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R.I. Lopez
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MS 09 - Worldwide Perspective/Review of Limitations, Resources, Programs and Accomplishments of Supportive Care and Palliative Care Multidisciplinary Teams, by Continent (ID 27)
- Event: WCLC 2015
- Type: Mini Symposium
- Track: Palliative and Supportive Care
- Presentations: 8
- Moderators:R.I. Lopez, A. Oton
- Coordinates: 9/07/2015, 14:15 - 15:45, 108+110+112
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MS09.01 - Nurse's Perspective (ID 1881)
14:15 - 15:45 | Author(s): T. Trabert
- Abstract
- Presentation
Abstract not provided
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MS09.02 - Doctor's Perspective (ID 1882)
14:15 - 15:45 | Author(s): A. Vigano, H. Bhanabhai
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- Presentation
Abstract:
Lung cancer is the leading cause of cancer death in Canada, and is associated with the highest levels of distress among all cancers (Canadian Cancer Statistics 2012, Zabora J et al 2001). Over two-thirds of newly diagnosed lung cancer patients are over 65 years of age and have advanced-stage disease. Many of these patients experience malnutrition comprising a combination of starvation (inadequate nutrient intake), sarcopenia (loss of muscle mass associated with loss of strength and or function), and cachexia (presence of systemic inflammation/altered metabolism). These factors are also major determinants of frailty in elderly lung cancer patients (ELCP), and are associated with reduced cancer treatment tolerance and response (Vigano and Morais, 2015). The addition of palliative care consultation initiated in parallel to treatment for lung cancer has been shown to improve both overall lung cancer mortality and patient symptom burden during cancer treatments (Greer et al, 2013). However, there is a paucity of information regarding the peri-diagnostic, pre-treatment phase. Most often, the pre-treatment phase of lung cancer care is defined as a prolonged period (mean = 6 weeks) of fragmented care that is associated with high levels of symptom burden and psychological distress (Dekhuijzen et al, 2014; Iyer et al 2013). The supportive care needs of patients during this period are often inadequately addressed. Thus, the potential for personalized interventions to reduce frailty in ELCP by targeting malnutrition and symptom burden have been largely unexplored during this critical phase. The Rapid Investigation Clinic (RIC) at the McGill University Health Centre (MUHC) currently investigates and stages patients with suspected lung cancer. The clinic operates on a bi-weekly basis and includes dedicated pulmonologists with a particular expertise in lung cancer, a dedicated nurse clinician, and a palliative care consultant. Once staged, patients’findings are discussed at tumor board meetings and are evaluated at the multidisciplinary lung cancer clinic. The mean time from referral to lung cancer treatment is approximately 6 weeks. When patients are identified at the RIC as requiring supportive care they are referred to one of seven interdisciplinary clinic/programs available at the Cancer Care Mission of the MUHC (see figure below). Figure 1 For instance, if a patient presents primarily with signs and symptoms of cachexia or deconditioning, he/she is referred to the Cancer Rehabilitation Program (CRP) and Cachexia Clinic (CC) at the MUHC, which are fully integrated with the MUHC Nutrition and Performance Laboratory (MNUPAL, www.mnupal.mcgill.ca) . MNUPAL is a state-of-the-art facility devoted to nutritional and functional assessment for patients with advanced cancer.. The primary goals of these assessments are: a) to identify presence and severity of cachexia and/or sarcopenia, b) to address reversible causes for these syndromes, such as inadequate symptom control, nutritional and hormonal deficits (i.e. hypogonadism, hypothyroidism etc), and c) to identify personalized interventions (pharmacological, nutritional, and functional) that will be appropriate for patients’ conditions and wishes. The current research at MNUPAL is driving some of the future directions of specific and personalized care, especially in terms of the Cachexia Clinic and the stages of cancer cachexia that will ultimately provide more specific and personalized care for those who are in the various stages of cancer cachexia (Vigano et al, 2012). The CRP and CC teams include a palliative care physician, a nurse clinician, a physiotherapist, an occupational therapist and a nutritionist. If patients present primarily with cancer related pain, they are referred to the Cancer Pain Clinic, whereas patients who have advanced disease and are no longer receiving treatment with a curative intent may be referred to the Palliative Care Clinic. Access to physiotherapy, occupational and nutritional services is available for all clinics which do not include these specialties in their teams.Patients assessed with psychosocial distress from all clinics are referred to the psychosocial oncology program and/or social services. CanSupport services (i.e. reimbursements for parking, transportation etc.) are also available upon request. Screening assessments for both malnutrition and symptom distress are available at the RIC. At the present