Supportive and Palliative Care in Cancer Patients

The term "supportive oncology" refers to those aspects of medical careconcerned with the physical, psychosocial, and spiritual issues facedby persons with cancer, their families, their communities, and their healthcareproviders. In this context, supportive oncology describes both those interventionsused to support patients who experience adverse effects caused by antineoplastictherapies and those interventions now considered under the broad rubric of palliativecare. At its core, palliative care is concerned with providing the maximumquality of life to the patient/family unit.Definitions and Evolution
In 1990, the World Health Organization (WHO) published a landmark document,Cancer Pain Relief and Palliative Care, that clearly defined the internationalbarriers and needs for improved pain and symptom control in the cancer patient.The WHO defined palliative care as[1]:...the active total care of patients whose disease is not responsive to curativetreatment. Control of pain, of other symptoms, and of psychological, social andspiritual problems is paramount. The goal of palliative care is achievement ofthe best quality of life for patients and their families. Many aspects of palliativecare are also applicable earlier in the course of illness in conjunction withanti-cancer treatment.In 1995, the Canadian Palliative Care Association chose a somewhat broaderdefinition that emphasizes a more expanded role of palliative care by combining itwith curative therapy[2]:Palliative care, as a philosophy of care, is the combination of active andcompassionate therapies intended to comfort and support individuals andfamilies who are living with a life-threatening illness. During periods of illnessand bereavement, palliative care strives to meet physical, psychological, socialand spiritual expectations and needs, while remaining sensitive to personal,cultural and religious values, beliefs and practices. Palliative care may becombined with therapies aimed at reducing or curing the illness, or it may bethe total focus of care.Clearly, palliative care has developed into a recognized discipline. In theUnited States, palliative care is rapidly evolving in parallel with a well-establishedhospice model. The US version of hospice remains a critically important part of thisbroader approach to palliative care, which attempts to help patients and theirfamilies deal with quality-of-life issues throughout the trajectory of illness, evenwhen treatment has curative intent. Palliative care is an emerging health-carespecialty with national boards, newly accredited fellowships in 2004, and NationalConsensus Clinical Practice Guidelines[3]; it is an important part of the medicalcommunity's response to the needs of patients and families throughout the trajectoryof serious and life-threatening illness-relief from their suffering, even whilethey receive therapies aimed at curing their cancer.Ending the Either/Or Dilemma: A Multidisciplinary Approach
Just as health is more than the absence of illness, so too is palliative care muchmore than the absence of disturbing symptoms. The fundamental mission ofpalliative care undoubtedly reflects the underpinnings of Dame Cicely Saunders,who pioneered the coordinated an interdisciplinary approach of physical, emotional,and spiritual symptom management at the end of life. However, since theintroduction of this philosophy of care in the United States, end-of-life hospice/palliative care has been driven by the restrictions dictated by the bureaucracy ofMedicare reimbursement regulations, life expectancy projections, and the unilateralchoice of services based on "either" often-fragmented curative aggressivetreatment "or" coordinated interdisciplinary comfort care. Although the literaturereports that there is high patient and caregiver satisfaction with the interdisciplinaryapproach to end-of-life care and symptom management, statistics reveal thatthese restrictions have significantly impacted willingness to utilize this scope ofservices, as patients would be required to make the "either/or" decision that oftencompromises their need to retain hope for cure or prolonged prognosis.All health-care clinicians have the ethical responsibility to "first do no harm"by alleviating the patient's burden of the dilemma of having to choose eitheraggressive treatment or comfort care, and hence physically supporting their needfor hope-something that is so vital to human existence. Humanism in health carecan be initiated by integrating palliative care into mainstream medicine, both withingeneral practice and across all specialty settings. Valuing quality-of-life symptommanagement should not occur just at the end of life, but should be aggressivelyimplemented from the onset of chronic disease diagnosis and throughout every daythat the patient lives with the illness that may eventually lead to death.Throughout the disease trajectory a patient requires both "high-tech" and"high-touch" care. This multidimensional and interdisciplinary approach meetsclinical, scientific, and functional needs with compassion. Integrating palliativecare with curative disease-oriented therapy requires a focus on communication andcollaboration with the primary treatment team. The concept of a palliative careteam can be valued as an extension of the primary team. This collaboration is bestestablished by frequent direct contact with the primary treating team and consistenthands-on bedside teaching. Back-to-basics "bedside care" establishes a sense ofphysical presence, provides the opportunity to teach by example, enhances continuityof care for the patient, and helps to diminish an adversarial or competitivefeeling between consultative and treating teams. All parties attain a sense ofcontribution and the patient benefits by the comprehensive coordination of care.The essence of palliative care is to provide a "win-win"forum, whereby the patientreceives optimum symptom management to ensure quality of life, and the primaryteam members concentrating on the cancer itself feel supported during the chosentreatment regime throughout the patient's disease trajectory.Fundamental Patient Concerns
Even when cancer can be effectively treated and a cure or life prolongation isachieved, there are always physical, psychosocial, or spiritual concerns that mustbe addressed to maintain functions and optimize quality of life. For patients wherecancer cannot be effectively treated, palliative care must be the dominant modeand one must focus intensively on the control of distressing symptoms. Planningfor the end of life and ensuring that death occurs with a minimum of suffering andin a manner consistent with the values and desires of the patient and family arefundamental elements of this care.A recent commentary in the Journal of the American Medical Associationdiscussed the inadequacy of clinical education and the need to better preparepractitioners to treat chronic disease.[4] Palliative care, when integrated with thecurative model, helps to ensure the continuity and integration of care that is soessential to the patient and family suffering with a cancer diagnosis. Palliative care,as a desired approach to comprehensive cancer care, is appropriate for all healthcaresettings, including the clinic, acute care hospital, long-term care facility, orhome hospice. Clinicians and health-care environments throughout the UnitedStates have viewed palliative care as being specifically for pain or end-of-life care.This is a critical barrier that must be overcome. Palliative care is clearly not only forpain or end-of-life care.In this special issue of ONCOLOGY, an attempt has been made to discussseveral important symptoms that an individual may experience during the course oftheir cancer trajectory. These symptoms include depression, delirium, fatigue, andpain. Clearly, this special issue is only a beginning-an introduction to a small partof palliative care. An individual with cancer can experience many different physical,psychological, social, and spiritual symptoms. The goal of palliative care is tohelp relieve all of these symptoms: to relieve suffering and improve quality of life.The vision is to successfully balance a humanistic, bedside-oriented, holistic philosophyof care and combine it with a rigorous scientific curative approach.Palliative care is best able to help integrate high-tech and high-touch care for anindividual with cancer.
The strength of palliative care includes the following aspects:

