Benefits of Integrating Surgical Palliative Care Into Treatment Protocols for Cancer

Palliative care is a practice that has come into its own. Specialty palliative care refers to care provided by dedicated palliative care teams, and primary palliative care denotes the care that the team in a specialty provides. Thus, in the oncology setting, primary palliative care relies on the oncology team, although optimizing surgical palliative care requires incorporating both specialty and primary palliative care.¹

Clinical practice guidelines from the American Society of Clinical Oncology (ASCO) recommend dedicated palliative care services for inpatients and outpatients with advanced cancer early in the course of their diseases, ie, while they are undergoing active treatment. The ASCO recommendation notes that “referral of patients to interdisciplinary palliative care teams is optimal.”²

Marisa R. Moroney, MD, and Carolyn Lefkowits, MD, MPH, MS, conducted a review of studies on integration of palliative care in surgical oncology.¹ Their review included these findings:

• Researchers who randomized 461 patients with an advanced cancer (estimated survival, 6 to 24 months) to standard oncology care or oncology care plus specialty palliative care found that patients in the palliative care arm had significantly improved quality of life and better symptom management, spiritual well-being, and satisfaction with their care.
• A trial in which 322 patients with advanced cancer were randomized to receive “psychoeducational” telephone consultations with an advanced practice nurse who had specialty palliative care training found that the patients in the nurses’ palliative care group had better quality of life, symptom management, and mood. The telephone consultations focused on symptom management, social support, and communication, as well as advanced care planning.
• In a study of patients with breast or gynecologic cancer, patients at different points in the disease course terminated their cancer-directed therapies and followed up with planned specialty palliative care. Researchers found that patients who received early palliative care had better quality of life, fewer episodes of depression, and required less chemotherapy in the last 6 weeks of life, compared with those whose palliative care was later. The researchers noted that earlier palliative care was an independent predictor of overall survival.
• A study involving patients who had undergone surgery for gynecologic cancer demonstrated improved symptoms within 1 day of their inpatient specialty palliative care consultation.¹

Understudied and Underutilized

Given that integrated palliative care has increasingly proven its efficacy in studies on surgical patients, and that ASCO recommends it for all patients with advanced cancer, expectations are that palliative care would be a common addition to surgical practices. However, that is not the case. In fact, palliative care is underutilized.

For example, in a study of medical and surgical patients with cancer diagnoses who had undergone major surgery within the last year of life, less than 50% of all patients and significantly fewer of the surgical patients received palliative care or a hospice consultation.¹

Several studies showed that formal education in palliative care skills is lacking, despite the recommendations of the Accreditation Council of Graduate Medical Education (ACGME) and the Society for Surgical Oncologists (SSO), who have advocated for training in palliative care skills to be integrated into graduate medical education.

A number of studies evaluating fellowship training in surgical oncology disciplines concluded that there is very little formal education in palliative care skills. One study found that only 51% of fellows were exposed to the specialty palliative care service during their fellowship, 46% had never observed faculty discussing goals of care with a patient, and 57% had never received critiques on their own palliative care skills.¹

Seek Out Self-Education Opportunities

“If you have a good palliative care team at your hospital, you can pick up many good tips that can really serve you and your patients just by your going to and observing family meetings,” notes Robert Milch, MD, a founder of the surgical palliative care movement. “My dad was also a surgeon and always conveyed to me that what went on in the operating room was but a small part of the totality of the care of the patient. That sensitized me to always take a holistic view of the patient and the practice of medicine.

“Once we come to the realization that most of what we do is ultimately palliative, that leads us to be able to redefine good outcome. It provides a continuity in caring that we often lose,” he added.³

Surgical specialty clinicians who do not have formal training in palliative care and want to introduce palliative care into their practice should take advantage of the palliative care nurse’s expertise. They can refer patients to outpatient care soon after a cancer diagnosis or consult the inpatient palliative care team. Through collaborating with nursing and other integrated palliative care services, they can integrate their surgical goals with the treatment, quality of life and comfort goals of their patients.

References

1. Moroney MR, Lefkowits C. Evidence for integration of palliative care into surgical oncology practice and education. J Surg Oncol. 2019;120(1):17-22. doi:10.1002/jso.25454.

2. Ferrell BR, Temel JS, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017;35(1):96‐112. doi:10.1200/jco.2016.70.1474

3. Dr. Robert Milch: Surgical Palliative Care Pioneer. The Surgical Palliative Care Podcast. January 13, 2020. Accessed October 14, 2020. https://thesurgicalpalliativecarepodcast.buzzsprout.com/740810/2454425-dr-robert-milch-surgical-palliative-care-pioneer