Abstract ES11-4: Balancing active treatment and palliative care in ABC patients
Authors: Smith TJ 
Published: February 2018

Background: The benefits of concurrent palliative care (PC) started early (within 8 weeks of diagnosis) versus late (near end of life (EOL) are established such that ASCO recommends for all advanced cancer patients. (Ferrell, JCO 2017) Benefits include better quality of life (QOL), symptoms, depression, distress, care at the end of life, equal or lower cost, and equal or improved survival. These benefits can accrue to breast cancer patients. (Distelhorst SR. Lancet Oncol. 2015) However, there will never be enough PC specialists so we must do primary palliative care alongside our oncology.

Methods: Literature search.

Results: Concurrent PC can be applied to breast cancer patients like other cancer patients. To get the same results as on the randomized clinical trials (RCT), practice must change to duplicate the RCT methods. Remember, “Usual” oncology practice was the control group in all the RCTs and was inferior to oncology + palliative care. We recommend the TEAM approach (Smith TJ, JOP 2017): Time-an extra hour each month assessing symptoms, coping, distress, spirituality, prognostic awareness, advance care planning. This can be in person or virtual, but is essential. E-education about realistic options, prognosis, and ACP. A-formal assessments of symptoms (ESAS, MSAS-C, etc.), spirituality, coping, mood. M-management by a team of MD, APN, social worker and chaplain.

Some special considerations in mABC include the long journey with many potential treatments; the promise of immunotherapy (that realistically helps 10-20%); the young age of many patients; and the difficulty of discussing heart-breaking topics like ACP, EOL decisions, and DNR.

Suggestions: 1. Establish a close working relationship with trusted PC partners, and refer early. If late in the course, refer at least 3 months before expected death to allow the PC team to help with transitions, avoid EOL hospitalizations, and save over $5200. (Scibetta C. J Palliat Med. 2016) 2. To do PC in the office, remember these tips. At each visit, ask “How are you and your family coping?” At each scan or assessment, ask “Would you like to discuss what this means?” This allows them to control the information. Only 4 of 64 oncs discussed prognosis at CT visits (Singh S, JOP 2017) even when this is the right time, as you know the disease trajectory and future has changed. 3. Set up a hospice information visit when you think the person might have 6 months to live (“surprise question”) to ensure a planned transition to hospice under your direction with an average time of 30 days, rather than abandoning them to a new treatment team near EOL. 4. Learn PC tricks: duloxetine is the only drug besides opioids proven to help CIPN (Smith E, JAMA 2013) so don't start with gabapentin or pregabalin. Trial topical 1% menthol for CIPN (Fallon M, Supp Care Ca 2015). Ask “What is your understanding of your situation?” on a regular basis. (Leong, Shah, Smith JOP 2016) 5. Automatically refer to PC with the start of immunotherapy, or DNA analysis for targets, 3rd line chemo, any effusion or hypercalcemia. If available, utilize navigators to improve care and reduce spending and EOL hospitalizations. (Rocque GB Breast Cancer Res Treat. 2017)

I will illustrate how to use the TEAM method to integrate PC into our care.

Citation Format: Smith TJ. Balancing active treatment and palliative care in ABC patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr ES11-4.