Supportive Care makes excellent cancer care possible Irma Verdonck-de Leeuw With many thanks to Age Schultz and Dorothy M Keefe
Supportive Care in Cancer The prevention & management of the adverse effects of Cancer and its treatment From early detection through diagnosis, treatment, survivorship or palliative care and End of Life care. Includes both physical and psychosocial support
Supportive Care in Cancer: alleviates symptoms and complications of cancer reduces or prevents toxicities of treatment supports communication with patients about their disease and prognosis allows patients to tolerate and benefit from active therapy more easily eases emotional burden of patients and care givers helps cancer survivors with psychological and social problems
SUPPORTIVE CARE THE DIFFERENT PHASES CANCER DIAGNOSIS CURATIVE PALLIATIVE REHABILITATION SURVIVORSHIP END OF LIFE CURE DEATH
The MASCC Mission Optimize supportive care in cancer patients worldwide Stimulate multi-disciplinary research Encourage international scientific exchange of information Expand professional expertise in supportive care Educate health care professionals worldwide in supportive care Serve as a resource for patients, families, and caregivers
MASCC: Multinational Association of Supportive Care in Cancer Over 800 members in more than 65 Countries Muliti-disciplinary Formed around Study Groups with an interest in a particular area of Supportive Care
17 MASCC Study Groups Anti-emetic Bone Education Fatigue Geriatrics Hemostasis Mucositis Neurological complications Nutrition and Cachexia Oral care Palliative care Pediatrics Psychosocial Rehabilitation, Survivorship & QOL Respiratory Skin Toxicity Neutropenia, infection & Myelosuppression
Palliative Care Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening ilness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. WHO 2002
Palliative and Supportive Care We need to remember that it is all about the patient, not about what we call the care There is room for both names - but maybe the emphasis of expertise is different We need to improve SC at the beginning without detriment to PC at the end
Differences Supportive Care is whole of Cancer journey Supportive Care is Cancer only Palliative Care is advanced disease and beyond Palliative Care is no longer confined to Cancer
Overlap is obvious Supportive Care Palliative Care Aims to optimize the comfort, function and social supports of the patient and their family at all stages of the disease Aims to optimize the comfort, function and social supports of the patient and their family when cure is not possible Cherny. Ann Oncol 2003;14:1335-1337
So, why is there confusion?
So, why is there confusion? Changing needs of patients Changing survival from cancer Problems with the image of the name Palliative Care A bit of Mission Creep
Paradox At the incurable disease end some Palliative Care services are now calling themselves Supportive Care so as not to frighten the patients. Simultaneously at the other end there is a move to call Supportive Care Palliative Care
Scenario 1 You are an Oncologist giving adjuvant chemotherapy to a 35yr old woman with breast cancer She has a 10 year survival prediction of 80% She develops severe nausea and febrile neutropenia from her chemotherapy Who should manage those side effects?
Option 1: Medical Oncology Medical Oncologists are trained in symptom management of the treatments they use No need for an extra referral Patient remains optimistic about survival Bread and butter part of the job
Option 2: Palliative Care Needs an extra referral Introduces the idea/fear of Palliative care You mean I am going to die? You mean you can make me sick but you can t help me when I get sick?! Do Palliative Care physicians really have the time or interest to manage such patients?
The patient is cured but has ongoing survivorship issues Who should see her now?
Option 1: Survivorship Service Area of great growth due to increased cure rates Models of care not fully developed
Option 2: Palliative Care Service Huge confusion You mean I am still going to die? Again, there are already practitioners in this space.
Option 3: Medical Oncology Possibly There are some with an interest in this area, but the majority don t really want to work in this space, and again have little spare time for it. Ripe for ongoing development by those with an interest
Cancer Survivors in USA Almost 14 Million 6 million over 70 years old 9 million have survived more than 5 years
Survivorship issues Oral complications Diarrhea/fistulas Bladder problems Cardiomyopathy Rehabilitation Depression Fatigue Communication Osteoporosis Quality of Life Neurotoxicity, cognitive dysfunction Lymphedema Fertility Psychosocial & spiritual support Comorbidity Polypharmacy Sexuality
Palliative Care & Survivorship Very, very important in relation to each other Including attention to both physical & psychosocial symptoms Interdisciplinary care. But the key issue really is the focus on identifying and managing symptoms in the post-treatment patient It is the successful completion of treatment and living well post-treatment that are the ultimate goals Mary McCabe. The ASCO Post 2013;4 (19)
Key Point In most of the world Palliative Care teams are in short supply and busy with advanced disease and death what priority would this woman be? Primary Palliative Care may also be part of Supportive Care and be the province of the Oncology Service
Scenario 2 56 year old heavy smoker with stage 4 lung cancer Starting palliative chemotherapy Already has pain and shortness of breath Prognosis is guarded at best Who should manage this patient?
Option 1: Medical Oncology Yes for the chemotherapy and acute symptoms of the treatment May not be so good for the pain and dyspnea This patient will (soon) have specialist palliative care needs
Option 2: Palliative Care Introduction of Palliative Care at this stage would be very beneficial Palliative care is going to clearly have an increasing role in his management over time Shared care at the start is optimum
So it all comes down to 2 things The name palliative is a bit scary for some, so a change to supportive has been suggested in some places. Palliative care should start at diagnosis of incurable disease not at diagnosis of curable cancer (which is where supportive care already sits).
Conclusion Palliative Care and Supportive Care are overlapping but not the same (even though the boundaries are blurred) Both are extremely important There is plenty of work for all of us to do Calling all of this care by one of these labels would diminish the care for the patient