Supportive care and palliative care: a time for unity in diversity
Authors: Matti S. Aapro
Journal: Annals of Oncology (2012)

This issue of Annals of Oncology highlights a number of articles that deal with topics related to the supportive and palliative care of cancer patients. What is the difference between these two aspects of patient care? Where does ‘palliation’ end or ‘support’ start? This has been an area of debate for a long time, but as in all subspecialties of oncology, one has to realize that there is a continuum. Today’s management of patients with cancer is of a multidisciplinary nature, a fact exemplified by the bi-annual European Multidisciplinary Cancer Care Conference. Historical reasons have led to the development of specialist groups that have dedicated their expertise more towards issues frequent at the end of life (often called palliative care) or more towards issues around treatment management and post-treatment issues (supportive care). According to the Multinational Association for Supportive Care in Cancer, supportive care is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side-effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship and end-of-life care are integral to supportive care. Supportive care alleviates symptoms and complications of cancer, reduces or prevents toxic effects of treatment, supports communication with patients about their disease and prognosis, allows patients to tolerate and benefit from active therapy more easily, eases emotional burden of patients and caregivers, helps cancer survivors with psychological and social problems [1.MASCCwww.mascc.org 10 June 2012, date last accessedGoogle Scholar].The European Society for Medical Oncology (ESMO) has recognized the importance of these approaches for a long time, and one of its key programs is its designated centers of Integrated Oncology and Palliative Care. Any oncology department or cancer center can apply: size is not important; to be eligible what matters are the quality and the extent of the integration of services. The criteria for accreditation are based on recommendations of the World Health Organization guidelines on the provision of palliative care for patients with cancer, and reflect the issues of integration, credentialing, service provision, research and education. The main objectives of the program are promoting the integration of palliative care services into the existing national cancer care guidelines, encouraging palliative care education and training for medical oncologists as well as other healthcare professionals, expanding the cooperation between ESMO and other existing professional medical associations and organizations worldwide in supporting and sustaining palliative care development [2.ESMOhttp://www.esmo.org/education-research/designated-centers-of-integrated-oncology-and-palliative-care.html 6 June 2012, date last accessedGoogle Scholar].Further, ESMO has dedicated its 2011 handbook to Nutrition and Cancer [3.ESMO Handbook of Nutrition and Cancer ESMO.2011http://www.esmo.org/education-research/handbooks.htmlGoogle Scholar], and as a final reference to ESMO’s recognition of the area of supportive and palliative care one should mention the various ESMO clinical practice guidelines [4.Pavlidis N. Stahel R. Hansen H. Cervantes A. Fourteen years of evolution of ESMO Guidelines: from the minimum recommendations to the consensus conference-derived guidelines.Ann Oncol. 2011; 22: vi7-vi11Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar], which are intended to provide the user with a set of recommendations for the best standards of cancer care, based on the findings of evidence-based medicine. There are presently nine guidelines for supportive and palliative care, and the one on prevention of nausea and vomiting is a nice example of collaboration with a society specifically dedicated to supportive care [5.Roila F. Herrstedt J. Aapro M. et al.ESMO/MASCC guidelines working group. Guideline update for MASCC and ESMO in the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting: results of the Perugia consensus conference.Ann Oncol. 2010; 21: v232-v243Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar].The word used to designate this activity is not trivial. Obviously translations in various languages and cultures render the discussion even more complex [6.Chin J.J. Ho C.W. Arima H. et al.Integration of palliative and supportive cancer care in Asia.Lancet Oncol. 2012; 13: 445-446Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar], but for several years there has been a negative perception of palliation, as if it was synonymous with patient abandonment by the ‘active’ treatment team. As indicated above, the reality is that supportive and palliative and ‘active’ are a continuum where each has a role to play at a particular moment of the patient's itinerary. In 2009, colleagues from the MD Anderson Cancer Center discussed that referrals to palliative care tended to occur late in the trajectory of illness [7.Fadul N. Elsayem A. Palmer J.L. 