“Practical and specific” guide for general oncologists about providing supportive care when specialists are unavailable
Palliative care specialists are not always available in everyday practice, and it often falls to general oncologists to assess palliative care needs. Oncologists must therefore be familiar with the requirements and priorities for primary supportive care — a topic recently reviewed by Naoto Ueno, MD, PhD, of the University of Texas MD Anderson Cancer Center in Houston, and colleagues, in an article in JCO Oncology Practice.
The priorities of palliative care for metastatic breast cancer (MBC) vary depending on patients’ disease progression status. However, the progression patterns of the disease are heterogeneous; patients experience acute and stable phases at different times. Oncologists should be able to recognize the needs and appropriate timing of palliative care, Ueno and colleagues stated.
“The purpose of this review is to provide a practical guide for oncologists to understand when and how to provide supportive care for patients with MBC, prioritized by phase of disease progression, in an individualized comprehensive manner,” the authors wrote.
In the following interview, Ueno, section chief of Translational Breast Cancer Research and executive director of the Morgan Welch Inflammatory Breast Cancer Research Program and Clinic, discussed key aspects of the review.
As you noted, guidelines for palliative care have already been published by several organizations. Why then did you decide to write this review?
Ueno: All the guidelines are not written from the perspective of oncologists, caregivers, or patients. Supportive care is quite complex and demanding. Therefore it was important to break down the content to make it easier to understand. Also, there is sometimes the misunderstanding that everything written in the guidelines needs to be provided regardless of patients’ overall status. We know that rapidly deteriorating patients may need a different focus. We know that in our mind, but we never clearly stated this as a manuscript. That is why we wrote this review.
The review provides palliative care checklists according to the disease progression phase. Can you tell us about these lists and how they were developed?
Ueno: We conducted a review of different topics — EBM [evidence-based medicine]-based — and also discussed different providers’ and caregivers’ experiences. Not all are based on previous literature. I recommend that you modify the checklist depending on your practice situation.
You write that performance status should be broadened to consider not only physical status but also psychosocial needs and cognitive condition. Why is this?
Ueno: The current performance status is more of a reflection of what you only can see or the patient will tell you. It does not reflect the emotional distress, which does not mean that the current scale of performance status will go down. Providing direct cancer treatment under good performance status without other components can result in a poor outcome of treatment and more toxicities. We need a better tool to do a better job as oncologists. Good performance status does not mean that we can start the treatment.
One barrier you mentioned to integrating palliative care into oncology is the timing of referral. Can you tell us about this and how it might be overcome?
Ueno: It a very challenging question. We all know that we cannot refer every patient to the palliative or supportive care service. The patient may not feel the need, or there is no capability to handle the volume. The key is the engagement of caregivers and patients. Furthermore, there is the need to make the supportive care approach for the oncologist more dynamic and easy to understand by improving the existing guidelines.
The current guideline is well written but it is hard for a medical oncologist to implement all the things that are written. I am not saying what we wrote is the best or the perfect one. I would consider prioritizing what would be the best for patients by using the checklists and providing better education to our oncologists who are not palliative care physicians.
Barbara Jacoby is an award winning blogger that has contributed her writings to multiple online publications that have touched readers worldwide.