In August 2010, Dr. Jennifer Temel and her colleagues1
reported in the New England Journal of Medicine that patients who received early palliative care integrated with standard oncologic care from the time of diagnosis of metastatic NSCLC experienced significant improvements in quality of life and mood, received less aggressive care at the end of life, and derived an overall survival benefit. These findings heralded a decade of palliative care innovation, investigation, and implementation.
Since then, early palliative care has been shown to improve outcomes in other advanced solid tumors and acute myeloid leukemia. In addition, palliative care models for both the inpatient and outpatient settings have been successful. Palliative care delivery also has been expanded to rural locations through telephone-based interventions.
In 2016, the American Society of Clinical Oncology recommended palliative care involvement for all patients with advanced cancer within 8 weeks of diagnosis and for any patient who is at risk for a high symptom burden or psychosocial distress, as well as for those patients with complex decision-making needs. Oncologists have been encouraged to implement primary palliative care for their patients.2
Although recommended by national organizations as the standard of care, there are not enough specialty palliative care providers to deliver early palliative care to all patients who would benefit. See Box 1 for primary palliative care competencies.
|Box 1. Primary Palliative Care Competencies That Should Be in The Skill Set of All Oncology Clinicians|
Empathic Communication Skills Central to Palliative Care
Empathic communication is one of the most important and challenging aspects of palliative care for patients with serious illnesses. Empathic communication skills include the ability to deliver serious news, elicit patient values and preferences, establish goals of care, identify a surrogate decision maker, and determine—through conversation with the patient and any caregivers—future wishes for life-sustaining treatment. Someone with strong empathic communication skills will be able to provide emotional support to the patient and caregiver while having these challenging conversations.
The Serious Illness Conversation Guide (SICG) has become the centerpiece of structured communication between oncology clinicians and their patients.3
The guide was developed by Ariadne Labs, the joint center for health systems innovation at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health. The guide provides eight questions that cover patients’ understanding of their illness; their information preferences; their goals, fears, preferences for life-sustaining treatment; and how much their family knows about their wishes. It provides patient-tested language for exploring these issues and can usually be completed in less than 10 minutes. Its use has been associated with more, earlier, and better conversations between patients and their oncologists and with significant reductions in patients’ emotional suffering.
As palliative care has evolved in the past decade, so too has the understanding of the biology of lung cancer, leading to targeted therapies and dramatic gains in overall survival for some patients. Because of these advances, this is a distinctly different landscape from the one in which Dr. Temel and her colleagues first demonstrated a survival advantage for early integrated palliative care. Patients with the best prognoses or on the most tolerable therapies may benefit from lower-intensity, or lower-dose, early palliative care than patients received in the Temel trial. One type of lower-intensity palliative care consists of a stepped approach in which patients with NSCLC meet with a specialty care provider at diagnosis but not again until the patient is hospitalized, has disease progression, or reports a decline in quality of life.4
This lower-intensity, stepped approach is currently being compared to the higher-intensity approach used in the Temel trial in a multisite randomized clinical trial. If this work demonstrates noninferiority of a stepped palliative care model to early integrated palliative care, then the researchers may define a role for this more accessible, scalable, and patient-centered approach to ambulatory palliative care for patients with advanced lung cancer.
Given ongoing advances in lung cancer care and novel therapeutics, it is imperative that the field of palliative medicine continue to evolve to meet the needs of patients and families dealing with this serious illness.
- 1. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
- 2. Quill TE, Abernathy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368:1173-1175.
- 3. Serious Illness Care – Ariadne Labs. Accessed at https://ariadnelabs.org/areas-of-work/serious-illness-care/
- 4. Temel JS. Randomized trial of stepped palliative care versus early integrated palliative care in patients with advanced lung cancer (STEP PC). ClinicalTrials.gov Identifier: NCT03337399.