time, there is ongoing research for using these screening to systematically identify frail elderly cancer patients prior to cancer treatment initiation. There is also a need to objectively determine if interventions targeted to decrease malnutrition and symptom burden will diminish frailty, may improve patient psychological and physiologic “readiness” for what are often aggressive treatments (chemotherapy, radiotherapy or surgery). There is a convincing body of research evidence including case reports (Carli et al., 2012, Carli et al., 2014), pilot studies (Li et al., 2013), and randomized clinical trials (Gillis et al., 2014) that supports geriatric patient engagement in multi-modal, cancer pre-habilitation programs designed to improve physical (physiological) and psychological (anxiety and depression) outcomes during a perioperative time period. We are therefore investigating ways to enhance access to supportive care services for elderly lung cancer patients, which include: Standardized screening for malnutrition and symptom burden. Standardized approaches to symptom control, psychological distress, as well as nutritional and functional problems Identification of specific therapeutic targets and interventions to reduce frailty Canadian Cancer Society’s Steering Committee on Cancer Statistics. Canadian Cancer Statistics 2012. Toronto, ON: Canadian Cancer Society; 2012. Carli F, Brown R, Kennepohl S. Prehabilitation to enhance postoperative recovery for an octogenarian following robotic-assisted hysterectomy with endometrial cancer. Can J Anaesth. 2012 Aug;59(8):779-84. doi: 10.1007/s12630-012-9734-4. Epub 2012 May 26. Carli F, Awasthi R, Gillis C, Kassouf W Optimizing a frail elderly patient for radical cystectomy with a prehabilitation program. Can Urol Assoc J. 2014 Nov;8(11-12):E884-7. doi: 10.5489/cuaj.2025. Dahele, M., R. J. Skipworth, L. Wall, A. Voss, T. Preston and K. C. Fearon (2007). "Objective physical activity and self-reported quality of life in patients receiving palliative chemotherapy." J Pain Symptom Manage 33(6): 676-685. Dekhuijzen PN, Prins JB. Distress in suspected lung cancer patients following rapid and standard diagnostic programs: a prospective observational study. Psycho-oncology. 2014 Sep 9. doi: 10.1002/pon.3660. [Epub ahead of print] Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, Carli F. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014 Nov;121(5):937-47. doi: 10.1097/ALN.0000000000000393. Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer.CA Cancer J Clin. 2013 Sep;63(5):349-63. doi: 10.3322/caac.21192. Epub 2013 Jul 15. Iyer S, Roughley A, Rider A, Taylor-Stokes G. The symptom burden of non-small cell lung cancer in the USA: a real-world cross-sectional study Support Care Cancer. 2014 Jan;22(1):181-7. doi: 10.1007/s00520-013-1959-4. Epub 2013 Sep 12. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, Kim do J, Vassiliou MC, Feldman LS. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013 Apr;27(4):1072-82. doi: 10.1007/s00464-012-2560-5. Epub 2012 Oct 9. Vigano A, Morais JA. The elderly patient with cancer: a holistic view. Nutrition. Published on line January 8, 2015. http://dx.doi.org/10.1016/j.nut.2015.01.001 Vigano A, Del Fabbro E, Bruera E, Borod M. The cachexia clinic: from staging to managing nutritional and functional problems in advancer cancer patients. Critical Reviews in Oncogenesis 2012 17(3), 293–304 Zabora J, Brintzenhofeszoc K, Curbow B, Hooker C and Piantadosi S. The prevalence of psychological distress by cancer site. Psycho-oncology 10 : 19–28 (2001)
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MS09.03 - Radiation Oncologist's Perspective (ID 1883)
14:15 - 15:45 | Author(s): J.D. Bradley
- Abstract
- Presentation
Abstract not provided
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MS09.04 - Patient and Caregiver's Perspective (ID 1884)
14:15 - 15:45 | Author(s): R.M. Fink
- Abstract
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Abstract:
Palliative care has been shown to improve outcomes for patients with life threatening illness and patients at the end of life, including decreasing symptom burden, improving quality of life, and working with patients and families to help ensure that the medical and nursing care provided is congruent with goals and preferences. Palliative care, focusing on assistance with advance care planning, decision-making, pain and symptom management, psycho-social support, and patient navigation, has the potential to improve care quality and reduce medical service utilization.[1] In a randomized controlled trial (RCT) of a palliative care intervention, Temel and colleagues demonstrated that patients with advanced lung cancer who received early palliative care had better quality of life, less depression, and lived longer.[2] The American Society of Clinical Oncology[3] and other organizations have published position statements supporting the need for oncologists, nurses, and other clinicians to participate in difficult conversations with patients regarding prognosis, preferences, and palliative care options earlier in the course of illness. Patients and their caregivers (family and/or significant others) need to be part of the discussion about care goals at the time of diagnosis, during treatment, and at the time of recurrence. Shared decision-making about end-of-life care must be based on patient/family caregiver beliefs, values, and preferences.