Palliative Care as a Strategy For Improving Quality and Fostering System Reform

Jeffrey Peppercorn, MD, MPHAssociate Professor of Medicine

Duke Cancer Institute

Definition of palliative care– Diane Meier, MD, Director,

Center to Advance Palliative Care, Mt Sinai Hospital

Palliative care is specialized medical care for people with serious illnesses focused on providing patients with relief from the symptoms, pain, and stress of disease and treatment.

The goal is to improve quality of life for both the patient and family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.

Palliative care can be provided together with curative treatment.”

Slide Courtesy of Tom Smith

Fatigue

Dyspnea

Chest Pain

Lutz, J of Pall Med (4) 2 2001

4-6 months before death0-3 months before death

Loss of Appetite

Cough Hemoptysis

Why is Palliative Care Part of Cancer Care?High Symptom Burden

Symptoms in Advanced Lung Cancer

High Burden on Family/Caregivers

40-70% report depression

Depression gets worse as patients status declines and they lose ability to perform normal activities

Rhee JCO 26 (36) 2008

Staus Quo: Lack of Realistic ConversationsPerceptions of chance for CURE among patients with

incurable cancer…

Weeks NEJM 367 (17) 2012

CanCORS Study 1,200 patients Stage IV Lung or Colorectal on

chemo Asked: “How likely is cure”

3/4 of patients with incurable disease believe they can be cured….

This might impact decisions about what toxicity patients endure, how they spend their time, whether they pursue hospice.

Late Discussion of Hospice

Survey of U S Oncologists: Keating, Cancer. 2010 Feb 15;116(4):998-1006

WHEN DO YOU DISCUSS HOSPICE?

• “when there are no more treatment options”~ 60% of Med Oncologists

• “at the time of diagnosis of incurable disease”~18% of Med Oncologists

• 50% of patients with lung cancer in U.S. have no discussion of hospice 2 months prior to death Huskamp HA, et al. Arch Intern Med. 2009 May 25;169(10):954-62

CONTEXT• 62 yo man with incurable Stage IV lung cancer spread to his

bone, lung, and his liver.• He doesn’t have mutation suggesting a role for targeted therapy• He is treated on 1st line Carboplatin + taxol with a partial

response, but after 5 months has progression of disease.• He now has shortness of breath, worsening pain, and fatigue

What are my options?

2nd Line therapy

Standard Rx

Clinical Trial

Palliative Care Hospice

Disease Directed Therapy

Research Participation

Symptom Focused Palliative

Care

“Ideal” Care will vary by patient

Preferences

Goals

Research Options

Comorbidity

Biomarkers

Performance Status

Symptoms

Family Support

Prior Rx

Cancer Care: What are we good at?

• Obtaining imaging, labs, biopsies to make a diagnosis

• Developing and implementing a treatment plan for the disease– Often with toxic chemotherapy– Increasingly with molecularly targeted agents– Emerging immune mediated agents

• Discussing and planning next treatment when the cancer gets worse

Cancer Care: What are we less good at?

• Managing symptoms of disease

• Identifying and managing side effects of treatment

• Having realistic conversations about prognosis

• Discussing the full range of options for care, including integration of palliative care and disease directed care, or of palliative care alone

• Discussing end of life care and death

WHY?

• We train cancer specialists in management of disease (breast cancer) not in management of symptoms (nausea, fatigue).

• Financial incentives reward action: give chemo, perform surgery…. Not talking

• Its hard to talk about treatments not working and its hard to talk about death

Just Because Something is hard, does not mean we shouldn’t do it…

Philae probe successfully lands on comet 300 million miles away - Nov 12th, 2014

We can probably have honest conversations…..

The Rationale to Integrate Palliative Care with Cancer Care

• Many cancers are incurable

• Patients, and their families, suffer as a result of disease and treatment

• Discussions of goals of care & focus on QOL often occur late, if ever

• When asked, patients often want more focus on palliative care

Discussing Prognosis and Preferencesimpacts care and QOL

• Coping With Cancer Study:– 332 patients with advanced cancer, 7 clinical centers

• ONLY 37% report discussing EOL preferences– Discussing EOL was NOT associated with depression or anxiety– Discussing EOL DID lead to less aggressive care, more hospice

• Aggressive care (ED, ICU, chemo in last weeks) associated with:– Worse Quality of Life – Higher risk for depression among caregivers

• Earlier hospice associated with better patient and caregiver QOL

Wright, JAMA 2010

+ Societal Imperative….Most spending on cancer in the U.S. occurs in the Last Year of Life

Mariotto t Al. J Natl Cancer Inst 2011; 103: 117-28

Bladder

Brain

Breast

Cervix

Colorectal

Esophagus

Head & Neck

Kidney

Leukemia

Lung

Lymphoma

Melanoma

Ovary

Pancreas

Stomach

Uterus

Prostate

$0 $50,000 $100,000 $150,000 $200,000 $250,000 $300,000

Initial Year of Diagnosis Continuing Last Year if Cancer Death

We are spending a lot without giving some patients what they need, and giving others what they don’t want….

