Thursday, July 22, 2010

Why not palliative oncology?

WHY NOT PALLIATIVE ONCOLOGY?

The goal of palliative care is to relieve symptoms, reduce suffering and improve a patient’s quality of life. In palliative oncology chemotherapy and radiation are used, not for a logarithmic cell kill, but to resolve specific problems caused by the cancer. Thus the focus of palliative oncology differs from its more aggressive traditional role. Here intent is the key difference; “curing” versus “healing”. Until recently the primary objectives of oncology had been summated in the following adage.

“Foremost to cure,
If no cure then to control,
If no control then to palliate”

With the advent of hospice and palliative care, palliative oncology should no longer be an issue of giving more and more pain medication. Chemotherapy and radiation can be administered, albeit at lower dosages and shorter schedules, for the purpose of reducing or eliminating symptomatic tumors. In short, palliative oncology can reduce the symptoms, suffering and pain medication requirement by controlling the cancer.

The primary targets of palliative oncology are these symptoms categorized below.
Compression; of nerves, vessels and lymphatics which can lead to neuropathies and limb edema / thrombosis. The application of radiation focally or chemotherapy for multiple-site effects can decrease pain and swelling. An example of this would be the administration of 30 Gy / 10 fractions in the treatment of spinal cord compression or carcinomatous plexopathy.
Hemorrhage; as with a cancerous skin wound can have radiation applied for as little as 250-800 cGy per fraction daily. This can stop weeping in a few days. It can also sclerose most bleeding vessels though its efficacy decreases as the target vessel becomes larger.
Obstruction; as with a hollow viscus chemoradiotherapy can be given to reduce tumor obstruction, thereby allowing a stent placement and hopefully obviating the need for a diverting ostomy.
Pain; and by this I mean intractability to medical management. Under circumstances where a growing cancer is causing increased pain it may only be a stopgap measure to increase a patient’s morphine or methadone, or to add adjuvant medications. With as little as 800 cGy / 1 fraction, for example, pain relief can be achieved and the radiation can be repeated later if necessary.

In the setting of metastatic ‘solid’ tumors palliation is always the main course with quality of life as the primary goal. For metastatic cancer the consensus of a European expert panel determined that the goals of (palliative) chemotherapy are to obtain maximum control of symptoms, prevent serious complications and increase survival without diminishing quality of life. (1) Palliative treatment should control disease in at least 20-30% of patients with an acceptable side-effect profile. The patient’s quality of life also seemed to fare better when personal issues were considered such as oral (versus intravenous) therapy, home (versus clinic / hospital) treatment and regimens designed so as to prevent or at least decrease the risk of hospitalization. Furthermore, the overall costs of home-based and oral-based chemotherapy are less than their traditional counterparts.

In the metastatic setting when a ‘cure’ is no longer obtainable the patient’s involvement in their quality of care becomes just as important. When offered second-line chemotherapy for advanced breast cancer patients were more likely to proceed with treatment due to the HOPE that the chemotherapy offered and, additionally, were most likely to take an active role in their treatment (than did women offered first-line chemo). They did so even though their expectations for a ‘cure’ were diminished. (2, 3, 4)

Palliative oncology typically involves adjusting or titrating regimens to fit the patient’s needs (eg improve the quality of life). Our standard chemotherapy regimens can be amended to provide maximal palliative effect with minimal toxicity, no matter what the patient’s status. This was recently echoed at the university level; “physicians at Moffitt have demonstrated that chronologic age poorly reflects physiologic age and that cancer treatment needs to be tailored to the individual patient”. (5)

Palliative oncology proffers a new point of view. Isn’t using chemotherapy and radiation for palliative care just as important as its use for cure? Do we dwell too much on new pain medications when we could offer our cancer patients these alternate ways to reduce their suffering?


References;
1. Crown J, Dieras V, Kaufmann M, von Minckwitz G, Kaye S, Leonard R, Marty M, Misset JL, Osterwalder B, Piccart M: Chemotherapy for metastatic breast cancer – report of a European expert panel. The Lancet Oncology. 2003;3:719-726.

2. Grunfeld E, Maher EJ, Browne S, Ward P, Young T, Vivat B, Walker G, Wilson C, Potts HW, Westcombe AM, Richards MA, Ramirez A: Advanced breast cancer patient’s perceptions of decision making for palliative chemotherapy. J Clin Oncol 2006;24(7):1090-1098.

3. Matsuyama R, Reddy S, Smith TJ: Why do patients choose chemotherapy near the end of life? A review of the perspective of those facing death from cancer. J Clin Oncol 2006;24(21):3490-3496.

4. Harrington S, Smith TJ: The role of chemotherapy at the end of life. JAMA 2008;299(22):2667-2678.

5. Extermann M. Senior adult oncology program. Moffitt Cancer Center / USF. June 2009.

by: Robert Killeen MD

9 comments:

sei said...

