By Leah Lawrence

The 2017 Palliative and Supportive Care in Oncology Symposium took place October 27-28 in San Diego, CA. It featured compelling research and the latest in clinical education that could be used to advance patient-centered care across the cancer continuum, according to Program Committee chair Tracy A. Balboni, MD, MPH, of Harvard Medical School.

Among the symposium highlights was the inspiring keynote session, Dr. Balboni said.

Keynote lecturer Angelo E. Volandes, MD, MPH, of Massachusetts General Hospital, featured his impactful work in the use of video-based patient- and community-centered educational methods to improve understanding and decision-making for end-of-life care.

“Patients repeatedly expressed how these educational videos brought an understanding of their end-of-life medical decisions in a way that words alone too often fail to achieve,” Dr. Balboni said.

Anthony Back, MD, of the University of Washington and Fred Hutchinson Cancer Research Center, received this year’s inaugural Walther Cancer Foundation Palliative and Supportive Care in Oncology Endowed Award and Lecture. During his lecture, he called for a multilevel, multistakeholder response to the epidemic of clinician burnout. 

“He described the need for not only personal burnout prevention strategies but also comprehensive workplace strategies,” Dr. Balboni said. “These include optimizing clinical workloads, strategizing to enhance systems efficiencies, systems changes to allow for clinician autonomy, attention to work-life balance, upholding shared values, and efforts to enhance community.” 

Symptom management

Dr. Balboni described the research presented during the symposium as compelling and practical. Several sessions addressed symptom management in patients with cancer, such as nausea and fatigue.

Nausea assessment doesn’t take long, according to Rudolph M. Navari, MD, PhD, FACP, of the University of Alabama at Birmingham, who presented on nausea associated with advanced cancer during General Session 3. Assessment should include simple questions about frequency, associated activities, and time of day. It is also important to establish whether nausea is associated with chemotherapy or radiation treatment because nontreatment causes are numerous. Nontreatment-related causes include bowel obstruction, malignant ascites, concurrent medications, anxiety, and depression. After etiology is determined, use of guideline-directed treatment, followed by regular reassessment, is recommended.

Cancer-related fatigue occurs in as many as 25% to 99% of patients with cancer and persists even among survivors, said Sandra A. Mitchell, PhD, CRNP, AOCN, of the National Cancer Institute. During General Session 3, Dr. Mitchell discussed the scope of cancer-related fatigue and challenges associated with it. For example, fatigue can be difficult to distinguish from other symptoms such as depression, cognitive dysfunction, or asthenia. Fatigue may occur alone or as a component within a cluster that includes pain, depression, and sleep disturbances. Because fatigue can affect health-related quality of life and long-term survival outcomes, it is critical to individualize fatigue management plans. This often means using one or a combination of fatigue interventions, including exercise, management of concurrent symptoms, yoga, rehabilitation, psychoeducational interventions, or cognitive behavioral therapy.

Engaging patients in a palliative care program early in their treatment can alleviate many cancer-related symptoms. However, dissemination of these services is a challenge, according to Michael Hoerger, PhD, MSCR, of Tulane Cancer Center. During Oral Abstract Session A, Dr. Hoerger presented data from a study designed to describe key elements of palliative care and to assess whether variation in these elements was linked with changes in patient-related outcomes and end-of-life care (Abstract 154). The study included patients with incurable lung or noncolorectal gastrointestinal cancer assigned to early palliative care integrated with oncology care. Patients with a higher percentage of palliative care visits that focused on coping had significantly improved quality of life and reduced rates of depression. When a higher percentage of visits focused on treatment decisions, patients had a higher quality of end-of-life care, including reduced odds of new chemotherapy and hospitalization in the 60 days before death.

Palliative care in elderly patients

Among the other diverse topics covered during the symposium were sessions on palliative and supportive care issues in older adults—a topic relevant to all oncologists because there is a projected increase in the number of patients older than age 65 who will develop cancer by 2030.