• Interdisciplinary assessment, intervention, and collaboration to improvequality of life during aggressive treatment
• Integration of complementary modalities to treat physical, emotional, andspiritual suffering
• Intervention not limited to pain management or end-of-life care
• Optimal outcomes achieved by early initiation and continued implementationthroughout the disease trajectory
• Aggressive research and palliative care treatment modalities that share andrespect parallel pathways to seek cure, maximize quality of life, and restore hopewithin the realism of the patient's situation
• A multidimensional approach that meets clinical, scientific, and functionalneeds with compassion

Conclusion

There are many promising new cancer treatments on the horizon. No matterwhat these new treatments will offer in terms of curing the disease or prolonginglife, cancer will remain a devastating illness not only for the affected patients, butfor their families, community, and heath-care providers. Excellent palliative careshould not be restricted exclusively to the dying. It is paramount that this paradigmbe extended from the onset of a chronic illness throughout the disease trajectoryuntil death. The goal needs to be on living with good symptom management, notjust a "good death."

Disclosures:

The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1.

World Health Organization: Cancer Pain Relief and Palliative Care. Technical ReportSeries 804. Geneva, World Health Organization, 1990.

2.

Canadian Palliative Care Association: Palliative Care: Towards a Consensus in StandardizedPrinciples and Practice. Ottawa, Ontario, Canadian Palliative Care Association, 1995.

3.

National Consensus Project: Clinical Practice Guidelines for Quality Palliative Care.Brooklyn, New York, 2004. www.nationalconsensusproject.org

4.

Holman H: Chronic disease: The need for a new clinical education. JAMA 292(9):1057-1059, 2004.