Excellent post. Reminds me that as Hospice has moved towards palliative care and is focusing on patients who are less close to the end of life, non-hospice docs (especially oncologists) should move toward hospice patients to see how their treatment modalities may be re-fashioned to help palliate sxs.

Rance said...

I agree with your comments in the posting. The concern I have and clinically see is the lack of honest prognostication and discussion of the medical condition.

Alex Smith said...

Enjoyed reading this post - very informative as well as thought provoking. I agree palliative treatments may involve expensive and high tech treatments usually associated with life-prolonging treatment, such as radiation or chemotherapy. The concern I have is that some treatments that are labled "palliative" are sometimes not explained as such to patients - in my experience many patients receiving palliative chemotherapy believe the purpose of the chemo is to prolong their lives, not control disease or reduce symptom burden. This communication breakdown is sometimes due to patient factors (e.g don't want to hear it) and sometimes due to cliniican factors (lack of informed disclosure). This distinction between chemo or radiation with the intent to cure vs. intent to palliate is important, because in my clinical experience, some patients decide against further chemotherapy when they understand that the chemo is targeted at reduction of tumor and symptom burden, not life-extension.

Cyndi said...

Thank you for a great post! I've been "preaching" this for years...
But I'd also like to add that there are a number of patients on drugs to prolong their lives a bit longer that should still be considered Palliative Care Patients.

I'm thinking of drugs like Avastin that aren't necessarily curing diseases like Lung Cancer, but are giving these patients more time--with quality!

I agree, too often these conversations are not done well. Too many cancer patients think that they are being cured when that is not the goal (short of that rare miracle--and they do happen--but they are few & far between.

That's why palliative care trained professionals are important members of the team--to have those "difficult conversations"...

ken covinsky said...

Thanks for a really interesting post. It is forcing me to rethink some of my perceptions about this issue.

During this and past medicine attending months, we have had a number of patients who were described as receiving "palliative chemotherapy." My usual initial reaction is a doubletake, as if the very term is an oxymoron. I have sometimes felt like asking, "so exactly what is that we are palliating?"

Dr. Killeen eloquently describes a number of situations where chemotherapy and radiation can truly be palliative, and help the patient symptomatically, and improve their quality of life.

But I also wonder if the term "palliative chemotherapy" is sometimes used too generically, to denote a situation in which we are giving chemotherapy we know to be non curative, but without a specific symptomatic targets in mind, hoping the chemotherapy will help the patient in some way.

It seems that a decision to give palliative chemotherapy should be accompanied by a clear statement of exactly what symptoms we are palliating. That way, we could have a way of assessing whether the chemotherapy meets the goals of palliation. Along these lines, if the chemotherapy is truly palliative, it seems there should be some explicit approach in which we decide if the palliative benefits of chemo are outweighing the side effects, with better criteria for continuing or stopping therapy.

I wonder how much palliative chemotherapy is based on actual evidence. Since the use of palliative chemotherapy seems to quite common, it would be nice to have more clinical trials that recognize this potential use and have end points focused on palliative goals.

Shreda Paire, MS, RN, FNP-C, ACHPN said...

This is an excellent discussion of a complicated issue.

As a palliative care NP when working with patients in similar states, I find that when the patients are still receiving chemo or radiation, they often have not been told (or heard) that this is palliative and not curative. These treatments are also not covered by the Medicare hospice benefit, which means that the patient and family are not receiving the support and care that hospice can provide. In many instances, I have seen the patient decline while undergoing these treatments and this can lead to a last minute hospice referral which can frustrate our hospice colleagues and really strains the patient and family as they both with developing trust with yet another new health-care team (hospice) and they struggle with end- stage symptom management. Until open access hospice is available, I think these issues will continue.

The cost of these treatments in the setting of our rapidly rising healthcare costs in America was not been mentioned. Who gets these treatments and who doesn't often depends on their insurance coverage and this is sure to evolve when more are required to be covered- is this a sustainable use of resources? No one knows but the implications are immense.

At a more basic level, we must remember that the more treatments and appointments that we schedule, these cost our patients and their families to spend hours, days and weeks in our facilities instead of spending their precious time doing the very important things that they might prefer in their limited remaining time.

Certainly, involvement of palliative care early would help to facilitate conversations (at diagnosis, in a perfect world).

Just my thoughts...

jessica forester said...

After 6 months of offering stem cell therapy in combination with the venous angioplasty liberation procedure, patients of CCSVI Clinic have reported excellent health outcomes. Ms. Kasma Gianopoulos of Athens Greece, who was diagnosed with the Relapsing/Remitting form of MS in 1997 called the combination of treatments a “cure”. “I feel I am completely cured” says Ms. Gianopoulos, “my symptoms have disappeared and I have a recovery of many functions, notably my balance and my muscle strength is all coming (back). Even after six months, I feel like there are good changes happening almost every day. Before, my biggest fear was that the changes wouldn’t (hold). I don’t even worry about having a relapse anymore. I’m looking forward to a normal life with my family. I think I would call that a miracle.”

