Richard Berman: traditional palliative care no longer serves the cancer population
A tsunami is coming.
Decades of investment in cancer treatments are paying off. The push to improve survival, our application of cancer genomics coupled with the explosion of targeted systemic anti-cancer therapies (SACT) is transforming the field of oncology (1). More and more people are surviving the disease. Many will live for longer, much longer, even with incurable disease. We now talk of ‘metastatic cancer survivorship’ (2), of ‘late effects’ (even in those on palliative treatments), and of ‘living with and beyond’ cancer.
So now a hard truth: The traditional palliative care approach no longer fully serves the needs of the cancer population. Twenty years ago, we could celebrate the integration of palliative care within oncology as being a pinnacle point in the provision of a wholly comprehensive package of care for people with the disease. End of life care still remains a hugely important component of cancer care. But things are getting very, very different. The world around palliative care has changed. Patients are not just living for longer. They are, in many cases, now living with cancer for significant periods of time. And with many of the newer targeted therapies having lower toxicity profiles than conventional chemotherapy, patients have come to expect a reasonable quality of life during their cancer journey. This does not mean this time period is without burden. On the contrary, prolonged periods of chronic ill health bring with them a complexity of physical, psychosocial and spiritual issues.
Palliative care developed in response to a pre-existing clinical need, initially prompted by a paradigm shift in how we manage terminal illness. The need for what is becoming known as “supportive care” (or more recently “supportive oncology”) – which encompasses the entire cancer spectrum - has developed in response to a changing patient demographic and rise in said populations. The Multinational Association of Supportive Care in Cancer (MASCC) defines this as ‘the prevention and management of the adverse effects of cancer and cancer treatments’. Optimal supportive oncology requires input from a broad range of medical and non-medical specialties working in an integrated way across the whole cancer pathway. Palliative care, with some tweaking (3), has a part in this, but can no longer be regarded as the sole provider. Alongside this, the research base to help guide our clinical practice in these groups is distinctly lacking. For example, how we manage pain at the end of life cannot the same as how we manage pain in those living with the disease for many years, or in those who have survived the disease. How we manage sickness at the end of life is very different from how we prevent/manage sickness induced by chemotherapy (1).
Palliative care is, alongside other supportive specialties, an essential component of supportive oncology. Indeed in many centres, early development of supportive oncology (often implemented through the Enhanced Supportive Care initiative) has been led by palliative care teams. In cancer, treatment advances and changing populations are triggering an urgent re-think in how we deliver care. Palliative care, as a specialty, has a great opportunity to embrace this. Not doing so may risk further side-lining the specialty.
(1) Berman R, Laird BJA, Minton O, Monnery D, Ahamed A, Boland E, Droney J, Vidrine J, Leach C, Scotté F, Lustberg MB, Lacey J, Chan R, Duffy T, Noble S. The Rise of Supportive Oncology: A Revolution in Cancer Care. Clin Oncol (R Coll Radiol). 2023 Apr;35(4):213-215. doi: 10.1016/j.clon.2023.01.015. Epub 2023 Jan 23. PMID: 36737312.
(2) Julia Lai-Kwon, Sarah Heynemann, Nicolas H. Hart, Raymond J. Chan, Thomas J. Smith, Larissa Nekhlyudov, and Michael Jefford
Evolving Landscape of Metastatic Cancer Survivorship: Reconsidering Clinical Care, Policy, and Research Priorities for the Modern Era
Journal of Clinical Oncology 2023 41:18, 3304-3310
(3) Power, J., Gouldthorpe, C. & Davies, A. Palliative care in the era of novel oncological interventions: needs some “tweaking”. Support Care Cancer 30, 5569–5570 (2022). https://doi.org/10.1007/s00520-022-07079-2