The review by Alesi et al attempts to answer an important question in real clinical practice: Is it better to refer patients directly to hospice when aggressive treatments have stopped working or rather to integrate palliative care (PC) earlier in the course of a patient’s disease? As a busy practicing oncologist and the medical director of a hospice in a dense urban setting, I am constantly challenged to decide when is the best time to start utilizing the unique PC resources that I have at my disposal. Although cancer patients are living longer and options for aggressive medical treatment are more numerous than they have ever been in the history of oncology practice, we must recognize that supportive care can play just as great a role as our chemotherapies. In fact, a recent article by Temel et al in the New England Journal of Medicine indicates that early PC in patients with lung cancer improves quality of life and less aggressive PC treatments could lead to a longer survival.
In Alesi et al, several models are presented of integrated PC alongside or within oncology clinical practices. Of note, all of the models were implemented at academic centers, with the exception of the US Oncology site that was a private oncology clinic. Unfortunately it would be unrealistic for any of the models at academic sites to be utilized in private practice, simply due to the fact that the lack of reimbursement would not support the additional staff. Many oncology practices are already cutting back on staff and services in the face of declining Medicare reimbursement. The most applicable model for community oncologists is the US Oncology business-centered model. In this model, an independent PC practice consisting of a PC attending and fellow were embedded in a private oncology practice. The majority of practicing private community oncologists already devote a significant amount of time to end-of-life issues and symptom palliation, even without officially being involved with a hospice service or PC team. In the US Oncology model, aside from the primary goal of offering a higher level of care to patients, it appears that a secondary benefit was a time savings for the referring oncologist. So, I agree with the authors that this may be evidence that an embedded integrated PC practice could translate into a relative cost savings if the referring oncologist uses this additional time to see more oncology patients.
In all of the models, integrated PC did seem to have a positive impact on symptom management. As addressed by Alesi et al, however, one clear advantage of a hospice referral is that an interdisciplinary team becomes immediately involved in patient care. This hospice team consists of professionals from medicine, nursing, and social work, as well as chaplains/spiritual advisors and bereavement counselors. Involvement of these professionals can be instrumental in comprehensively addressing patient suffering; furthermore, as Dr. Cicely Saunders describes, the concept of total pain includes not just physical pain, but also social, psychological, and spiritual pain. In my experience, these “non-clinical” team members are often critical in alleviating psychosocial pain experienced by the patient and the family. In families at risk for complicated grief, oftentimes, a patient’s physical pain is only one of many issues that contributes to his or her overall suffering. In all of the models mentioned by Alesi et al, a full interdisciplinary team was not immediately available, although the VCU model probably came closest to providing all of the above interdisciplinary specialties. Unfortunately, as most oncologists will attest, psychosocial pain can arise at any time, early or late, usually from the moment patients are told they have a diagnosis of cancer. I believe the lack of a full interdisciplinary team is a critical shortcoming that will limit the potential effectiveness of any integrated PC model.
Many of the models described by the authors, and their review of randomized trials in the literature, showed that integration of PC into oncology care provides a total cost savings to the healthcare system related to reduced ED visits, lower hospital charges, and a shorter inpatient length of stay. The VCU model described by the authors unfortunately did not provide or study any of the potential financial benefits of integrated PC in this regard. This important information would be helpful in demonstrating any financial advantages of early palliative care and would be the only realistic hope of gaining more supporters of PC. Somehow, the lower medical costs associated with early PC need to be clearly demonstrated so that the additional resources and funding necessary for a full PC team would be justified.
For oncologists in private practice, it is clear that integrated PC is a work in progress. A business-centered model with an embedded PC team is the most feasible approach. There may be significant shortcomings, but for patients there seems to be a direct benefit. Indeed, the ideal model would involve a full interdisciplinary PC team from the moment of diagnosis, with the oncologist and PC physician working in concert handling different aspects of patient care. This would create a seamless transition of care from the curative to the palliative. Sadly for the private oncologist, from a financial standpoint, this ideal is not possible in today’s current medical economic environment. Further work still needs to be done in terms of public awareness and government support. Until integrated PC is more recognized as an essential component of oncology practice, both clinically and financially, its true potential remains to be realized.
Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.