[4] Developing rapport with patients and starting the conversation about care goals is often difficult and time-consuming. Often, patients do not understand the difference between palliative care and hospice and may not want to participate in a palliative care program because of their concern that health care providers are “giving up” on them. In a survey of health care professionals, barriers to goals of care discussions with seriously ill hospitalized patients and families include: patients’ and family members’ difficulty accepting a poor prognosis and understanding limitations/complications of life-sustaining treatments, family member disagreement about care goals, and patient incapacity to make care decisions.[5 ] Interventions to improve communication and shared decision making about plans and goals of care are key and must take into account cultural and spiritual preferences. Cultural and linguistic barriers increase disparities in providing palliative care for ethnic minorities. Patient and family cultural values have a major impact on care preferences at the end of life for some ethnic minorities and should be considered by the health care professional. Cultural, spiritual, and religious values often influence how palliative care and pain/symptom management are perceived and accepted. While nationwide averages of completed advance directives are low for all groups, patients of ethnic minority are less likely to have a living will, durable power of attorney, or a Do Not Resuscitate (DNR) order, are more likely to choose very aggressive care in the face of serious or incurable illness, and less likely to acknowledge their terminally ill status.[6] Palliative care and hospice services are rarely accessed by non-Caucasians. In addition, expanding evidence suggests that adequate pain and symptom assessment and management is not achieved for many persons with late stage disease; pain occurs in approximately 80% of patients with life-threatening illness.[7] Solano et al. found breathlessness and fatigue were present in >50% of patients with cancer and COPD.[8] All of these barriers suggest that improving palliative care access may have benefit for patients and their family caregivers. However, tertiary palliative care cannot grow fast enough to meet the demand. Models of care that promote primary palliative care are required in outpatient, community, homecare, and rural settings to maintain the capacity for the ever-growing needs of patients and their family caregivers. Primary care physicians and nurses play important roles in delivering palliative care, and may in fact not have the knowledge and skills to do so effectively. Significant barriers to integrating palliative care include lack of access to palliative care resources to implement change, personnel constraints, inadequate basic knowledge about palliative care strategies and communication, and little training, skills, or certification in palliative care.[11] It is imperative for health care professionals to improve their knowledge about palliative care, support the provision of early palliative care, and establish relationships with patients to understand values and preferences. Dr. Atul Gawande, in his recent book Being Mortal, suggests that patients be asked five key questions to open discussion about care goals.[12] These questions include the following: 1. What is the understanding of your current health and condition? 2. If your condition worsens, what are your goals? 3. What are your fears? 4. Are there any tradeoffs you are willing to make or not? 5. What would a good day be like? Additional suggestions and strategies to improve communication with patients and their family caregivers in the palliative care setting will be discussed in this presentation. 1. Ferris FD, Bruera E, Cherny N, et al. Palliative cancer care a decade later: accomplishments, the need, next steps -- from the American Society of Clinical Oncology. J Clin Oncol 2009;27:3052-8. 2. 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;363:733-42. 3. Peppercorn JM, Smith TJ, Helft PR, et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol 2011;29:755-60. 4. Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134:835-43. 5. You JJ, Downar J, Fowler RA, et al. Barriers to goals of care discussions with seriously ill hospitalized patients and their families: a multicenter survey of clinicians. JAMA Intern Med February 2, 2015;epub E1-8. 6. Smith AK, McCarthy EP, Paulk E, et al. Racial and ethnic differences in advance care planning among patients with cancer: impact of terminal illness acknowledgment, religiousness, and treatment preferences. J Clin Oncol 2008;26:4131-7. 7. Kutner JS, Bryant LL, Beaty BL, Fairclough DL. Time course and characteristics of symptom distress and quality of life at the end of life. JPain Symptom Manage 2007;34:227-36. 8. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Sympt Manage 2006;31:58-69. 9. Fink RM, Oman KS, Youngwerth J, Bryant L. A palliative care needs assessment of rural hospitals. J Pall Med 2013;16(6):638-644. 10. Gawande A. Being Mortal: medicine and what matter in the end. New York: Metropolitan Books, Henry Holt and Company, 2014.