According to a study presented by Wendi G. Lebrett, a medical student at University of California, San Diego, during Oral Abstract Session A, palliative care can have a substantial effect on health care costs among elderly patients with advanced cancer (Abstract 91). The case-control study compared costs between Medicare beneficiaries with metastatic lung, colorectal, breast, or prostate cancers who received palliative care consultation and those who did not. Among the more than 2,500 patients studied, health care costs were balanced in the 30 days before palliative care consultation but significantly differed after. The introduction of palliative care reduced total health care costs per patient in the subsequent 120 days by 28%, or approximately $3,000 ($6,880 vs. $9,604; p < 0.001).

“These sessions also provided guidance in how clinicians should regularly apply geriatric assessments in cancer care decision-making in older adults,” Dr. Balboni said. “They featured models in how to collaborate with our geriatric medicine colleagues in providing interdisciplinary cancer care.”

During General Session 2, Aminah Jatoi, MD, of Mayo Clinic, Rochester, discussed how to approach care for vulnerable, frail patients with cancer. She gave several practical recommendations for the treatment of this patient population, including the use of clinical trials, in which older patients are often underenrolled. However, among the most important tools for care of older patients is the use of geriatric assessments, Dr. Jatoi said. Research has shown that these assessments take only 22 minutes on average but provide valuable information such as the detection of frailty issues, predicted toxicity, and predicted survival. These assessments may also help clinicians decide when not to give chemotherapy.

To further illustrate some of the particular issues faced by older adults with cancer, Noam A. VanderWalde, MD, of the University of Tennessee West Cancer Center, presented a case study of an older patient with head and neck cancer, a disease in which more than half of patients are older than age 65. The patient was a 73-year-old man who presented with left throat pain and a growth in his neck. A previous smoker, the man was divorced and lived alone, and he recently had a fall down some steps.

The patient was diagnosed with a small bilateral base of tongue tumor with positive lymph nodes and positive margins. Standard of care would be combined adjuvant radiation with concurrent chemotherapy. However, concurrent chemotherapy adds significant toxicity, Dr. VanderWalde noted. This patient received only two of six planned courses of chemotherapy, developed several adverse events, and required hospitalization for a fall that resulted from malnutrition. This hospitalization led to a 3-day delay in his radiation treatment.

These toxicities could have been predicted with the use of proper tools like geriatric assessments, Dr. VanderWalde said. Specifically, research has shown that just one fall in the prior 6 months predicted almost a 2.5-fold increased risk for grade 3 to 5 toxicity with chemotherapy. With older patients, Dr. VanderWalde concluded, it is important to weigh the risks and benefits of therapy as you determine the stage of not just the cancer but also the patient.

Improving patient quality of life

Quality of life is an important part of cancer care, whether a patient is a cancer survivor or has advanced disease.

For example, patients with incurable cancer often have marked anxiety that is associated with poor quality of life. During Oral Abstract Session B, Joseph Greer, PhD, of Massachusetts General Hospital, presented data to show that patients with incurable cancer gained significant improvements in quality of life, anxiety, and depression with the intervention of a cognitive behavioral therapy mobile app or a mobile health education program (Abstract 175). The mobile application taught skills to relax the body, reduce worry, stay focused in the present, improve communication, and plan/pace activities.

The introduction of early palliative care also can improve quality of life in patients with advanced cancer. During Oral Abstract Session B, Jamie M. Jacobs, PhD, of Massachusetts General Hospital, presented data from a study of 350 patients with newly diagnosed incurable lung or noncolorectal gastrointestinal cancer who were randomly assigned to oncology care with or without early palliative care integration (Abstract 92). The study showed that early palliative care significantly improved the patients’ use of active coping, such as positive reframing and acceptance. Use of these active coping strategies was associated with improved quality of life and depressive symptoms.

