Tj Tumori. Consensus document of the Italian Association of Medical Oncology and the Italian Society of Palliative Care on early palliative care

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1 792478TMJ / Tumori JournalCorsi et al. editorial2018 Editorial Tj Tumori Journal Consensus document of the Italian Association of Medical Oncology and the Italian Society of Palliative Care on early palliative care Tumori Journal 1 10 Fondazione IRCCS Istituto Nazionale dei Tumori 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: journals.sagepub.com/home/tmj Domenico C. Corsi 1, Adriana Turriziani 2, Luigi Cavanna 3, Piero Morino 4, Angela S. Ribecco 5, Marco Ciaparrone 1, Gaetano Lanzetta 6, Carmine Pinto 7 and Vittorina Zagonel 8 Abstract A consensus document on early palliative care was produced by a committed Working Group of the Italian Society of Medical Oncology and the Italian Society of Palliative Care to improve the early integration of palliative care in medical oncology and to stimulate and guide the choices of those who daily face the problems of advanced stage cancer patients. The simultaneous administration of antineoplastic treatments and early palliative care was shown to be beneficial in metastatic cancer pathway outcomes. Patients who could benefit from early palliative care are those with an advanced cancer at presentation, a compromised PS for cancer, and/or morbidities, and who are too frail to receive treatment. According to the Bruera practice models, in which the combination of cancer management with early palliative care can be offered, three groups of patients needing simultaneous care were identified and three different models of the delivery of palliative care were proposed. In patients with good prognosis and low need of simultaneous care, the solo practice model and the request for consultations were suggested, while in patients with poor prognosis disease with high need of simultaneous care and in conditions with high need of simultaneous care, regardless of cancer prognosis, the integrated care approach should be offered. Palliative care consultation services are seldom accessible in the majority of Italian hospitals; thus the application of various practice models depends on available resources, and a shared care model with the structures of palliative care operating in the area is often required. Keywords Consensus document, early palliative care, Italian Association of Medical Oncology, Italian Society of Palliative Care, simultaneous care Date received: 17 December 2017; revised: 19 April 2018; accepted: 28 May Medical Oncology Unit, Fatebenefratelli-Isola Tiberina Hospital, Rome, Italy 2 Palliative Care Unit, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy 3 Department of Hematology and Oncology, Medical Oncology Unit, Piacenza Hospital, Piacenza, Italy 4 Coordination of Palliative Care, Azienda USL Toscana Centro, Florence, Italy 5 Department of Oncology, Azienda USL Toscana Centro, Medical Oncology Unit, S. Giovanni di Dio Hospital, Florence, Italy 6 Medical Oncology Unit, INI Grottaferrata, Rome, Italy 7 Department of Medical Oncology, S. Maria Hospital IRCCS, Reggio Emilia, Italy 8 Department of Clinical & Experimental Oncology, Medical Oncology Unit 1, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy. Corresponding author: Domenico C. Corsi, Medical Oncology Unit, Fatebenefratelli Isola Tiberina Hospital, Piazza Ponte Quattro Capi 39, Rome, Italy. domenicocristiano.corsi@fbf-isola.it

2 2 Tumori Journal 00(0) Box 1. Final recommendations of the Italian Society of Medical Oncology Italian Society of Palliative Care document on early palliative care. A palliative approach based on an earlier assessment and treatment of all symptoms combined to antineoplastic treatment should be guaranteed early to all patients with metastatic disease and/or significant symptoms. Key elements to recognize patients who come to the final stage of their lives are as follows: The use of clinical prognostic indicators of orientation such as the surprise question A systemic evaluation approach of the disease and the complexity of the individual patient s needs and the family (global view of the patient, attention to symptom control and quality of life, appropriateness and proportionality of the intervention, and multiprofessional teamwork) The advice of a palliative care specialist In the oncology unit, it is necessary to identify an oncologist who serves as an interface with the palliative care service that operates in the hospital or with the structures of palliative care operating in the area. In patients with symptomatic malignant diseases in which the effect of treatment on the natural history is limited or where the quality of life is severely compromised by the same, shared management with the interdisciplinary palliative care team has a positive impact on the prolongation of survival, improving the quality of life and the management of symptoms of patients; increasing the awareness of disease allows a better decision-making process and leads to a reduction in costs and to a proper allocation of available resources. Decision-making in transition to palliative care has particular characteristics: It is shared with the patient and his family It is dynamic and progressive It involves a multidisciplinary and multiprofessional team It needs adaptation and flexibility over time In palliative care and early simultaneous care: It is important that there is integration among the involved professionals and that there is the identification of a case manager for an agreed treatment strategy The informed consent is a progressive consensus, which includes the advanced care planning For patients with advanced cancer disease, in early palliative care we recommend the use of multidimensional assessment instruments that include the most common symptoms and psychosocial and spiritual dimensions. Introduction The complexity of the needs of patients with advanced cancer and their caregivers begins many months before the end-of-life period 1,2 ; despite progress in cancer prevention, diagnosis, and treatment, about half of all patients with cancer will die of their disease within 5 years. 