FT. LAUDERDALE, FlaPalliative care, broadly defined, can
benefit cancer patients who are newly diagnosed and who are in active
treatment, as well as those who are near death. In creating
guidelines for palliative care, the National Comprehensive Cancer
Network (NCCN) Palliative Care Panel members found agreement on this
We didnt want this just to be end-of-life care,
said Michael Levy, MD, PhD, chair of the NCCN Palliative Care Panel.
Dr. Levy is medical director, Palliative Care Service, Fox Chase
Cancer Center, and assistant professor of medicine, Temple University.
The NCCN panel defined palliative care as comprehensive,
interdisciplinary care that maximizes patient and family quality of
life throughout the continuum of cancer.
In this model, elements of palliative care, especially symptom
control and psychosocial support, are expected to overlap with
curative treatment. When the risks of curative therapy outweigh the
benefits, palliative care becomes the primary mode of continuing
care. Palliative care continues after the patients death to
include bereavement support for family members.
The panel is in the process of creating the first NCCN treatment
guidelines for palliative care. Once it completes its task, the panel
would like to see the palliative care guidelines inserted into all
disease-specific guidelines. Palliative care should be included
in all the NCCN guidelines as a clear therapeutic intervention,
Dr. Levy said.
Dr. Levy, Susan Block, MD, chief of Adult Psychosocial Oncology,
Dana-Farber Cancer Institute, and Michael A. Carducci, MD, co-chair
of the Palliative Care Task Force at Johns Hopkins, reported on the
panels progress at the NCCNs Fifth Annual Conference.
The proposed NCCN guidelines will offer practical steps for
implementing palliative therapy throughout the course of treatment
for a cancer patient. Special emphasis will be placed on the
management of a patients final hours. This section will include
relief measures that often are not found in other guidelines, such as
the intentional use of sedation for the relief of refractory symptoms
in the imminently dying, Dr. Levy said.
Physicians will also be given suggestions for dealing with requests
for hastened death, which are often expressions of depression.
Physician-assisted suicide, recently legalized in Oregon, will not be
addressed in the guidelines, however. The first level of
intervention really needs to be access to excellent palliative care
for all patients throughout our country before we can get to the next
level of discussion about the appropriateness and ethical issues
involved in assisted suicide and euthanasia, Dr. Block said in
response to a question from the audience.
This kind of comprehensive approach presents challenges to writing
guidelines, panel members acknowledged. At times it even seems
resistant to the classic NCCN format, which begins with screening and
assessment and proceeds along step-by-step decision trees.
One of the more difficult decisions facing the palliative care panel
was determining at what point in the course of treatment should
oncologists begin screening patients for palliative care. When
do you pick up the palliative care guideline? Dr. Levy asked.
Two possible points for when to recommend palliative care screening
are under consideration. One possible entry point is when a patient
is expected to live only another 12 months or less. The other point
is whenever the patient faces a high expectation of cancer-related
death, even if that death is years away.
Panel members seemed to express their support for the second
approach. Ongoing discussions about fears of death and dying
need to be woven into ongoing practice and not just take place in the
context of DNR [do not resuscitate] discussions or
withholding/withdrawing treatment discussions with patients and
families, Dr. Block said.
Dr. Levy added: On average, 50% of the patients who have cancer
in this country are cured of their disease. But if we focus on the
subset of patients who get combined-modality therapy for advanced
disease, in fact the intent to cure is only 15%, and the cure rate,
the long-term remission rate, is about 7.5%. So really, more than 90%
of the patients that the average cancer center sees in active
anticancer disease therapy have a high expectation of cancer-related
death. The panel said it welcomed written comments from the
audience regarding this issue.
Oncologists can attend to palliative care issues early in their
treatment of a cancer patient by determining the patients
likelihood of death from cancer, determining the patients life
goals, and considering how further treatment will affect daily
With this knowledge of the individual patient, clinicians can develop
a palliative care plan. Such a plan is necessary, Dr. Carducci said,
because cancer patients will be sidetracked from taking care of
end-of-life issues if we are always focusing on the treatment of
Reflections at the End of Life
Good palliative care addresses the psychosocial and spiritual needs
of patients as well as their physical needs, Dr. Block said. When
death is near, many patients wish to reflect upon their lives and
attend to any unfinished emotional business. In addition to saying
good-bye to friends and family, patients may wish to repair troubled
relationships and create a legacy for those left behind.
Although not every patient undertakes this process, known as
life closure, good palliative care should be prepared to
help those patients who do, she said.
So what is the oncologists role? Dr. Block acknowledged that
facilitating life closure doesnt sound very
oncologic, but the panel felt it was an important issue.
Life closure provides a positive focus for the patient with
advanced illness and the family, and can be an antidote to
hopelessness, both for the patient and the clinician, Dr. Block
said. It allows patients to create meaning. They retain a sense
of purpose in the face of progressive disease if they have things to
do and tasks to accomplish.
Oncologists can help with life closure by focusing on the
patients goals for the time they have left and managing
physical and psychological symptoms to optimize their quality of
life. Since home is usually the best place to accomplish life closure
goals, the oncologist can help by enabling the patient to remain at
home, if that is desired, Dr. Block said.
Excellence in providing care to these very complex and ill
patients really requires an interdisciplinary team, Dr. Block
said. We are not expecting you as oncologists to do it
alone. An interdisciplinary team that includes a social worker,
chaplain, psychiatrist, and nurse as well as an oncologist, is going
to be able to best address all the needs of the patient and family,
Panel members agreed that more studies need to be done in the area of
palliative medicine and that research has been hampered by the
difficulties of measuring outcomes of palliative care. Because
of the lack of evidence so far, this is a really important area for
clinical research, Dr. Carducci said. I think it is going
to be quite rewarding.