As Dennis et al demonstrate, palliative care (PC) is a unique and multifaceted philosophy of care geared towards patients living with serious illness, not only those dying from it. At its core is a skill set that facilitates the systematic assessment and management of issues impacting patients' quality of life (QOL), including aggressive symptom management, assistance with transitions of care, formulation of goals of care, and psychosocial support for patients and their families.
Palliative care is a wide-ranging and flexible approach intended to reduce the physical, psychosocial, and existential burdens faced by people with life-threatening illness. It can be applied anywhere along the illness trajectory, becomes increasingly important as life shortens, and should transition to the end-of-life care model of “hospice care” at the appropriate time. In the United States, the terms “hospice” and “palliative care” are often used interchangeably. The conflation of these terms betrays a lack of understanding about the wider reach that PC can and should have in patients' lives. Emerging data highlight the potential value of palliative approaches earlier in the course of life-limiting disease, even alongside cancer chemotherapy.[1,2] As the oncology community increasingly advocates for PC as an integral component of comprehensive cancer care, we face difficult dilemmas regarding how to meet this important goal.
Current US models of healthcare delivery do not facilitate provision of PC outside of rather late-stage, end-of-life settings. Most PC provided to cancer patients is hospice care, which is generally for individuals who have either opted out of or are no longer candidates for cancer chemotherapy. Several factors make it unusual for hospices to offer anti-neoplastic therapies, including reimbursement rates and philosophy, even if the intent is entirely palliative. While the hospice subset of PC is indeed an incredibly important one, it is still just that: a subset. Hospice care is perhaps the most optimal way to deliver end-of-life care to dying patients, but current reimbursement models do not allow us to palliate those who are still living with cancer, rather than dying from it; these patients are far more numerous, and in significant need. The focus on very-late-stage management forces us to miss out on many opportunities to intervene sooner.
With few exceptions, current practice patterns and models of reimbursement do not allow us to serve cancer patients where they are most in need: in the community, while they are receiving cancer treatment. What is meant by “community”? As Kamal and colleagues describe, “Most [people needing PC] are living and receiving care ‘in the community,' that is, in their personal homes or other private homes, nursing homes, and retirement communities. Thus they confront the psychological, social, emotional, and spiritual issues related to advanced cancer, as well as burdensome cancer-related symptoms, in a context often far removed from a cancer center.” The important study by Temel and colleagues gives us a glimpse into the potential benefits of such an approach for a group of patients with newly diagnosed metastatic lung cancer. This model is one of co-management, wherein palliative assessment and management are built into the patient's experience within the cancer clinic. Until models of care delivery catch up to this science, such an approach will remain largely confined to the realm of research.
The many unmet needs of cancer patients within the community make the pursuit of offering optimal PC in this setting a necessity. To make this possible, however, several important issues must be addressed. First, reimbursement models must be modified to encourage and support community-based PC. Despite the many potential benefits of early PC in the cancer setting, it is unlikely to be possible in the community without sizeable changes to current reimbursement models. Pathways for referral must be also defined, to facilitate early yet appropriate involvement of PC professionals in patients' care, and to enable more collaborative work with oncologists. We also need a strategy for providing the necessary workforce to care for this added number of patients. This must include an expansion in the number of fellowship training programs, along with more targeted training regarding PC co-management of patients with oncologists. Lastly, ongoing research is needed. Although emerging data demonstrate that early PC yields significant improvements in the lives of cancer patients, comparatively little is known about specifically what should be included in PC services, and how and when to provide them. Further inquiry will help to identify the most critical components of PC and their best timing, and even how to apply them to other settings such as chronic heart or lung disease.
This is an incredibly exciting time for palliative medicine. How we face and respond to the challenges of PC delivery in the oncology setting will shape the landscape of comprehensive cancer care for years to come. No longer should we follow an ‘either/or' approach regarding cancer chemotherapy vs palliation; the time has come to work collaboratively, to enhance the services we provide, and to expand the sphere of influence of PC into the community, where cancer patients need us most (see Figure 1).
Financial Disclosure: The authors have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.