Palliative care is finally getting its due, with the kickoff of the Inaugural Palliative Care in Oncology Symposium in Boston, MA, Friday, October 24, 2014. The Symposium is jointly sponsored by four medical societies: American Society of Clinical Oncology (ASCO), American Academy of Hospice and Palliative Medicine (AAHPM), American Society for Radiation Oncology (ASTRO), and the Multinational Association of Supportive Care in Cancer (MASCC).
Themes of the Palliative Care in Oncology Symposium segue from presentations at last week’s ASCO Quality Care Symposium. At that meeting, the focus was on palliative care—an important component of quality care, especially at end of life. Billions of dollars a year are wasted on unnecessary direct care, much of it on end of life care (in fact a 2012 IOM report states that it reaches $210 billion each year). The field is moving toward greater acceptance and use of palliative care when appropriate.
The pre-symposium press cast for the Palliative Care Symposium featured four presentations that addressed strategies to improve palliative care and the treatment-related financial burdens of cancer care for patients (referred to by quality care experts as “financial toxicity”).
Addressing Patients’ Financial Burdens (Abstracts 238 and 161)
In an analysis of nearly 1600 cancer survivors, a sizeable proportion of cancer patients reported financial and work-related burdens: about half were under age 65; 96% reported some kind of insurance; 27% reported at least one financial difficulty (defined as borrowing money, debt, bankruptcy, worry, and financial sacrifices), and 37% reported having to make at least one work modification (defined as early retirement, changing jobs, turning a promotion down, unpaid or extended leave) due to a cancer diagnosis.
People younger than age 65 reported 130% more financial difficulties than older survivors; the uninsured had 67% more financial difficulties than the insured; and minority groups reported 42% more financial difficulties than whites. The 14% of patients currently in active treatment made 120% more work modifications than those less than 5 years post-treatment; non-white minorities made 57% more work modifications than whites.
Lead author Robin Whitney, RN, BSN, a cancer survivor and PhD student at the University of California, Davis, Betty Irene Moore School of Nursing, said: “Many cancer survivors, particularly those who are younger and from underserved populations, experience financial or work-related hardship –even when insured and years out from treatment.” She and her co-authors say the findings of this study are generalizable to the U.S. population and reveal the need for screening and support for financial and work challenges across the survivorship trajectory.
“We now have more than 12 million cancer survivors,” said press cast moderator Jyoti Patel, MD, representing ASCO, “We need to address their financial hardships. As we deal with the consequences of cancer treatment and therapy, we need to find creative ways to address these burdens.”
Cancer Patients Make Lifestyle Adjustments
A related nationwide survey showed that due to treatment-related financial burdens, many insured cancer patients either make adjustments in lifestyle or make a compromise with their medical care. The study included 174 patients currently undergoing treatment for solid tumors—all of them insured and requesting financial assistance through a national copay assistance program.
Overall, 89% reported at least one lifestyle-altering strategy while 39% reported at least one medical care-altering strategy. Most common medical care-altering strategies were not filling a prescription (28%) and taking less medication than prescribed (23%). Lifestyle-altering coping strategies included spending less money on leisure activities (78%), spending less on food and clothing (57%), borrowing money (54%), and spending savings (50%).Younger age and lower income people were associated with increased care-altering strategies; while younger age, higher education level, and shorter time on chemotherapy were associated with greater likelihood of adopting lifestyle coping strategies compared with their counterparts.
“We need a better, more open dialog between patients and providers about the financial burdens associated with cancer care costs. People use a range of coping strategies, and we need to engage with patients on their choices and develop screening tools to identify patients who are likely to make potentially harmful decisions about their treatment,” said lead author Ryan Nipp, MD, an oncology fellow at Dana-Farber Cancer Institute in Boston.
Dr. Patel commented, “As we make strides in understanding the whole patient, it is incumbent upon us to have these discussions about financial burden with them. We need guided efforts to help support these patients, especially those at risk.”
“Co-Rounding” at Duke (Abstract 3)
According to a retrospective cohort analysis of a pioneering approach of “co-rounding” at Duke University Medical Center, daily collaboration between medical oncologists and palliative care specialists improved health system-related and patient-related outcomes. “Co-rounding” teams included 1 medical oncologist and 1 palliative care specialist as attending physicians, as well as ancillary healthcare providers. The teams met each day to discuss individual patients.
This first evaluation of “co-rounding” at Duke took place after one year of the new partnership which functioned in the hospital’s inpatient solid tumor oncology unit. Comparison between 731 patients admitted pre-intervention and 783 admitted in the first year of the intervention showed that “co-rounding” was associated with a significant decrease in length of hospital stay (4.17 days versus 4.51 days, respectively, P=.02); 15% reduction in the risk of 7-day readmission (P<.0001), and a 23% risk reduction for 30-day readmission (P=.048). ICU transfers were decreased by 15% from pre- to post-intervention, and hospice referrals were increased by 17% after “co-rounding” was instituted. Doctors and nurses expressed satisfaction with the new approach.
“Leveraging the skill sets of both palliative care physicians and medical oncologists has allowed us to better manage symptoms, shorten hospital stays, and prevent readmissions. We’ve also been able to dispel any misconceptions that individuals may have had about the role of palliative care, and we’ve shown that nursing and physician impressions of palliative care, as a whole, are very favorable,” stated lead author Richard Riedel, MD, Duke University Medical Center, Durham, NC.
“This study shows that integrating palliative care into oncology defines good oncologic care. We see that a novel approach called ‘co-rounding’ has achieved impressive results,” Dr. Patel stated.
“Smart Phone” System for Home Hospice (Abstract 85)
Preliminary findings from a randomized study of 319 hospice dyads and 121 nurses (some cared for multiple families) suggest that daily use of “smart technology” with an automated telephone-based remote symptom monitoring and coaching system alleviated patients’ symptoms and caregiver burden during home hospice care in the final weeks of life. The study population was drawn from 12 hospices in four different states. Almost half the patients (n=153) were randomly assigned to the intervention and the other patients (n=166) received usual care, which entailed symptom reporting alone.
“This is the first study to evaluate automated collection of patient-reported symptoms and its effect on family caregiver well-being and on coaching families on ways to improve care for their family member,” said lead study author Kathi Mooney, PhD, RN, Utah College of Nursing and the Huntsman Cancer Institute in Salt Lake City.
“Remote symptom care, working through the caregiver, provides benefits to the dying patient and caregiver,” stated Bob Wong, PhD, a statistician from the same institution who was an author of the study.
The automated, telephone-based symptom monitoring system used computer-based technology; the caregiver entered daily ratings (0-10, with 10 being the most severe) for 11 common symptoms that the patient could have experienced in the past 24 hours, and then got feedback from the system if any of the symptoms were rated 4 or higher. The feedback included tips for the caregiver about how to relieve patient’s symptoms; for example, coaching on such maneuvers as positioning the patient for greater comfort or improved breathing, and how to improve time together. Caregivers also reported their own difficulties during the past 24 hours, such as fatigue, anxiety, difficulty sleeping and negative mood.
Over a 91-day period, patients whose caregivers were assigned to the automated system experienced 44% fewer days of moderate or severe fatigue or anxiety compared with patients in the usual care group. Caregivers in the intervention group had no worsening of vitality (as measured by daily functioning and sleep) over that period, while the usual care caregivers had worsened vitality.
“Caregiving is a 24-hour-a-day, 7-days-a-week job,” Dr. Patel commented. “Most caregivers cannot do it alone. This remote monitoring system proactively supports the caregiver at this difficult time when the patient is near death.”
By Alice Goodman