FACT 1: We spend too much on futile care

FACT 2: We often do this, without giving patients what they want• Many with incurable cancer never discuss their preferences• When they do, they often choose symptom management over

disease directed care.• Opportunity to improve care AND reduce costs….

Total Medicare Spending (patients

>65):~ 500 Billion

(2010…)

1/3 on Last Year of Life:

~ 165 billion

40% on Last 30 Days :

~ 66 billion

12% of US Budget 2% of US Budget!~ 2x NIH Budget…

Ramsey et al, JNCI 2013

Potential Benefits of Early Palliative Care

• Improve QOL

• Improve understanding Informed choices

• Reduce futile care• Chemo within weeks of death, death in ICU/hospital

• Improve allocation of healthcare resources• Spend $ on high value care, research to find cure?

• Improve survival?

A better Model?:Integrating Palliative and Oncology Care

Slide Courtesy of Jennifer Temel

Palliative Care in Randomized Trials

• Home PC vs. standard care in homebound terminally ill patients– Improved patient satisfaction and quality of life– Decreased use of ER and Hospital – Brumley J Am Ger Soc. 2007

• PC vs. standard in patients with poor prognosis chronic illness – PC improved shortness of breath, anxiety, sleep, well-being – Rabow, Arch Int Med 2004

• RCT: Hospital PC vs. standard in patients with terminal illness– Increased use of hospice, decreased ICU care – Gade, J Palliative Med 2008

Improved quality of life, fewer symptoms, and less depression. Bakitas M, et al. Project ENABLE. JAMA 2009

• “Educate, Nurture, Advise, Before Life Ends” • RCT in 322 rural patients with advanced cancer: intervention vs. standard care• 4 weekly telephone educational sessions + monthly f/u by nurse• 41% GI, 36% lung, 12% GU, 10% breast

Project ENABLE: Palliative Care Outreach + standard Oncology Care

Proof of Principle for Early Palliative Care

Temel, NEJM, 2010

Early palliative care integrated with standard oncology care

Standard oncology care

Baseline Data Collection

RANDOMIZED

Study DesignMeet with palliative care within 3 weeks of signing consent and at least monthly thereafter

Meet with palliative care only when requested by patient, family or oncology clinician.

-Within 8 wks of diagnosis-ECOG PS 0-2-English speaking-Receiving care at MGH-Not already receiving palliative care

150 patients with newly diagnosed metastatic NSCLC

Temel, NEJM, 2010

PC provided by MD or NP in Cancer Center on day of clinic visits with med onc, rad onc, or surgeryPatients admitted to hospital also followed by PC team

How many visits?

Palliative Care Visits by 12-weeks

Palliative Care Visits Standard Care (N=74)N (%)

Early Palliative Care (N=77)N (%)

None 64 (87%) 1 (1)*

1 7 (9%) 0

2 3 (4%) 8 (10%)

3 0 18 (23%)

4 0 26 (34%)

> 5 0 24 (31%)

* Died within 2 weeks of enrollment

88% 3 or more

11% 1-2 visitsTemel, NEJM, 2010

Early palliative care + standard oncology care improved survival by almost 3 months vs. usual oncology care!

Temel J, et al. NEJM 2010; Greer J, et al. JCO 2011

Longer and better survival Better understanding of

prognosis Less IV chemo in last 60 days Less aggressive end of life

care More and longer use of

hospice Lower costs of care

AND improved QoL, Less Anxiety and Depression, - Temel JCO 2011

The American Society of Clinical Oncology now recommends “…combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”

Smith TJ, et al. J Clin Oncol. 2012 Mar 10;30(8):880-7.

AAHPM Choosing Wisely Task Force and ASCO Choosing Wisely Converging on how to achieve HIGH VALUE CARE

2. Don’t delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.

Slide Courtesy of Tom Smith

Access to Palliative Care:Growing Rapidly

> 5,700 registered hospitals in U.S.

Access to Palliative Care?:Not Everywhere

Center to Advance Palliative Care, 2012 Report Card

Only 60% of Hospitals nationwide had palliative care programs as of 2012

Some Challenges

SCIENCE •What are the most important aspects of palliative care?•Is the survival benefit reproducible? Seen in other cancers?•Need more research focused on symptom management

Care Delivery •How is it best delivered? Separate team? Oncology Office? •How do we offer this to all patients?•Reimbursement for symptom management and care planning?

Behavior Change •Are patients interested? Do they know what they are missing?•Are Physicians receptive to this?•How do we educate patients and oncologists regarding benefits