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Top Takeaways from ASH: Palliative care emerges in treatment for hematologic malignancies
An educational session presented over two mornings at the ASH Annual Meeting and Exposition provided a comprehensive view of implementing palliative care in the treatment of patients with hematologic malignancies.
With the multidisciplinary approach often misunderstood in current practice, experts in attendance shared their key takeaways on the new definition of, mounting data in and emerging role of palliative care in practice.
“This is the first time in history that ASH has held an educational session for palliative care, and this is very exciting,” Eric J. Roeland, MD, of the Moores Cancer Center, University of California San Diego, La Jolla, CA, a presenter in the session, told Healio.com.
Eric J. Roeland
Misperceptions, definition and collaboration
Although palliative care has historically has been synonymous with end-of-life care, Roeland said the “modern definition” conveyed in the session was different.
“It really supports how palliative care can be integrated in standard oncology care starting at diagnosis,” he said.
Hematologists need to understand palliative care is specialized medical care for patients diagnosed with a serious illness, according to Thomas W. LeBlanc, MD, MA, of the Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, N.C., session chair and presenter.
“People tend to just think we are talking about something like hospice, but really this is sophisticated sub-specialty medical care for people who are facing illnesses like hematologic malignancies or other cancers,” LeBlanc told Healio.com.
Thomas W. LeBlanc
He emphasized the community now uses very specific language, based off public opinion polling, to define palliative care. This includes: a focus on relieving the symptoms and stress of a serious illness; providing an extra layer of support to patients in addition to standard cancer care; and is appropriate at any age and any stage in a serious illness.
The educational session also shed light on the distinct types of palliative care, another area lacking clarity, Roeland said.
“Primary palliative care is provided by the treating oncologist or hematologist; this is basic symptom management and basic advanced care planning,” he said. “Specialty palliative care is provided by a team that has extra training in complex symptom management, communication and advanced care planning. The third level is sub-specialty palliative care, which is specific to medical contexts.”
Roeland highlighted stem cell transplantation as an example of the subspecialty level, noting it requires a thorough understanding of the culture surrounding the procedure, as well as its treatments and related toxicities.
“We’re incorporating palliative care more and more in specific areas such as cardiology, end-stage liver disease, nephrology and neurology,” he said. “Generally-trained palliative care providers are really challenged unless they understand the nuances of each disease and [its] course.”
The many oncologists now being trained in palliative care stand to be “effective conduits” in integrating care approaches, Roeland added.
He said the community stands to benefit from taking advantage of new opportunities for collaboration.
“As cancer care becomes increasingly complex, palliative care providers need to be open to partnering with oncologists in the same way that oncologists need to learn about the ever-changing landscape of palliative care and all these new data and tools.”
Evidence, research and efforts
Several large randomized controlled trials demonstrate that early concurrent palliative care as part of treatment improves symptom management, quality of life, depression and mood, health care utilization and even survival, LeBlanc said.
One study showed patients with metastatic non-small-cell lung cancer experienced significant quality of life and mood improvements with palliative care vs. standard care, as well as longer survival with less aggressive treatments.
In Project ENABLE (Educate, Nurture, Advise, Before Life Ends), patients with advanced cancers demonstrated better quality of life and mood with palliative care vs. standard care in one trial, and in another longer survival was observed among patients who started palliative care early.
“If we saw these kind of outcome improvements with a cancer drug, it would be a billion-dollar blockbuster,” he said. “We really need to figure out how to bring palliative care more to standard cancer care.”
That being said, the available data on integrating palliative care in oncology treatment has all been in the solid tumor patient population.
Roeland noted some methods used to measure care in oncology, such as ICU admissions or incidence of chemotherapy within the last 14 days, may not be appropriate in hematology.
LeBlanc concurred, noting that additional investigation was needed “explicitly” in patients with blood cancers.
“We need to study what are the most effective ways to integrate palliative care into standard oncology care, specifically in benign and malignant and hematologic diagnoses,” he said.
New data from research by Areej R. El-Jawahri, MD, of Massachusetts General Hospital, Boston, and colleagues looking at early palliative care vs. standard oncology care in patients with hematologic malignancies undergoing stem cell transplantation, is anticipated within the next year.
“We're going to learn from that a lot of nuances that are quite different between solid and liquid cancers,” Roeland said.
He also highlighted an “exciting” palliative care task force spearheaded by Effie Wang Petersdorf, MD, president of the American Society for Blood and Marrow Transplantation and member of the clinical research division at Fred Hutchinson Cancer Research Center, Seattle.
“This large group is really trying to define what the needs are for hematologic malignancies and then to effectively engage with institutions such as the American Academy of Hospice and Palliative Medicine and ASH to look at how we are going to fund research in this critical area,” Roeland said. - by Allegra Tiver
Reference: Palliative Care in Hematological Malignancies. Presented at: ASH Annual Meeting and Exposition; Dec. 5-8, 2015; Orlando, Fla.
Disclosures: LeBlanc reports consulting for Epi-Q and Flatiron; serving on a board/committee for Boehringer Ingelheim; and receiving honoraria/research funding from Helsinn Therapeutics. Roeland reports no relevant financial disclosures.