3 Palliative care represents a comprehensive package of care for patients and their caregivers based on the holistic vision of patient and family as a single unit of care. The main objective of palliative care is to maintain the best quality of life for patients, addressing and treating not only physical symptoms such as pain but also psychosocial and spiritual needs, in order to alleviate the suffering of patients and their caregivers. 4 Over the last decade, the palliative care sector has undergone substantial changes and progressive growth due to expanded evidence-based experiences, new care delivery models, and increasing public and professional awareness. 5 The American Society of Clinical Oncology (ASCO) published a provisional clinical opinion (PCO) in 2012, in which the Panel consensus was that the combination of standard oncology care and palliative care should be considered from the outset of disease for all patients with cancer metastasis and/or high-load symptoms. 6 This PCO was recently updated by a group of systematic data review experts reported between 2010 and January Outpatients should receive dedicated palliative care services simultaneously with active treatment, from the beginning and throughout the course of the disease. 7 So as to improve the early integration of palliative care in medical oncology and to stimulate and guide the choices of physicians, programmers, administrators, and members of civil society who daily face the problems of advancedstage cancer patients, a consensus document on early palliative care was produced by a committed Working Group of the Italian Society of Medical Oncology (AIOM) and the Italian Society of Palliative Care (SICP). The final document was approved by AIOM and SICP board members in 2015 and has been published on both the AIOM and SICP websites. 8 Its final recommendations are listed in Box 1. Epidemiologic data Every day in Italy, there are approximately 1000 new diagnoses of cancer, and approximately 30% 35% of the patients present with advanced/metastatic disease; each year approximately 175,000 people die as a consequence of cancer, and these individuals therefore need dedicated palliative care services during the trajectory of the end-oflife phase. 9 However, as reported by WHO, 10 many people also require a palliative care approach in the year before death, so the real number of cancer patients who demand palliative care each year in Italy will necessarily increase.

3 Corsi et al. 3 There is, furthermore, growing evidence that early integration of specialized palliative care in the treatment of cancer patients can significantly improve quality of life and even prolong survival in patients with metastatic cancer, can additionally reduce costs, and it is also beneficial for family caregivers. 6,7,11 17 Hence, we can distinguish two visions of providing palliative care: an old one, which is the prevailing model offered in Italy, which refers to advanced/metastatic cancer patients who have received all possible lines of anticancer treatment and who are initiated in a specialized palliative care program at the end-of-life phase; and a modern vision, coherent with the provisional clinical opinion of ASCO and its update, 6,7 recommending an early combination of standard oncology care and a dedicated palliative care approach in the course of the disease for any patient with metastatic cancer and/or poorly controlled symptoms. This new integration will increase the number of patients attending palliative care programs. Early palliative care (simultaneous care) The recent ASCO PCO uses the National Consensus Project definition of palliative care: Palliative care means patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitates patient autonomy, access to information, and choice. 18 The European Association for Palliative Care (EAPC) adopted a similar definition, underlying that 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. 19 An early incorporation of palliative care in the course of cancer management is supported in the aforementioned WHO resolution, which underlines the need to include palliation in the continuum of care and in which the lack of integration of palliative care into health and social care systems is recognized as the main factor preventing adequate and equitable access to such care. 10 A timely activation of palliative care is an indicator of quality of care; the patients who have access to this care beforehand, during the course of their illness, avoid inappropriate diagnostic and therapeutic approaches and are preserved from the sense of abandonment in the terminal phase of cancer. 