Less Pain, More Gain: Palliative Care Strategies for

Recurrent Ovarian Cancer

Carolyn Lefkowits, M.D. M.P.H. M.S.Assistant Professor, Gynecologic Oncology & Palliative Care

University of Colorado Denver

SHARE Webinar Sept 27, 2017

Objectives• Define palliative care & differentiate it from

hospice

• List at least 3 evidence-based benefits of palliative care

• Differentiate between primary & specialty palliative care

• Leave with homework

Outline: Palliative Care

• What is it?

• Why do we need it?

• How can you get it?

• Barriers

• Next steps

What is Palliative Care?

Palliative Care (PC): “therapies that address the

multiple issues that cause suffering for patients and

their families and impact their quality of life”

NOT synonymous with end-of-life care/hospice

Can be offered concurrently with curative therapy

Smith et al JCO 2012

What is Palliative Care?

“Palliative care is specialized medical care for

people living with serious illness. It focuses on

providing relief from the symptoms and stress of a

serious illness. The goal is to improve quality of life

for both the patient and the family…It is appropriate

at any stage in a serious illness and can be provided

along with curative treatment.”

“an extra layer of support”

Center to Advance Palliative Care

What is Palliative Care?

Palliative Care

Hospice

What is Palliative Care?

Radwany & von Gruenigen 2012

ASCO & AAHPM Domains of Palliative Care

1. Symptom assessment &

management

2. Psychosocial assessment

& management

3. Spiritual & cultural

assessment &

management

4. Communication & shared

decision making

5. Advance care planning

6. Coordination/continuity of

care

7. Appropriate specialty

palliative care & hospice

referral

8. Carer support

9. End-of-life care

ASCO Palliative Care in Oncology Symposium, 2015

Outline: Palliative Care

• What is it?

• Why do we need it?

• Barriers

• How can you get it?

• Next steps

Why do we need palliative care?

You are a Bridge: Palliative Care

1 min 40 sec youtube video

(https://youtu.be/lDHhg76tMHc)

Benefits of palliative care

Nonrandomized studies have shown the following benefits without decreased survival

• Reduced pain & other distress

• Improved health-related QOL

• High patient & family satisfaction with care

• Increased likelihood of location of death being outside of hospital

• Reduction in hospital & ICU length of stay Meier et al 2006

• Randomized trial: 151 stage IV lung cancer patients– Arm 1: standard care

– Arm 2: palliative care integrated from the time of diagnosis

• Palliative care group– Improved quality of life– Less depression– Less aggressive care at the end-of-life

– Statistically significantly longer survival

“It is the panel’s expert consensus that

combined standard oncology care and palliative

care should be considered early in the course

of illness for any patient with metastatic

cancer and/or high symptom burden”

• n=87 patients discontinuing anti-cancer therapy

• Integrated Care Model (ICM) patients had seen PC prior to decision to d/c anti-cancer therapy

• ICM patients

– Better QOL

– Less depression

– Less chemo within last 6 wks of life (40% vs 6%, p=0.001)

– Improved median survival (HR 0.48, p=0.46)

• n=95 patients with gyn malignancy & inpatient PC consultation for

symptom management

• Improvement in prevalence moderate to severe symptom

intensity

– between PC consult & discharge for: pain, anorexia, fatigue & nausea

(magnitude 58-66%)

– within one day of PC consult for: pain, fatigue, nausea (magnitude 50-55%)

• Majority of improvement that occurred between consult &

discharge happened within 24hrs of consult

• Model of routine care vs routine care + PC referral at time of diagnosis of recurrent platinum-resistant disease

• Data from Temel et al informed creation of model

• Early palliative care associated with – Cost savings $1285 per patient over routine care

– ICER <$50,000/QALY

– Assuming no clinical benefit other than QOL improvement, remained highly cost-effective

Palliative Care & The Society of Gynecologic Oncology (SGO)

Palliative Care & Ovarian Cancer: Christine’s Story

https://soundcloud.com/get-palliative-care/a-quality-life-episode-1-christines-story

Outline: Palliative Care

• What is it?

• Why do we need it?

• How can you get it?

• Barriers

• Next steps

Where can you get palliative care?

• Primary palliative care: delivered by non-palliative care specialists

• Specialty palliative care: delivered by palliative care specialists– In the hospital– In an outpatient clinic– At home

• Home palliative care• Hospice care

What actually happens at a palliative care appointment?

• n=67 patients with advanced lung cancer

• 1st palliative care visit median 55 minutes

(range 20-120 min)

• Mean minutes spent (range)

– Symptom management 20 mins (0-75)

– Patient & family coping 15 mins (0-78)

– Illness understanding & education 10 mins (0-35)

Jacobsen et al JPM 2011

Center to Advance Palliative Care(getpalliativecare.org)

• Quiz – “is palliative care right for you?”

• Searchable provider directory

Outline: Palliative Care

• What is it?

• Why do we need it?

• How can you get it?

• Barriers

• Next steps

Barriers to Palliative Care Integration

• Limited availability

• Poor reimbursement

• Lack of provider education

• Palliative care has a branding problem

Barriers: Lack of Provider Education

• Survey 327 practicing gyn oncologists– Only 45% said training helped them relate to

terminally ill patients & families

• Survey 103 gyn oncology fellows– Quality & quantity of palliative care training

rated lower than other common oncologic topics

• Survey 29 gyn onc fellowship directors– 14% written pall care curriculum– 48% elective/required pall care rotation

Ramondetta et al 2004Lesnock et al 2013Lefkowits et al 2015

Palliative Care Has a Branding Problem

Palliative Care Has a Branding Problem

“How knowledgeable, if at all, are you about palliative care?”

CAPC 2011

Branding Problem: Providers

• Lack knowledge of specialty palliative care services & their benefits

• Equate palliative care with end-of-life care

• Patients unlikely to request palliative care referral, but open to it when recommended by oncologist

CAPC 2011Schenker et al JOP 2014Schenker et al JPM 2014

Palliative Care Has a Branding Problem

“One of the greatest remaining challenges is the

need for better understanding of the role of

palliative care among both the public and

professionals across the continuum of care so that

hospice and palliative care can achieve their full

potential for patients and their families”

Institute of Medicine (IOM)

Dying in America 2014

Palliative Care Has a Branding Problem

Age 25+ Age 65+

Very likely 63% 62%

Somewhat likely 29% 28%

Not too/Not at all likely 6% 6%

“How likely, if at all, would you be to consider palliative

care for a loved one if they had a serious illness?”

Outline: Palliative Care

• What is it?

• Why do we need it?

• How can you get it?

• Barriers

• Next steps

Next Steps to Improve Palliative Care Integration for Women with Ovarian

Cancer

• Education

• Research

• Policy

Objectives• Define palliative care & differentiate it from

hospice

• List at least 3 evidence-based benefits of palliative care

• Differentiate between primary & specialty palliative care

• Leave with homework – familiarize yourself with palliative care resources near you (getpalliativecare.org)

Take Home Points

• What is palliative care – “an extra layer of support”

• Why palliative care– Because it improves clinical outcomes without

adversely affecting survival

• How palliative care– Getpalliativecare.org

• When palliative care– Why not now?

Thank you!