Download 14. Palliative Chemotherapy

Palliative Chemotherapy: When
is it appropriate?
Mariela Macias, M.D.
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
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.
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
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
Palliative care vs. Hospice
Palliative
Hospice
• Can be implemented at all
stages of disease
• End of life care
• Active concurrent cancer
treatment can have a role
• Disease Modifying measures
• Usually active cancer
treatment not appropriate
• Not disease modifying, natural
progression
Models of Palliative Care:
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
Performance Scales
ECOG
Karnofsky
Definitions
0
1
2
100
80-90
60-70
3
40-50
Asymptomatic
Symptomatic, fully ambulatory
Symptomatic, in bed less than 50%
of the day
Symptomatic, in bed more than
50% of the day, but not bedridden
4
20-30
Bedridden
CASE 1:
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?
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
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
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
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
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
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
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
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.
Overall Survival in Metastatic Cancer
Colorectal Cancer and Non Small Cell Lung Cancer
20
18
16
14
12
10
Supportive
8
Chemo
6
4
2
0
CRC
NSCLC
Bottom line: Metastatic Cancer is heterogeneous
Why the hesitancy for early referral?
• Healthcare Provider barriers:
▫ Eliminating hope
▫ Difficulty in delivering “bad news”
▫ Hesitancy in the name “palliative” vs. “supportive”
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
Other Physician Fears:
Hospice will reduce
patient survival
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
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
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
CASE 2:
• 55 year old F diagnosed with stage
III invasive ductal carcinoma
ER/PR+ at age 44, received neoadjuvant 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
Certain Cancers Can Resemble Chronic
Disease: Metastatic Breast Cancer
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
Palliative Care in Case 2:
• Indicated? YES
▫ patient may be having symptoms related to
therapy
▫ Anxiety of disease progression
▫ Family dynamics
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
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
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.
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
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.