20 Early access to palliative care, moreover, provides for a mutual and trustful collaboration between medical oncologists and palliative care teams. 21 The detection of patients with a life-limiting disease depends on clinical judgement and on a simultaneous assessment of a number of other characteristics, including the primary neoplasm, its extension, therapeutic potential, previous clinical outcomes and response to treatments, comorbidities, psychosocial factors, and rate of decline. Patients with advanced cancer at presentation, a poor performance status (PS) due to cancer and/or morbidities, or who are unfit to receive treatment should be strongly considered for referral to specialized palliative care. 22,23 In particular, PS (Karnofsky Performance Status [KPS] or Eastern Cooperative Oncology Group) is intimately associated with survival time in patients with advanced cancer, regardless of the type of diagnosis. 24,25 Several prognostic prediction tools for short-term survival have been validated, including the Palliative Prognostic Index, 26 the Palliative Prognostic Score (PaP Score), 27 the PaP Score with Delirium, 28 and the Prognosis in Palliative Care Study predictor model. 29 The consideration of criteria based on some biologic factors related to systemic inflammatory response or on clinical elements of various advanced pathologies such as progressive weight loss (>10%), unplanned admissions to the hospital in the last 6 months, as well as conditions that require more care at home can make it possible to identify those patients who must be addressed to early palliative care. 30,31 However, such tools are able to identify most (though not all) patients who have a life expectancy of just a few weeks, but are much less reliable for patients who may still have 6 12 months to live and who need early palliative care. Oncologist estimates of the prognoses of cancer patients are frequently inaccurate and overoptimistic, with deterioration and death coming sooner than expected by all concerned. The surprise question (SQ) was developed more than a decade ago as a simple test to identify patients who might benefit from hospice and palliative care, 32 and it has been incorporated into the Gold Standards Framework Prognostic Indicator Guidance guidelines as a screening tool for patients likely to have a short life expectancy, in order to encourage better prediction of patients who might benefit from palliative care, including discussions about end of life. 33,34 The SQ involves a clinician reflecting on the question Would I be surprised if this patient dies in the next 12 months? and it is a simple, feasible, and effective tool for identifying patients who have a greatly increased risk of 1-year mortality; its prognostic value for cancer patients has been shown in several empirical studies, 35 and in a recent review its accuracy was slightly better in cancer patients than in other disease groups. 36 It should, however, be acknowledged that the SQ alone may be useful only as an initial screening tool because it shows a low sensitivity and might be more accurate when used as part of a wider prognostic assessment that includes both general measures of PS and disease burden along with disease-specific indicators Especially in a formal Delphi expert consensus paper published in 2016, Hui and colleagues 40 proposed 11 major

4 4 Tumori Journal 00(0) Table 1. Early palliative care indicators tool (modified by Hui et al. 48 ). 1. Ask: Surprise question Would I be surprised if this patient dies in the next 6 12 months? 2. General clinical indicators Performance status poor (limited self-care; in bed or chair over 50% of the day) or deteriorating Progressive weight loss (>10%) over the last 6 months Two or more unplanned admissions in the last 6 months Patient is in a nursing care home or continuing care unit, or needs more care at home 3. Cancer-related indicators Performance status deteriorating due to metastatic cancer and/or comorbidities Too frail for oncology treatment 4. Patient needs-based criteria Severe physical symptom (e.g. pain, dyspnea, or nausea score 7 10 on a 10-point scale) Delirium Brain or leptomeningeal metastases Spinal cord compression or cauda equine Severe emotional symptoms (e.g. depression or anxiety score 7 10 on a 10-point scale) Request for hastened death Spiritual or existential crisis Assistance with decision-making or care planning Patient request Social frailty and/or economic hardship Absence or limited caregiver support Out-of-work immigrants 5. Patient time-based criteria Within 3 months of diagnosis of advanced or incurable cancer for patients with median survival of 1 year of less Diagnosis of advanced cancer with progressive disease despite second-line systemic therapy (incurable) criteria to identify patients suitable for outpatient specialty palliative care. They considered the presence of severe physical symptoms, including neurologic complications of cancer; severe emotional symptoms; the patient s request for hastened death; spiritual or existential crisis; and disease-trajectory-related time-based criteria as factors triggering an outpatient palliative care referral. 