered by medical activism. The patient may be relieved because the oncologist is recommending ‘antitumor’ therapy,” Dr. Davis explained. “Hope is no longer a verb—it becomes a noun. Hope is the next treatment for the patient.”
Several studies have shown that many patients with incurable cancer do not understand that palliative care is unlikely to cure cancer. In one study, only one-third of patients with incurable cancer realized that the treatment they were receiving was not going to cure their cancer. Patients who did understand that the therapy was unlikely to work entered palliative care earlier.
Collusion leads to loss of autonomy for the patient. One unintended result of collusion is that patients are relieved that the oncologist is giving them treatment and may neglect making appropriate plans for the future based on the actual trajectory of their disease.
“Misdirection occurs both ways,” Dr. Davis said. Physicians fail to communicate goals of therapy, and patients fail to comprehend that their cancer is fatal. Oncologists may deliver aggressive care at end of life, leading to increased admission to the intensive care unit and emergency department. Dying patients are not referred to hospice, and then bereavement becomes even more complicated.
Training oncologists on how to communicate the true prognosis to a patient with terminal cancer are one way to prevent collusion. Instituting early palliative care will help patients have realistic goals and better quality of life (QOL). Also, consistent use of symptom checklists and QOL tools can bring objectivity to discussions. Oncologists need to have discussions with patients about advanced directives, reshaping conversation away from cancer-centered goals to patient-centered goals. Mindfulness training can also be helpful, Dr. Davis said.
Dr. Davis went on to discuss the benefits of early palliative care, barriers to implementation, and financial toxicity from inappropriate end-of-life care.
Early Palliative Care
Palliative care can be delivered in the hospital according to the acute-care model late in the course of cancer, or an oncologist can provide palliation in settings where there is no palliative care specialty. The congress model provides multidisciplinary palliative services, including pain referrals, psychological services, a chaplain, and social worker. Specialist palliative care can be integrated into cancer care as a standard for the treatment of advanced cancer.
A landmark study found that early institution of palliative care led to improved QOL, less depression, reduced aggressive end-of-life care, and a 3-month improvement in overall survival (N Engl J Med. 2010;363:733-742).
Early palliative care provides continuity for the patient and rests on cooperation and collaboration between specialists and the oncologist. It should be available and embedded in outpatient clinics, delivered on top of usual care by a multidisciplinary team. Early palliative care also provides expert symptom management, enhances patient autonomy and patient understanding about goals of therapy and prognosis, and allows preferred decision-making and advanced care planning in a supportive environment.
Barriers to Early Palliative Care
Funding is a major barrier. A recent MASCC survey showed that although respondents overwhelmingly agreed that palliative care benefited oncology patients, only about 17% of cancer centers surveyed were willing to devote budgets to early palliative care (Support Care Cancer. 2015;23:2677-2685). Also, only a limited number of trained palliative specialists are available.
The field of cancer is focused on new drugs, and these drugs are approved based on efficacy rather than cost. These include targeted therapies and immunotherapies. Oncologists are largely unaware of the per incremental cost-effectiveness ratio (ICER) of quality-adjusted-life-year (QALY) for new drugs. The costs of newer drugs are unacceptable, and the bar has been set very high.
“Some people would accept $180,000 per ICER QALY,” he said. “Drug value should move from market to ICER-based standards.”
Early palliative care is cost-effective. Adopting early palliative care instead of aggressive end-of-life care and use of new expensive drugs could bring large cost savings to institutions, “particularly with bundling and value-based care,” Dr. Davis stated.
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