1. DiGiulio, Sarah

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When researchers tried delivering integrative palliative care treatment to a cohort of patients with incurable lung cancer and another cohort of patients with incurable gastrointestinal cancer, all of the patients' quality of life improved-but some more than others (J Clin Oncol 2016; doi: 10.1200/JCO.2016.70.5046).

Eric J. Roeland, MD.... - Click to enlarge in new windowEric J. Roeland, MD. Eric J. Roeland, MD

The research highlights specifically which outcomes were better for which patients and what parts of that palliative care intervention worked best for each cohort. But the conclusion from the study illustrates a larger problem in the current delivery models of palliative care, Eric J. Roeland, MD, Assistant Clinical Professor of Oncology at University of California, San Diego, argues in an editorial about that research (J Clin Oncol 2016; doi: 10.1200/JCO.2016.71.2174).


"Palliative care requires a tailored approach to meet the dynamic and specific needs of each unique population of patients with cancer. Here, too, one size does not fit all," Roeland wrote.


And that tailored approach is not happening, he explained in a phone interview with Oncology Times. Roeland elaborated on why current models of palliative care delivery are not sufficing, not efficient, and not sustainable, as well as what he thinks would work better.


1 You make the argument in the editorial you wrote that current models of palliative care aren't working. What's wrong with palliative care delivery now?

"For people practicing oncology and palliative care, what we're up against are the very pragmatic issues about how we get it done. And I think one major opportunity is to really invest in outpatient palliative care.


"There's been immense focus and resources spent on inpatient palliative care, rather than outpatient. And there's been a steady growth over time with inpatient palliative care services. But the growth of outpatient care in the palliative setting has basically been 1 or 2 percent since 2000 to 2009, versus an increase in inpatient consults up to around 12 or 13 percent (J Natl Compr Canc Netw 2016;14:439-445).


"If you're constantly focusing on making sure palliative care touches and evaluates patients on the inpatient side, you're not going to shift culture. You're not going to shift the way that we're taking care of patients over time-and I would argue that the 'advanced care planning' that's done on the inpatient service is not advanced care planning. It's really point-of-care planning.


"Advanced care planning is a process that takes time and multiple discussions, and needs to be done in the outpatient setting with the people patients trust most, which are the oncologists and their oncology team.


"We need to build outpatient [palliative care] to try to avoid hospitalization [for patients] and try to encourage people to be planning for emergencies outside of an emergency."


2 What's driving this focus on inpatient rather than outpatient palliative care?

"It's easier to organize this on the inpatient setting. The advantage of having a palliative care team see patients in the inpatient [setting] is that they're there-you can spend lots of time with them.


"Outpatient palliative care requires a lot of infrastructure and organization. And so, as an organization, am I going to devote time, space, and resources to organize appointments around [the patients'] other appointments-their infusions, their radiation, their surgery? Am I going to give palliative care teams clinic space? Frequently, palliative care teams are not seen as a core component of oncology care, but rather an add-on.


"So, until that shift occurs and it's seen that the palliative care appointment has equal value as the oncology appointment, there's going to be some major disconnect between the guidelines and what's recommended and what's actually happening day-to-day."


3 How does that shift happen? And what would you say is the bottom line that all oncology care providers should know about how to make that shift happen?

"The major issues here are culture. Culture takes decades. And if you talk to some of the founding members of the palliative care movement they would say where we are today is a night-and-day [difference] compared to where we were. But there's still a lot to move forward with.


"One of the remaining things is this idea that palliative care is end-of-life care and you wait until people are dying before you refer. The big issue is this cultural shift [that needs to happen] from doctors still equating palliative care with end-of-life care.


"What I would like to see is more collaboration and more interaction between palliative care and oncology in an era of personalized cancer therapies and immunotherapy. We have more to learn from each other-more opportunities to work together and do research together and improve quality of life and even survival of our patients.


"It shouldn't be like two rival gangs-we should all be working together here."