40 An early palliative care indicator tool is represented in Table 1. Early palliative care: Which models? Bruera and Hui 1 have defined three practice models in which the simultaneous combination of cancer management with early palliative care can be offered. In the first, the solo practice model, the oncologist takes care of both the treatment of the neoplastic disease and symptom management. In the congress approach, the primary oncologist relies on specialist consultants for the control of the patient s symptoms, and the role of the palliative care team is limited to addressing end-of-life issues. In the integrated care approach, the oncologist almost exclusively addresses the treatment of cancer, whereas the palliative care team handles most of the physical and psychosocial concerns. In March 2010, the Italian Parliament approved the first national law about palliative care, which stated that palliative care is a fundamental right for all Italian people without any distinction of age and for all diseases. All local health services have the duty to implement networks to guarantee palliative care, specifying different levels of the provision of palliative care: palliative care consultation by a medical and nursing team with specific competencies, expertise, and experience; performance of care during the daytime provided through the regional palliative organizational system; ambulatory activity; and inpatient hospice care, where this structure is present. Nevertheless, palliative care consultation services are seldom available in the majority of Italian hospitals, so the application of the various practice models depends on available resources and a shared-care model with the structures of palliative care operating in the area is often required. AIOM recently published a position paper on early palliative care in oncology practice (simultaneous care) with the following recommendations: highlight the role of skills and competence in palliative care along with implementation of adequate organizational models to accomplish simultaneous care, which is considered a high priority in order to grant the best quality of life for cancer patients and their families. 41 In this context, AIOM has also developed a program for training the medical oncologists in palliative medicine, considering it an integral part of their core curriculum in order to improve the culture of value and personalized medicine in oncology and expertise in the field of palliative care. The program aims to provide the individual units of medical oncology at least one oncologist who is more experienced in palliative care and who can interface with the palliative care service when operating in hospital or with the structures operating in the area. Nevertheless,

5 Corsi et al. 5 Table 2. Models for early palliative care. Solo practice model/request for consultation Good prognosis and low need of simultaneous care: mild symptomatic diseases with a median survival >12 months with the use of all active treatments breast, colorectal, ovarian, kidney cancer, prostate cancer in hormonal therapy, testis tumors, EGFR mutated lung cancer, soft tissue sarcomas, gastrointestinal stromal tumors, neuroendocrine tumors, lymphoma Integrated care approach Poor prognosis disease with high need of simultaneous care: diseases in which median overall survival by treatment is lower than 12 months or for which therapy side effects are very limiting in terms of quality of life glioblastomas, head and neck cancers, esophagus and stomach cancer, liver tumors, tumors of the pancreas and of the biliary tract, EGFR wild-type lung cancer, mesothelioma, bladder cancer, cancers of endometrium and cervix Integrated care approach High need for simultaneous care regardless of cancer prognosis patients with high psychological and social complexity due to age and to the inadequacy of family social network for lack of a caregiver or economic hardship foreign patients in socially vulnerable situations other priorities were retained, increasing the number of oncology units obtaining European Society for Medical Oncology Designated Centre certification and involving patient associations to share the objectives of care. 42 Early palliative care: Which patients? Eligibility for early palliative care includes both patients with symptomatic metastatic cancer with a KPS between 50 and 80 who receive specific anticancer therapies and patients and families without awareness of the course of disease and of the effectiveness of treatments. A previous experience of the MD Anderson Cancer Center has shown that the demand for palliative care varies according to the basic oncologic disease 43 ; thus, the need for simultaneous care is in some way related to the type of tumor. The AIOM-SICP working group has therefore identified diseases with a good prognosis and low need of simultaneous care, disease with poor prognosis and high need of simultaneous care, and conditions with high need of simultaneous care regardless of cancer prognosis (Table 2). In the first group, we included mild symptomatic diseases with a median survival >12 months with the use of all active treatments, such as breast, colorectal, ovarian, kidney cancer, prostate cancer in hormonal therapy, testicular tumors, EGFR mutated lung cancer, soft tissue sarcomas, gastrointestinal stromal tumors, neuroendocrine tumors, and lymphoma. A high need of simultaneous cure is instead requested for diseases in which the median overall survival by treatment is lower than 12 months, or for which therapy side effects are very limiting in terms of quality of life. Among these, we included glioblastomas, head and neck