Guidelines Ignored in Supportive and Palliative Care

SAN DIEGO—Too often, strategies known to be effective within the realm of supportive and palliative cancer care remain on the back burner. This often-observed fact was reinforced at a recently convened ASCO-sponsored symposium, where results from several studies revealed that guidelines are being ignored or overlooked to the detriment of optimal care.

Prophylaxis for chemotherapy-induced vomiting is one of two examples that illustrate the point. Many patients with cancer do not receive what has been proven to improve quality of life, according to data presented at the Palliative Care and Supportive Care Oncology Symposium by Eric J. Roeland, MD, a hospice and palliative care physician at Massachusetts General Hospital, Boston.

The data were pulled from an electronic medical database with records from 40 institutions. New starts of highly emetogenic chemotherapy (HEC) were matched with new starts of antiemetic prophylaxis. Current guidelines for control of emesis from ASCO, ESMO, and the NCCN in patients initiating HEC call for triple-drug prophylaxis with an NK1 receptor inhibitor, such as aprepitant; a 5-HT3 receptor inhibitor, such as ondansetron; and dexamethasone.

Of the three regimens currently classified as HEC that were evaluated, physicians were found to be more than 90% adherent to guideline-directed triple-drug antiemetic prophylaxis in 56% of patients initiating a course of cyclophosphamide plus anthracycline; 32% in patients initiating a course of cisplatin; and 2% in patients initiating carboplatin, Dr. Roeland reported.

The low adherence rate for carboplatin can be discounted because this drug only received a HEC designation in 2017, which came after the study period, but cisplatin had a listing as a HEC requiring triple-drug prophylaxis during the time of the study, and it is notorious for its emetogenic propensity. Published studies suggest up to 90% of patients receiving cisplatin in a dose of 50 mg/m2develop nausea and vomiting within 24 hours if prophylaxis is not provided. The results from Dr. Roeland’s study database suggest that up to 68% of these patients are exposed to toxicity that could be modified.

Triple therapy “is an achievable target,” he said, citing the low but still substantial proportion of physicians who did reach 90% adherence. Of physicians who failed to achieve this level of adherence, many did not come close. The distribution of adherence among below 90% adherence was “scattered across lower levels down to zero.”

“Opportunities still exist for most physicians to improve individual adherence of evidence-based guideline-recommended antiemetic prophylaxis,” he said.

As the risk of emesis from HEC-designated drugs in guidelines is known, “upfront triple prophylaxis” should be standard, according to Dr. Roeland.

His data provide another reminder that clinicians often overlook proven and guideline-recommended strategies beyond standard anti-cancer regimens with the potential to make their patients’ lives better. A similar statement could be made about palliative care based on data presented at the same meeting.

Palliative care strategies

Neither of two studies that evaluated palliative care strategies was focused on the proportion of patients who go untreated, but both implied that this therapy is not being offered routinely. The reason is that each had control groups who were not treated even though ASCO has already released clinical practice guidelines for the routine integration of palliative care (Ferrel BR et al. J Clin Oncol 2017;35:96-112).

Not surprisingly, given the background, both studies associated palliative care with benefit. On the basis of the results, both sets of authors recommended routine palliative care despite existing evidence-based guidelines that make the same recommendation.

One of the two studies was a multicenter randomized trial. In this trial, 302 patients with unresectable lung (40%), gastrointestinal (27%), prostatic (18%) or other solid tumors were randomized to palliative care, which included psychosocial support and physical exercise guided by a specialized team, or usual care without palliative strategies.

Patients customized their care by identifying aspects of quality of life for which they needed help. These were evaluated with a validated tool called EORTC-QLC-C30. Change from baseline in the same domains with EORTC-QLC-C30 was the primary study outcome. The absolute 3.0-point difference favoring palliative care reached significance (P=0.047). When assessed with a sensitivity analysis, the 3.3-point difference favoring palliative care was even more robust (P=0.005).

The conclusion, delivered by Lise Nottelmann, MD, Palliative Team, Department of Oncology, Vejle Hospital, Vejle, Denmark, was that palliative care “integrated into the standard oncology treatment” offers meaningful benefit to patients.

In a second study, which enrolled 118 lung cancer patients and 62 caregivers, evaluated a palliative care protocol for the outpatient community-based setting. The author of this study, Huong Q. Nguyen, PhD, RN, Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, acknowledged that palliative care has been shown to be beneficial previously. However, “most trials have been conducted in specialized centers with limited translation into the real-world setting.”

This study was conducted in two phases. After a first phase of usual care over 14 months, nurse-led palliative care was initiated and evaluated over 23 months. Again, care was customized by concerns defined as most important by enrolled patients. Change from baseline in quality of life was evaluated in both patients and caregivers with multiple tools, including FACT-L and FACIT-SP12.

In patients, “significant immediate improvements observed in physical, emotional, and functional well being at one month [on palliative care] were sustained at three months when compared to usual care (P=0.01),” reported Dr. Nguyen. In caregivers, improvements in physical (P=0.04) and spiritual (P=0.03) domains were also documented relative to usual care.

The findings demonstrate that palliative care “can be successfully adapted to the community setting,” Dr. Nguyen concluded.

On the basis of their results, both authors advocated the integration of palliative care into standard management of patients with late stage cancer, but they only reinforce current guidelines. The fact that the studies were considered necessary underscores an unstated premise that acceptance of palliative care remains incomplete. Like antiemetic prophylaxis for emetogenic drugs, the question is not whether palliative care can improve quality of life, the question is why the opportunity for benefit is so often overlooked.

By Ted Bosworth

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