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; 115: 2013-2021Crossref PubMed Scopus (253) Google Scholar]. It was hypothesized that the perceived association between the name palliative care and hospice was a barrier to early patients' referral. They conducted a survey among a random sample of 100 medical oncologists and 100 midlevel providers from The University of Texas MD Anderson Cancer Center. A total of 140 of 200 (70%) participants responded (74 midlevel providers and 66 medical oncologists). More participants preferred the name supportive care (80%, 57%) compared with palliative care (27%, 19% P < 0.0001). Medical oncologists and midlevel providers stated increased likelihood to refer patients on active primary (79% versus 45%, P < 0.0001) and advanced cancer (89% versus 69%, P < 0.0001) treatments to a service-named supportive care. The name palliative care compared with supportive care was perceived more frequently by medical oncologists and midlevel providers as a barrier to referral (23% versus 6% P < 0.0001), decreasing hope (44 vs 11% P < 0.0001) and causing distress (33% versus 3% P < 0.0001) to patients and their families. Medical oncologists and midlevel providers much more preferred the name supportive care and stated more likelihood to refer patients on active primary and advanced cancer treatments to a service-named supportive care.As a follow-up to this study, the team changed the name of the unit. The result was remarkable. In a study of records of 4701 consecutive patients with a first palliative care consultation before and after the name change they found: (i) a 41% greater number of palliative care consultations (1950 versus 2751 patients; P < 0.001), mainly as a result of a rise in inpatient referrals (733 versus 1451 patients; P < 0.001), and (ii) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio (HR), 0.85; P < 0.001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; P < 0.001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; P < 0.001) [8.Dalal S. Palla S. Hui D. et al.Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center.Oncologist. 2011; 16: 105-111Crossref PubMed Scopus (185) Google Scholar]. The name change to supportive care was thus associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitated earlier access to supportive/palliative care and we can agree with the authors that it should be established in more centers.In line with this observation, this issue of Annals of Oncology carries a study that reports on the positive impact of early access to a palliative/supportive care intervention on pain management in patients with cancer [9.Bandieri E. Sichetti D. Romero M. et al.Impact of early access to a palliative/supportive care intervention on pain management in patients with cancer.Ann Oncol. 2012; 23: 2016-2020Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. This is a multicenter cross-sectional study carried out in 32 Italian hospitals including 1450 patients receiving analgesic therapy for cancer pain. Statistically significant differences in the analgesic drug administration according to the care model were found: non-opioids were more frequently used in a standard care (SC) setting (9.5% versus 2%; P < 0.001), while strong opioids were introduced more frequently in the early access to a palliative/supportive care (ePSC) group (80% versus 63%; P < 0.0.001). The number of patients with severe pain was lower in the ePSC group compared with the SC group (31% versus 17%; P < 0.0.001).One has to finally mention the recent interest in palliative care as a means to support patients and have an impact on survival, an interest sparked by the publication of a study evaluating patients with advanced non-small-cell lung cancer, which reported that early palliative care in these patients improves the quality of life, mood, and survival despite less aggressive end-of-life care compared with standard oncology care alone [10.Temel J.S. Greer J.A. Muzikansky A. et al.Early palliative care for patients with metastatic non-small-cell lung cancer.N Engl J Med. 2010; 363: 733-742Crossref PubMed Scopus (4872) Google Scholar].The American Society of Clinical Oncology (ASCO) is to be commended for having published a provisional clinical opinion on the topic [11.Smith T.J. Temin S. Alesi E.R. et al.American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care.J Clin Oncol. 2012; 30: 880-887Crossref PubMed Scopus (961) Google Scholar]. This balanced review of the available evidence (seven randomized, controlled trials) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care concludes that survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings but substantial evidence demonstrates that palliative care—when combined with standard cancer care or as the main focus of care—leads to better outcomes in patients and caregivers. Therefore, it was the ASCO panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.However, as mentioned by the ASCO committee, ESMO had already stated in 2003 [12.Cherny N.I. Catane R. Kosmidis P. ESMO takes a stand on supportive and palliative care.Ann Oncol. 2003; 14: 1335-1337Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar] that ‘since most cancer patients receive their cancer care in dedicated clinics or hospitals, it is imperative that these facilities provide an adequate supportive and palliative care infrastructure as part of the global service. Key tasks of supportive and palliative care provision in the cancer center include the screening of cancer patients to identify patients with specific needs, and the provision of real-time supportive and palliative care interventions as part of routine cancer care.’ This was already a call for unity in diversity. This issue of Annals of Oncology highlights a number of articles that deal with topics related to the supportive and palliative care of cancer patients. What is the difference between these two aspects of patient care? Where does ‘palliation’ end or ‘support’ start? This has been an area of debate for a long time, but as in all subspecialties of oncology, one has to realize that there is a continuum. Today’s management of patients with cancer is of a multidisciplinary nature, a fact exemplified by the bi-annual European Multidisciplinary Cancer Care Conference. Historical reasons have led to the development of specialist groups that have dedicated their expertise more towards issues frequent at the end of life (often called palliative care) or more towards issues around treatment management and post-treatment issues (supportive care). According to the Multinational Association for Supportive Care in Cancer, supportive care is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side-effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship and end-of-life care are integral to supportive care. Supportive care alleviates symptoms and complications of cancer, reduces or prevents toxic effects of treatment, supports communication with patients about their disease and prognosis, allows patients to tolerate and benefit from active therapy more easily, eases emotional burden of patients and caregivers, helps cancer survivors with psychological and social problems [1.MASCCwww.mascc.org 10 June 2012, date last accessedGoogle Scholar]. The European Society for Medical Oncology (ESMO) has recognized the importance of these approaches for a long time, and one of its key programs is its designated centers of Integrated Oncology and Palliative Care. Any oncology department or cancer center can apply: size is not important; to be eligible what matters are the quality and the extent of the integration of services. The criteria for accreditation are based on recommendations of the World Health Organization guidelines on the provision of palliative care for patients with cancer, and reflect the issues of integration, credentialing, service provision, research and education. The main objectives of the program are promoting the integration of palliative care services into the existing national cancer care guidelines, encouraging palliative care education and training for medical oncologists as well as other healthcare professionals, expanding the cooperation between ESMO and other existing professional medical associations and organizations worldwide in supporting and sustaining palliative care development [2.ESMOhttp://www.esmo.org/education-research/designated-centers-of-integrated-oncology-and-palliative-care.html 6 June 2012, date last accessedGoogle Scholar]. Further, ESMO has dedicated its 2011 handbook to Nutrition and Cancer [3.ESMO Handbook of Nutrition and Cancer ESMO.2011http://www.esmo.org/education-research/handbooks.htmlGoogle Scholar], and as a final reference to ESMO’s recognition of the area of supportive and palliative care one should mention the various ESMO clinical practice guidelines [4.Pavlidis N. Stahel R. Hansen H. Cervantes A. Fourteen years of evolution of ESMO Guidelines: from the minimum recommendations to the consensus conference-derived guidelines.Ann Oncol. 2011; 22: vi7-vi11Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar], which are intended to provide the user with a set of recommendations for the best standards of cancer care, based on the findings of evidence-based medicine. There are presently nine guidelines for supportive and palliative care, and the one on prevention of nausea and vomiting is a nice example of collaboration with a society specifically dedicated to supportive care [5.Roila F. Herrstedt J. Aapro M. et al.ESMO/MASCC guidelines working group. Guideline update for MASCC and ESMO in the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting: results of the Perugia consensus conference.Ann Oncol. 2010; 21: v232-v243Abstract Full Text Full Text PDF PubMed Scopus (583) Google Scholar]. The word used to designate this activity is not trivial. Obviously translations in various languages and cultures render the discussion even more complex [6.Chin J.J. Ho C.W. Arima H. et al.Integration of palliative and supportive cancer care in Asia.Lancet Oncol. 2012; 13: 445-446Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar], but for several years there has been a negative perception of palliation, as if it was synonymous with patient abandonment by the ‘active’ treatment team. As indicated above, the reality is that supportive and palliative and ‘active’ are a continuum where each has a role to play at a particular moment of the patient's itinerary. In 2009, colleagues from the MD Anderson Cancer Center discussed that referrals to palliative care tended to occur late in the trajectory of illness [7.Fadul N. Elsayem A. Palmer J.L. 