Thomas J. Smith, MD

Cancer-related fatigue is a common, albeit complex, symptom experienced by many cancer patients. Identification of fatigue and assessment of its severity should be a part of routine office care and can be performed using simple, one-question screening tools.

We review here the recommendations of the American Society of Clinical Oncology, as well as some new and promising approaches to neuropathy, including new neuromodulation techniques.

If we can successfully initiate advance care planning discussions with our patients and families, their end-of-life processes will improve, resulting in better care, less use of the hospital, and more honoring of newly discerned choices.

To place responsibility for rationing chemotherapeutics on the oncologist not only increases his or her emotional burden, but it also strains the doctor-patient relationship. We should not allow oncologists to become bedside healthcare rationers simply because no one else wants to do the job.

In this podcast we discuss integrating palliative care into standard oncology care with Thomas J. Smith, director of palliative medicine at Sidney Kimmel Comprehensive Cancer Center.

This article addresses the practical application of palliative care (PC) in the outpatient oncology setting.

Oncologists often do not give honest prognostic and treatment-effect information to patients with advanced disease, trying not to “take away hope.” The authors, however, find that hope is maintained when patients with advanced cancer are given truthful prognostic and treatment information, even when the news is bad.

The use of the term "futility" in cancer care has been prompted, in part, by increasing requests from patients for treatments thought to be ineffective as well as costly.[1] The appropriate role of chemotherapy near the end of life is a complex issue.[2]

Twenty years of research in controlling symptoms such as pain andnausea have shown persistent suboptimal performance by the US oncologysystem. The data suggest that some of the tools of palliative careprograms can improve physical symptoms of seriously ill patients at acost society can afford. To fix these problems will require recognitionof the symptoms or concerns, a system such as an algorithm or careplan for addressing each, measurement of the change, and accountabilityfor the change. Symptom assessment scales such as the EdmontonSymptom Assessment Scale or Rotterdam Symptom Check List work tomake symptoms manifest. Listing symptoms on a problem list is a necessarystep in addressing them. Physical symptoms such as pain can beimproved by use of computer prompts, algorithms, dedicated staff time,team management, or combinations of these strategies. Less concreteproblems such as medically appropriate goal-setting, integrating palliativecare into anticancer care sooner, and informing patients aboutthe benefits and risks of chemotherapy near the end of life require morecomplex solutions. We review what is known about symptom control inoncology, how and why some programs do better, and make suggestionsfor practice. Finally, we suggest a practical plan for using symptomassessment scales, listing the problems, and managing them accordingto algorithms or other predetermined plans.

Dr. Cherny’s article on the managementof cancer pain is acomprehensive review thatshould prove to be a helpful resource.As physicians in a palliative care andoncology program, we discuss howwe utilize these principles and whatwe see put into practice by others.Cherny and Catane have already documentedthat the great majority ofoncologists do a substantial amountof palliative care, whether they call itthat or not, and that most oncologistswould be willing to work with palliativecare or symptom managementspecialists.[1] Knowledge is only onepart of the solution, and must be pairedwith better practice by health-care professionalsand help from our patients.Articles like this will only help if oncologistspay attention.

Only a few studies have assessed the economic outcomes of palliative therapy. The major areas of interest include hospice care, the process and structure of care, symptom management, and palliative chemotherapy

In 1985, a survey found that only about one-third of physicians and oncology nurses would have consented to chemotherapy for non-small-cell lung cancer. In response to statements made at a recent American Society of Oncology (ASCO) Board of Directors meeting questioning whether these data are still valid, Dr. Smith and colleagues conducted a new survey of oncologists attending a 1997 National Comprehensive Cancer Network (NCCN) annual meeting. The results of that survey are summarized and analyzed.

The costs and relative cost-effectiveness of different treatments for common illnesses are an increasing concern. New treatments for advanced non-small-cell lung cancer are having an impact. However, these treatments vary markedly in their direct financial costs, toxicity, and quality-of-life profiles. Direct comparisons between most combination regimens are not yet completed. Vinorelbine (Navelbine) is the first new agent approved in the United States for the treatment of metastatic non-small-cell lung cancer in more than a decade. We previously reported results of a post-hoc economic analysis that compared the anticipated cost-effectiveness of three regimens used to treat non-small-cell lung cancer (vinorelbine alone versus vinorelbine plus cisplatin [Platinol] versus vindesine plus cisplatin, the assumed standard treatment in Europe). Results showed that vinorelbine plus cisplatin was the most effective regimen. Using vinorelbine alone as a baseline, vinorelbine plus cisplatin added 56 days of life at an additional cost of $2,700, resulting in a cost-effectiveness ratio of $17,700 per year of life gained. Similarly, vindesine plus cisplatin added 19 days of life at a cost of $1,150, or $22,100 per year of life gained. Compared to vindesine plus cisplatin, vinorelbine plus cisplatin added 37 days of life at a cost of $1,570, or $15,500 per year of life gained. We conclude that the incremental cost-effectiveness of the vinorelbine plus cisplatin regimen was less than most commonly accepted medical interventions. If vinorelbine is preferred because of its favorable toxicity profile, the additional effectiveness of cisplatin added substantial efficacy at an acceptable cost.[ONCOLOGY(Suppl 4):14-17, 1998]

Research shows that chemotherapy for inoperable non-small-cell lung cancer (NSCLC) improves survival. The economic implications of this treatment choice may be substantial. This paper reviews studies examining the cost-

We easily believe that which we wish.-Pierre Corneille (1606-1684)

The 1992 metaanalysis of adjuvant therapies after surgery in early breast cancer summarizes the most extensively studied of all cancer treatments via randomized controlled trials. This study found overall benefits with use of adjuvant therapies, and their expanded use outside the clinical trial setting was assumed to be effective and implied to be cost effective. Thus, the primary remaining questions are which form of adjuvant therapy to use and how to identify which patients are unlikely to benefit. In British Columbia, the effectiveness of adjuvant therapy outside the clinical trial setting was reassuringly similar to the metaanalysis efficacy. Our decision analysis model of hypothetical cohorts of women with early breast cancer confirmed that the efficacy of adjuvant treatment is the primary determinate of its incremental cost effectiveness. Future cost-effectiveness and quality of life assessments should move from hypothetical cohorts assessed via models to prospective data collected within clinical trials or integrated health delivery system. [ONCOLOGY 9(Suppl):129-134, 1995]

Medical College of Virginia-Virginia Commonwealth University, and Virginia Commonwealth University School of Health Administration.