cancers, esophagus and stomach cancer, liver tumors, tumors of the pancreas and of the biliary tract, EGFR wild-type lung cancer, melanoma, mesothelioma, bladder cancer, and endometrial and cervical cancers. A high need for simultaneous care, regardless of cancer prognosis, is also required for patients with high psychological and social complexity due to age, inadequacy of the family social network for the lack of a caregiver or for economic hardship, and for foreign patients in socially vulnerable situations, because a large number of these frail patients refer to emergency room and are hospitalized during antineoplastic treatment. Communication and ethics All patients should be provided with clear, accurate, and understandable information through effective communication between the doctor and the patient; however, the majority of patients with cancer often report having poor communication satisfaction by judging discussions with their physicians inadequate regarding the prognosis and the purpose of treatment, especially in crucial decisions such as the initiation, continuation, and withdrawal of palliative antineoplastic therapy. 44,45 The decision-making about healthcare should, however, be shared decision-making, based on the active involvement of the patient across critical steps of treatment through a progressive and dynamic process, characterized by assessment and reassessment at each complex healthcare decision, both in oncology and palliative care. Therefore, the clinical, psychological, social, and spiritual needs of the patient, the effectiveness of treatment, the additional costs/benefits, and the patient s will must be evaluated before each decision. In early palliative care, the case manager plays an important role; after the initial period, in which the case manager is usually the oncologist, as the patient s needs increase the palliative care physician will be the case manager, especially approaching the end of the patient s life. Training that fosters the exchange of knowledge among the different clinicians should be guaranteed, to facilitate clear, shared communication with the patient

6 6 Tumori Journal 00(0) and his or her family during the treatment course, in order to reach the same goals and according to the evolution of clinical conditions. The early integration of palliative care and oncology care is not only useful in maintaining the best possible quality of life but also allows the development of a relationship with the palliative care team and reduces the sense of abandonment when the antineoplastic treatment is stopped. In managing end-of-life decisions, advanced care planning is an important part of early palliative care interventions that should be offered to the patient and family, but only after patient consent and after the patient has the opportunity to discuss different options, such as a place of care, and his or her preferences about treatment and eventually palliative sedation. This open communication should be part of a continuing care process and should be guided by the patient s willingness to take part in it. Sharing of evaluation tools Recording the subjective clinical variables can allow the evaluation of quality of life in patients with cancer; the systematic use of patient-reported outcome measures is crucial in early palliative care and may improve the care process, providing better symptom control and increasing patient satisfaction. The employment of multidimensional assessment instruments, including both the most common symptoms and the psychosocial and spiritual dimensions, such as the Edmonton Symptom Assessment System, is highly recommended. 46 In the last few years, the EAPC has also proposed a minimum data set built on the basis of a formal agreement of familiar tools (EAPC basic data set, Table 3). 47 Indicators of the integration between palliative care and oncology The need for integration between oncology and palliative care has led healthcare professionals to promote and experiment with models of integration, which affirm the need for a comprehensive approach to palliative care and whose usefulness has been tested for the control of symptoms as well as to the best use of cost-sparing resources. However, at present, the measurable indicators to evaluate this integration are not unequivocally defined and can also vary depending on the organization of the structures, the care setting (home, hospital), and the involved players (oncologists vs palliative care team). Recent systematic evaluation of the literature has reported some useful indicators for the promotion of simultaneous combination of palliative and oncology care and for assessing effectiveness and impact of such a combination on the care pathway at different levels. 48 Based on the data from the literature and on the assessment of the reality in Italy, the AIOM-SICP Working Group has identified the following as an expression of the integration between oncology and palliative care: the presence of a specialist multidisciplinary team of palliative care and specialist outpatient palliative care, as clinical process indicators; the place of death being consistent with the wishes of the patient, monitoring of symptoms and quality of life in the 2 weeks prior to death, the proportion of admissions in the last 30 days of life, the proportion of visits to the emergency department in the last 30 days of life, the proportion of patients started on the path of palliative care, the proportion of patients who died in hospice or at home, and the proportion of patients admitted to hospice a week before death as clinical outcomes indicators; theoretical and practical training in palliative care as part of the Postgraduate School of Oncology and continuing education in palliative care for oncologists and in oncology for palliative care physicians as education indicators; and the presence of integrated research projects between palliative care and oncology as research indicators. 