Other recent MS patients who have had Autologous Stem Cell Transplantation (ASCT), or stem cell therapy have posted videos and comments on YouTube. www.youtube.com/watch?v=jFQr2eqm3Cg.

Dr. Avneesh Gupte, the Neurosurgeon at Noble Hospital performing the procedure has been encouraged by results in Cerebral Palsy patients as well. “We are fortunate to be able to offer the treatment because not every hospital is able to perform these types of transplants. You must have the specialized medical equipment and specially trained doctors and nurses”. With regard to MS patients, “We are cautious, but nevertheless excited by what patients are telling us. Suffice to say that the few patients who have had the therapy through us are noticing recovery of neuro deficits beyond what the venous angioplasty only should account for”.

Dr. Unmesh of Noble continues: “These are early days and certainly all evidence that the combination of liberation and stem cell therapies working together at this point is anecdotal. However I am not aware of other medical facilities in the world that offer the synthesis of both to MS patients on an approved basis and it is indeed a rare opportunity for MS patients to take advantage of a treatment that is quite possibly unique in the world”.

Autologous stem cell transplantation is a procedure by which blood-forming stem cells are removed, and later injected back into the patient. All stem cells are taken from the patient themselves and cultured for later injection. In the case of a bone marrow transplant, the HSC are typically removed from the Pelvis through a large needle that can reach into the bone. The technique is referred to as a bone marrow harvest and is performed under a general anesthesia. The incidence of patients experiencing rejection is rare due to the donor and recipient being the same individual.This remains the only approved method of the SCT therapy. For more information visit http://ccsviclinic.ca/?p=838

robert taylor said...

“Unnecessary risks are being taken by patients seeking the liberation treatment.” says Dr. Avneesh Gupte of the CCSVI Clinic. “It has been our contention since we started doing minimally invasive venous angioplasties nearly 6 years ago that discharging patients who have had neck vein surgery on an outpatient basis is contra-indicated. We have been keeping patients hospitalized for a week to 10 days as a matter of safety and monitoring them for symptoms. Nobody who has the liberation therapy gets discharged earlier than that. During that time we do daily Doppler Ultrasounds, blood work and blood pressure monitoring among other testing. This has been the safe practice standard that we have adopted and this post-procedure monitoring over 10 days is the subject of our recent study as it relates to CCSVI for MS patients.”

Although the venous angioplasty therapy on neck veins has been done for MS patients at CCSVI Clinic only for the last 18 months it has been performed on narrow or occluded neck veins for other reasons for many years. “Where we encounter blocked neck veins resulting in a reflux of blood to the brain, we treat it as a disease,” says Gupte. “It’s not normal pathology and we have seen improved health outcomes for patients where we have relieved the condition with minimal occurrences of re-stenosis long-term. We believe that our record of safety and success is due to our post-procedure protocol because we have had to take patients back to the OR to re-treat them in that 10-day period. Otherwise some people could have run into trouble, no question.”

Calgary MS patient Maralyn Clarke died recently after being treated for CCSVI at Synergy Health Concepts of Newport Beach, California on an outpatient basis. Synergy Health Concepts discharges patients as a rule without in-clinic provisions for follow up and aftercare. Post-procedure, Mrs. Clarke was discharged, checked into a hotel, and suffered a massive bleed in the brain only hours after the procedure. Dr. Joseph Hewett of Synergy Health recently made a cross-Canada tour promoting his clinic for safe, effective treatment of CCSVI for MS patients at public forums in major Canadian cities including Calgary.

“That just couldn’t happen here, but the sooner we develop written standards and best practices for the liberation procedure and observe them in practice, the safer the MS community will be”, says Dr. Gupte. “The way it is now is just madness. Everyone seems to be taking shortcuts. We know that it is expensive to keep patients in a clinical setting over a single night much less 10 days, but it’s quite absurd to release them the same day they have the procedure. We have always believed it to be unsafe and now it has proven to be unsafe. The thing is, are Synergy Health Concepts and other clinics doing the Liberation Treatment going to be changing their aftercare methods even though they know it is unsafe to release a patient on the same day? The answer is no, even after Mrs. Clarke’s unfortunate and unnecessary death. Therefore, they are not focused on patient safety…it’s become about money only and lives are being put at risk as a result.”

Joanne Warkentin of Morden Manitoba, an MS patient who recently had both the liberation therapy and stem cell therapy at CCSVI Clinic agrees with Dr. Gupte. “Discharging patients on the same day as the procedure is ridiculous. I was in the hospital being monitored for 12 days before we flew back. People looking for a place to have the therapy must do their homework to find better options. We found CCSVI Clinic and there’s no place on earth that’s better to go for Liberation Therapy at the moment. I have given my complete medical file from CCSVI Clinic over to my Canadian physician for review.” For more information Log on to http://ccsviclinic.ca/?p=866 OR Call on Toll Free: 888-419-6855.

Leo Voisey said...

Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike "differentiated" cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
History
Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner. For more information please visit http://www.neurosurgeonindia.org/