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; 115: 2013-2021Crossref PubMed Scopus (253) Google Scholar]. It was hypothesized that the perceived association between the name palliative care and hospice was a barrier to early patients' referral. They conducted a survey among a random sample of 100 medical oncologists and 100 midlevel providers from The University of Texas MD Anderson Cancer Center. A total of 140 of 200 (70%) participants responded (74 midlevel providers and 66 medical oncologists). More participants preferred the name supportive care (80%, 57%) compared with palliative care (27%, 19% P < 0.0001). Medical oncologists and midlevel providers stated increased likelihood to refer patients on active primary (79% versus 45%, P < 0.0001) and advanced cancer (89% versus 69%, P < 0.0001) treatments to a service-named supportive care. The name palliative care compared with supportive care was perceived more frequently by medical oncologists and midlevel providers as a barrier to referral (23% versus 6% P < 0.0001), decreasing hope (44 vs 11% P < 0.0001) and causing distress (33% versus 3% P < 0.0001) to patients and their families. Medical oncologists and midlevel providers much more preferred the name supportive care and stated more likelihood to refer patients on active primary and advanced cancer treatments to a service-named supportive care. As a follow-up to this study, the team changed the name of the unit. The result was remarkable. In a study of records of 4701 consecutive patients with a first palliative care consultation before and after the name change they found: (i) a 41% greater number of palliative care consultations (1950 versus 2751 patients; P < 0.001), mainly as a result of a rise in inpatient referrals (733 versus 1451 patients; P < 0.001), and (ii) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio (HR), 0.85; P < 0.001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; P < 0.001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; P < 0.001) [8.Dalal S. Palla S. Hui D. et al.Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center.Oncologist. 2011; 16: 105-111Crossref PubMed Scopus (185) Google Scholar]. The name change to supportive care was thus associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitated earlier access to supportive/palliative care and we can agree with the authors that it should be established in more centers. In line with this observation, this issue of Annals of Oncology carries a study that reports on the positive impact of early access to a palliative/supportive care intervention on pain management in patients with cancer [9.Bandieri E. Sichetti D. Romero M. et al.Impact of early access to a palliative/supportive care intervention on pain management in patients with cancer.Ann Oncol. 2012; 23: 2016-2020Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. This is a multicenter cross-sectional study carried out in 32 Italian hospitals including 1450 patients receiving analgesic therapy for cancer pain. Statistically significant differences in the analgesic drug administration according to the care model were found: non-opioids were more frequently used in a standard care (SC) setting (9.5% versus 2%; P < 0.001), while strong opioids were introduced more frequently in the early access to a palliative/supportive care (ePSC) group (80% versus 63%; P < 0.0.001). The number of patients with severe pain was lower in the ePSC group compared with the SC group (31% versus 17%; P < 0.0.001). One has to finally mention the recent interest in palliative care as a means to support patients and have an impact on survival, an interest sparked by the publication of a study evaluating patients with advanced non-small-cell lung cancer, which reported that early palliative care in these patients improves the quality of life, mood, and survival despite less aggressive end-of-life care compared with standard oncology care alone [10.Temel J.S. Greer J.A. Muzikansky A. et al.Early palliative care for patients with metastatic non-small-cell lung cancer.N Engl J Med. 2010; 363: 733-742Crossref PubMed Scopus (4872) Google Scholar]. The American Society of Clinical Oncology (ASCO) is to be commended for having published a provisional clinical opinion on the topic [11.Smith T.J. Temin S. Alesi E.R. et al.American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care.J Clin Oncol. 2012; 30: 880-887Crossref PubMed Scopus (961) Google Scholar]. This balanced review of the available evidence (seven randomized, controlled trials) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care concludes that survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings but substantial evidence demonstrates that palliative care—when combined with standard cancer care or as the main focus of care—leads to better outcomes in patients and caregivers. Therefore, it was the ASCO panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. However, as mentioned by the ASCO committee, ESMO had already stated in 2003 [12.Cherny N.I. Catane R. Kosmidis P. ESMO takes a stand on supportive and palliative care.Ann Oncol. 2003; 14: 1335-1337Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar] that ‘since most cancer patients receive their cancer care in dedicated clinics or hospitals, it is imperative that these facilities provide an adequate supportive and palliative care infrastructure as part of the global service. Key tasks of supportive and palliative care provision in the cancer center include the screening of cancer patients to identify patients with specific needs, and the provision of real-time supportive and palliative care interventions as part of routine cancer care.’ This was already a call for unity in diversity.