8 The integrators are summarized in Table 4. Possible models of care As previously described, we have thus far identified three groups of patients with advanced/metastatic cancer who need palliative care: patients with a good prognosis and low need of simultaneous care, patients with poor prognosis with high need of simultaneous care, and conditions with high need of simultaneous care regardless of cancer prognosis. Three different models of delivering palliative care may therefore be proposed. 5 In patients with metastatic/ advanced disease, who show response to anticancer treatments and have PS 0 1, and who are without cancer symptoms or with only mild symptoms, with life expectancy >12 months and good caregiver support, the organizational models can be represented by the solo practice and by the request for consultations reported by Bruera, 1 even though the availability of resources could also allow the application of the integrated model in this patient population. In patients with life expectancy <12 months, with low responsive disease, and with PS 2, or in patients receiving therapies whose side effects compromise the quality of life, the integrated care approach should meet needs of the patients, ensuring responses to patients symptoms and improving their quality of life, decreasing hospital admissions, and shortening waiting lists and length of stay, and thus reducing costs. In some patients, a high need for simultaneous care is always required regardless of cancer prognosis and the integrated care approach should be offered; these include patients with metastatic cancer and social frailty, even those

7 Corsi et al. 7 Table 3. European Association for Palliative Care basic dataset. Patient form Date of birth (Day, month, year) Sex Male Female Living situation Alone With spouse/partner With spouse/partner and children With children With other adult(s) In an institution Other Highest completed level of education Primary school Secondary school/high school College/university Ethnicity Symptoms Please circle the number that best describes how you feel NOW: No pain Worst possible pain No tiredness Worst possible tiredness (tiredness = lack of energy) No drowsiness Worst possible drowsiness (drowsiness = feeling sleepy) No nausea Worst possible nausea No lack of appetite Worst possible lack of appetite No shortness of breath Worst possible shortness of breath No depression Worst possible depression (depression = feeling sad) No anxiety Worst possible anxiety (anxiety = feeling nervous) Best wellbeing Worst possible wellbeing (wellbeing = how you feel overall) Best sleep Worst possible sleep No constipation Worst possible constipation No vomiting Worst possible vomiting Health care personnel form Date of birth (Day, month, year) Principal diagnosis ICD-10 code: Date of the principal diagnosis (month, year) Stage of the cancer disease Local Locally advanced Metastatic/disseminated Site of metastases Bone Liver Lung CNS Other Present anticancer treatment Radiotherapy Chemotherapy Hormone therapy Other anticancer therapy No anticancer therapy Additional diagnoses ICD-10 code:,,,,,,,,,, Stage of the noncancer disease Chronic heart failure: The New York Heart Association (NYHA) Functional Classification; NYHA class: I, II, III, IV Chronic obstructive pulmonary disease: GOLD classification; Stage: I, II, III, IV Dementia: FAST scale; stage: 1, 2, 3, 4, 5, 6, 7 (Continued)

8 8 Tumori Journal 00(0) Table 3. (Continued) Date of birth Medication Weight loss Performance status Cognitive function Place of care Provision of care (Day, month, year) Nonopioid analgesics Opioids Coanalgesics Corticosteroids Antidepressants Antiemetics Neuroleptics Sedatives/anxiolytics Drug(s) for acid-related disorders Laxatives Antibiotics Diuretics Heart medication /anti-hypertensives Other Involuntary weight loss % and duration of weight loss months 100 Normal; no complaints; no evidence of disease 90 Able to carry on normal activity; minor signs or symptoms 80 Normal activity with effort; some signs or symptoms of disease 70 Cares for self; unable to carry on normal activity or to do active work 60 Requires occasional assistance but is able to care for most needs 50 Requires considerable assistance and frequent medical care 40 In bed more than 50% of the time 30 Almost completely bedfast 20 Totally bedfast and requiring extensive nursing care by professionals and/or family 10 Comatose or barely rousable 0 Dead The patient has cognitive impairment No Mild Moderate Severe Home Long-term care facilities Hospice/palliative care unit Hospital Other Inpatient Outpatient Day care with response to treatment; patients who are without caregiver support or who have only fragmentary and limited caregiver support; patients with poor income; and out-ofwork immigrants. Discussion Even though law passed by the Italian Parliament in March 