One-Step Screening Tool Identifies Patients Needing Palliative Care

Researchers have developed a one-step screening tool to help oncology providers identify cancer patients with complex palliative care needs who may benefit from referral to a palliative care specialist.

In the study, researchers created an 11-point questionnaire with scores ranging from 0–14 that was then validated by a panel of palliative care experts. They administered the tool to a group of patients at Memorial Sloan Kettering Cancer Center in New York, and compared the results with data obtained from a previous study of screening and referral at the same center based on a National Comprehensive Cancer Network (NCCN) guideline.

Using the simplified tool, about one-third of patients qualified for referral to a palliative care specialist based on a score of 5 or more. That’s twice as many as occurred when oncologists relied on subjective judgment. In addition, scores were higher for patients who were closer to death or who had more pain and other symptoms. The results are published in the Journal of Oncology Practice.

Although the NCCN guideline already recommends palliative care screening for cancer patients, the process is complex, the authors wrote. In addition to a checklist of 24 physical or psychosocial problems, the guideline calls for performing an evaluation covering six domains: pain; psychological distress; comorbid physical and psychosocial conditions; treatment options; concerns about disease course; and prognosis.

In contrast, the simplified tool covers five clinical areas, including extent of disease, performance status prognosis, comorbidities, and palliative care-specific problems.

“At a time when workforce issues in both oncology and palliative care are becoming more pressing, this is an important tool for busy oncologists to have at their disposal,” the authors said. “Its scoring system provides clinicians with a means to identify which of their large volume of patients should be considered for palliative care referral.”

Although the screening tool could help promote earlier integration of palliative care, its use has significant workforce implications, the authors noted. They estimated that approximately half of the 1.5 million patients diagnosed in the United States with cancer each year would score 5 or more at an initial visit, resulting in the need for about 400 additional full-time palliative care specialists.

Nurses and oncologists have expressed concerns about the accuracy and reliability of the scoring system because many items are subjective or vaguely defined, according to the study. The authors suggested addressing those concerns by creating an electronic version of the tool that would be populated with clinical data from the electronic health record, supplemented with information from patients and families.

Another potential concern is that too many patients would automatically score 5 or more as a result of having metastatic disease and an Eastern Cooperative Oncology (ECOG) performance status (PS) of 3. However, the authors cautioned against using the screening score as an automatic trigger for consult.

“It should prompt the oncologist to consider a palliative care consult if he or she has not already done so and discuss this with the patient and family,” they said. “Nevertheless, as a group, patients with metastatic cancer and an ECOG PS of 3 have a survival typically measured in a small number of months and increasing symptom burden and distress, so it is likely that a palliative care specialist would be able to assist in the care of many of these patients.”