Adolescents and young adults with cancer also are at high risk for poor psychosocial outcomes, possibly because they do not yet have the skills needed to navigate the burdens of illness, according to Abby R. Rosenberg, MD, MS, FAAP of Seattle Children’s Hospital Cancer and Blood Disorder Center. During Oral Abstract Session B, Dr. Rosenberg presented the results of a study that examined the use of the Promoting Resilience in Stress Management (PRISM) tool, a brief manualized intervention that targets stress management, goal setting, cognitive reframing, and meaning-making (Abstract 176). The study included 100 adolescents or young adults who underwent four in-person, 30- to 60-minute sessions and a facilitated family meeting. At the 6-month follow-up assessment, PRISM was associated with improved patient-reported resilience, improved cancer-specific quality of life and hope, lower psychosocial distress, and fewer cases of depression.

General Session 5 featured sexual health issues in palliative and supportive care, and it included data to describe the frequency of this important quality-of-life issue together with simple strategies to address it. The strategies included inquiries about sexual functioning, assessment of the impact on quality of life, determination of the cause of dysfunction, and provision of strategies to address the cause. 

During this session, Areej El-Jawahri, MD, of Harvard Medical School, presented details of a pilot study that assessed the feasibility and preliminary efficacy of a sexual dysfunction intervention designed to improve sexual function in survivors of allogeneic hematopoietic stem cell transplantation (Abstract 191). All patients were screened for sexual dysfunction that caused distress, and the approximately one-third who tested positive attended monthly multimodal interventions visits. After the intervention, participants had significant improvements in satisfaction and interest in sex, as well as in sexual function. In addition, the intervention led to improvement in quality of life and mood.

Opiate management

Another important session addressed difficult issues in opiate management such as the importance of universal screening of patients for the risk of developing substance abuse disorder before opiates are prescribed.

During General Session 4, David J. Copenhaver, MD, MPH, of University of California, Davis, Medical Center, discussed who is at risk for opioid addiction and how to assess for this risk. Before patients with chronic pain begin opioid therapy, clinicians should assess for certain factors associated with increased risk for opioid misuse, including a history of sexual abuse or trauma, post-traumatic stress disorder, untreated psychiatric comorbid conditions, and issues related to past substance abuse. Several opioid screening tools, such as the Opioid Risk Tool, the Screener and Opioid Assessment for Patients with Pain tool, and the Diagnosis, Intractability, Risk, and Efficacy tool, are available to help clinicians classify patients by low, medium, or high risk for misuse or abuse.

Dr. Copenhaver also discussed some universal precautions used in prescribing opioids, including an initial assessment of the patient, an opioid treatment agreement, informed consent, regular urine drug tests, review of prescription drug monitoring programs, and regular assessment of treatment goals and progress. Finally, if clinicians decide that opioids are necessary, Dr. Copenhaver said, they should monitor for the four As: analgesia, activity, aberrant drug-taking behaviors, and adverse effects.

Jeremy M. Hirst, MD, of the University of California, San Diego, addressed another challenge related to opiates: What should be done when a patient needs both opioids and benzodiazepines? These two drugs together are not contraindicated, but they need to be given with a “common sense approach,” Dr. Hirst said. First, start each drug separately to make sure that the patient tolerates each one well. Then, conduct frequent assessments for adverse effects, including sedation and cognitive impairment. In addition to adverse effects, it is important to assess for benefit or improvement in functional status.

“Ask, ‘Is this really helping or not?’” Dr. Hirst said.

Finally, if the patient is having difficulty tolerating both drugs, or if the combination does not seem to be effective, it is important to consider alternatives to benzodiazepines, such as antidepressants, or to consider “de-prescribing.”

Looking ahead to the 2018 symposium

All in all, the 2017 symposium did not disappoint, Dr. Balboni said. It featured valuable networking opportunities, such as a Trainee and Early-Career Networking Luncheon, and the Conversation Café, where attendees and faculty had roundtable discussions of topics that ranged from research in palliative oncology care to burnout. 

“This year’s symposium pushed the field forward to address the quality-of-life needs of patients living with cancer through both education and research,” Dr. Balboni said. “I hope you’ll join us for next year’s 2018 symposium in San Diego, November 16 and 17, to continue to advance this field to the benefit of patients with cancer and their families."

Originally published in ASCO Daily News.