2010 attests that palliative care is a fundamental right for all Italian citizens, there is still a noticeable difference in the reality of the various Italian regions; palliative care consultation services are seldom accessible in the majority of Italian hospitals and the application of various practice models depends on the availability of the resources. Although there are still oncologists in Italy who offer their patients the possibility of palliative care only in the terminal phase of their disease, most oncologists are promoting the spread of early palliative care and have developed expertise in providing symptom control. A shared care model with the structures of palliative care operating in the area is often required, but its correct implementation is complicated by the absence of adequate economic resources and by bureaucratic difficulties; thus, a substantial updating of the current organizational models of healthcare, together with close collaboration between community-based and hospital assistance, is urgently needed to improve services dedicated to people with cancer. Independent of treatment intention, patients and their families are waiting for a multidimensional approach in which the integration of the competences of oncology and the palliative care approach may offer optimal standardized cancer care pathways, as individual plans, with clear

9 Corsi et al. 9 Table 4. Indicators of integration between oncology and palliative care. Clinical process indicators Presence of specialist multidisciplinary team of palliative care Presence of specialist outpatient palliative care Clinical outcomes indicators Place of death consistent with the wishes of the patient Monitoring of symptoms and quality of life in the 2 weeks prior to death Proportion of admissions in the last 30 days of life Proportion of emergency department visits in the last 30 days of life Proportion of patients starting the path of palliative care Proportion of patients who died in hospice or at home Proportion of patients admitted to hospice a week before death Education indicators Theoretical and practical training in palliative care as part of the postgraduate school of oncology Continuing education in palliative care for oncologists Continuing education in oncology for palliative care physicians Research indicators Presence of integrated research projects between palliative care and oncology indications of roles and competencies at any given point in time and with a clear characterization of how the specialists involved in simultaneous care should work together at any time during the course of the disease. AIOM and SICP are working together to promote early integration of palliative care, to raise awareness of the choices of politicians to guarantee the rights of cancer patients and to grant a better quality of life to both patients and their families. Declaration of conflicting interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. References 1. Bruera E and Hui D. Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care. J Clin Oncol 2010; 28: Zimmermann C, Swami N, Kryzanowska M, et al. Early palliative care for patients with advanced cancer: a clusterrandomised controlled trial. Lancet 2014; 383: Gomes B. Palliative care: if it makes a difference, why wait? J Clin Oncol 2015; 33: Turriziani A, Attanasio G, Scarcella F, et al. The importance of measuring customer satisfaction in palliative care. Future Oncol. Epub ahead of print 3 February DOI: / fon Campion EW, Kelley AS and Morrison RS. Palliative care for the seriously ill. N Engl J Med 2015; 373: Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol 2012; 30: Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline updated. J Clin Oncol 2017; 35: Documento del Tavolo di Lavoro AIOM SICP. Cure Palliative Precoci e Simultanee, sicp%20cure%20palliative%20precoci%20e%20simultanee/1,1148,1 (2015, accessed 15 December 2017). 9. AIOM-AIRTUM. I numeri del cancro in Italia 2017, (accessed 15 December 2017). 10. WHO. Strengthening of palliative care as a component of integrated treatment throughout the life course. Executive Board 134th session; provisional agenda item ; December Temel JS, Greer JA, Muzikansky A, et al. Early palliative for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363: Ramchandran K and Von Roenn JH. Palliative care always. Oncology 2013; 27: 13 16, 27 30, passim. 13. Shnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol 2012; 30: Dionne-Odom JN, Azuero A, Lyons KD, et al. Benefits of early versus delayed palliative care to informal family caregivers of persons with advanced cancer: outcomes from the ENABLE III randomized controlled trial. J Clin Oncol 2015; 33: Maltoni M, Scarpi E, Dall Agata M, et al. Systematic versus on-demand early palliative care: results from a multicentre, randomised clinical trial. Eur J Cancer 2016; 65: Maltoni M, Scarpi E, Dall Agata M, et al. Systematic versus on-demand early palliative care: a randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life. Eur J Cancer 2016; 69: Kavalieratos D, Corbelli J, Zhang D, et al. Association between palliative care and patient and caregiver outcomes a systematic review and meta-analysis. JAMA 2016; 316: Dahlin C. Clinical Practice Guidelines for Quality Palliative Care (3rd ed). Pittsburgh: National Consensus Project for Quality Palliative Care; 2013.

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