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MS09.05 - Latin America (ID 1885)
14:15 - 15:45 | Author(s): E.A. Richardet
- Abstract
- Presentation
Abstract not provided
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MS09.06 - Africa (ID 1886)
14:15 - 15:45 | Author(s): M.M.A. Elhassan
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Cancer has emerged as a major health problem in Africa.[1]Healthcare in Africa differ widely, countries in North Africa and the republic of South Africa have better health care services than those in sub Saharan Africa. In Africa particularly in sub-Saharan region, due to the limited access to cancer screening and early diagnosis, an estimated 80% of cancer patients are present with advanced stage. [2]Additionally, inadequate access to standard cancer therapies result in difficulty to achieve cure even for patients with early stage cancer. Despite the clear public health needs for multidisciplinary palliative care for millions of cancer patients, access to this option is limited in most African countries. Information regards palliative care in Africa is lacking.[3]It was estimated that only 5% of patients in need to palliative care receive it.[4]This is especially true in sub-Saharan Africa, where about 80% of cancer patients are likely to experience suffering in the course of their advanced illnesses.[2] Palliative care is a relatively new discipline in Africa, Initiatives in South Africa and Zimbabwe dated back to 1970s. There has been significant progress over the last ten years. From being significantly present in only five countries in 2004, palliative care services was established in nearly half of African countries in before the World Health Assembly in 2005.[4]These services usually confined to large cities, most of which are pain clinics driven by nongovernmental sector. The majority of health care professionals at palliative care clinics lack the appropriate training for pain assessment and management and they are relying on their own personal experience while practicing palliative care. Clark et al. [3]have conducted a multi-method survey to review services and experiences of palliative care development in 47 African countries. The 47 countries studied could be grouped into four categories of palliative care development: No identified hospice or palliative care activity (21 countries); Capacity-building activity underway to promote hospices and palliative care delivery (11countries); localized provision of hospices and palliative care in place, often supported by external donors (11countries); and Hospices and palliative care services achieving some measure of integration with mainstream service providers and gaining wider policy recognition (4 countries) The Limitations to the development of multidisciplinary palliative care programs in Africa are that: high burden of HIV and cancer, extreme shortage of trained health care professionals in palliative care, insufficient facilities, weak referral systems and lack of access to opioid or the restriction of their use in many African countries.[5, 6]Moreover, there is still a general lack of government policies that recognize palliative care as an essential component of health care along with great challenge to acquire funding for palliative care programs.[5] Despite these limitations, there has been some success so far. Uganda, Kenya, South Africa, and Zimbabwe developed successful models for the development of affordable, sustainable community- based hospices and palliative care services. [3]Kenya, South Africa, Uganda and Tanzania have integrated palliative care into healthcare policy. Uganda has mad oral morphine freely available to its patient’s population and it has passed law to allow prescription of morphine by nurses.[7]The Ministry of Health in Malawi acknowledged palliative care as part of a minimum standard of care for all tertiary institutions.[8] The importance of palliative care in the African setting have been recognized by the World Health Organization (WHO). There are several palliative care initiative in Africa that have provided good quality palliative care in limited recourse setting.[3]The majority of successful palliative care initiatives are supported by international organizations in collaboration with governments and non-governmental organization (NGOs) e.g. the WHO 5-country palliative care project. The Foundation for Hospices in Sub-Saharan Africa, has a grant support program operating in several African countries. The African Palliative Care Association (APCA) has a fast developing program of activities to promote development across the continent and supports governments and other local service providers to ensure the provision of opioids and other palliative care medications. The role of education and training has been essential in strengthening capacities to develop multidisciplinary palliative care programs. Efforts to develop in country training are underway in few African countries. The University of Cape Town offers Post Graduate Diploma/MPhil, in Palliative Medicine. Makerere University through its affiliated institution Hospice Africa Uganda in partnership with APCA offers a Bachelor’s Degree in Palliative Care. Nairobi Hospice in collaboration with Oxford Brookes University offers diploma in palliative care. The National Cancer Institute, Cairo offers Master degrees in pain management and palliative care has been incorporated in the curriculum of the oncology nursing program in the same institute. Palliative care in Africa is still at an early stage of development and faces many obstacles. A lot of progress has been made already, however much still remains to be done, particularly across sub-Saharan Africa. Many challenges cannot be corrected without governments and NGOs willing to effect changes and commit funds to research and training. References 1. Basu, A., B.N. Mittag-Leffler, and K. Miller, Palliative care in low- and medium-resource countries. Cancer J, 2013. 19(5): p. 410-3. 2. Spence, D., A. Merriman, and A. Binagwaho, Palliative care in Africa and the Caribbean. PLoS Med, 2004. 1(1): p. e5. 3. Clark, D., et al., Hospice and palliative care development in Africa: a multi-method review of services and experiences. J Pain Symptom Manage, 2007. 33(6): p. 698-710. 4. Grant, L., et al., Palliative care in Africa since 2005: good progress, but much further to go. BMJ Support Palliat Care, 2011. 1(2): p. 118-22. 5. Ddungu, H., Palliative care: what approaches are suitable in developing countries? Br J Haematol, 2011. 154(6): p. 728-35. 6. Harding, R. and I.J. Higginson, Palliative care in sub-Saharan Africa. Lancet, 2005. 365(9475): p. 1971-7. 7. Ramsay, S., Leading the way in African home-based palliative care. Free oral morphine has allowed expansion of model home-based palliative care in Uganda. Lancet, 2003. 362(9398): p. 1812-3. 8. Tapsfield, J.B. and M. Jane Bates, Hospital based palliative care in sub-Saharan Africa; a six month review from Malawi. BMC Palliat Care, 2011. 10: p. 12.
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MS09.07 - Asia/Oceania (ID 1887)
14:15 - 15:45 | Author(s): C.R. Underhill
- Abstract
- Presentation
Abstract not provided
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MS09.08 - Supportive Care and Palliative Care in Europe (ID 1888)
14:15 - 15:45 | Author(s): J. Herrstedt
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The major societies of Supportive and Palliative Care in Europe are the Multinational Association of Supportive Care in Cancer (MASCC), the European Society for Medical Oncology (ESMO) and the European Association for Palliative Care (EAPC). Supportive Care is defined by MASCC as: “Supportive Care in Cancer is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship and end of life care are integral to Supportive Care [1].” Palliative Care is defined by EAPC as: “Palliative Care is the active, total care of the patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of social, psychological and spiritual problems is paramount. Palliative Care is interdisciplinary in its approach and encompasses the patient, the family and the community in its scope. In a sense, palliative care is to offer the most basic concept of care – that of providing for the needs of the patient wherever he or she is cared for, either at home or in the hospital. Palliative care affirms life and regards dying as a normal process; it neither hastens nor postpones death. It sets out to preserve the best possible quality of life until death [2].” ESMO took a stand on Supportive and Palliative Care in 2003 as follows: “Supportive Care’ is defined as care that aims to optimize the comfort, function and social support of the patients and their family at all stages of the illness. This dimension of care emphasizes the oncologist’s role in optimizing quality of life for all patients, including those with potentially curative illness.” “Palliative Care’ is defined as care that aims to optimize the comfort, function and social support of the patients and their family when cure is not possible. This dimension of care emphasizes the special needs of patients whose illness is either unlikely to be cured or that is incurable. These needs include physical and psychological symptom control, education and optimization of community supports [3].” These definitions are summarized in the Figure. The definitions all respect the recent trend of early integration of Palliative Care in patients with advanced cancer. Two randomized studies showed a survival benefit [4] or an improvement in some quality of life parameters [5], whereas a recent randomized study was unable to demonstrate any benefit of early integration of Palliative Care [6]. Recently MASCC, ESMO and EAPC joint forces and completed two surveys to disclose the use of existing palliative care programs in Europe. The result of these surveys will be summarized [7, 8]. Figure 1 References 1. MASCC homepage accessed July 7, 2015 - http://www.mascc.org/about-mascc 2. EAPC homepage accessed July 7, 2015 - http://www.eapcnet.eu/Corporate/AbouttheEAPC/Definitionandaims.aspx 3. Cherny NI, Catane R, Kosmidis P et al. ESMO takes a stand on supportive and palliative care. Ann Oncol 2003;14:1335-1337. 4. Temel N, Greer JA, Muzikansky A et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42. 5. Zimmerman C, Swami N, Krzyzanowska M et al. Eraly palliative care for patients with advanced cancer: a cluster randomised controlled trial. Lancet 2014;383:1721-30. 6. Groenvold M, Petersen MA, Damkier A et al. The Danish palliative care trial (DanPaCT), a randomised trial of early palliative care in cancer: results of the primary analysis. EAPC 14th World Congress May 8-10, 2015: abstract PL7. 7. Davis MP, Strasser, F, Cherny N. How well is palliative care integrated into cancer care? A MASCC, ESMO and EAPC project. Support Care Cancer DOI 10.1007/s00520-015-2630-z 8. Davis MP, Strasser F, Cherny N, Levan N. MASCC/ESMO/EAPC survey of palliative care programs. Support Care Cancer 2015;23:1951-1968.
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