Goals of palliative cancer therapy: scope of the problem

Development of Palliative and End of Life Care: The Current Situation in Saudi Arabia

As part of the health care reforms and transformation project of the Vision 2030, a group of expert healthcare professionals was tasked with the development of a model of care for patients with life-shortening illnesses in Saudi Arabia. This Care Design Group (CDG 1-3) held a series of workshops and conducted surveys and online discussions to systematically document and develop a model of care. These interventions were aimed at achieving a national standard of care. This short article is a description of this very successful process of development.

[Optimizing health care using the example of rehabilitation. Intended goals have to be defined and achieved goals have to be confirmed]

In this article, the authors try to apply the actual problem of health care financing to the area of rehabilitation medicine. It is shown that there are considerable reserves in this system - like in any other area of health care -, which should not be saved but should be rather transformed into efficient health services. If we save these resources, the problems will remain the same but it will be easier to pay for them. If, however, we consider how to generate additional health care values, we will solve more problems than before.The article shows that these improvements require a clear definition of goals of health care. Goals of health care can be attained only if they are defined, and the conditions which have to be met for goal attainment can be identified only if the attained goals are quantified. There is need for action if it is unknown how often intended goals can really be attained.

Therapeutic guidelines for the treatment of bone metastasis: a report from the American College of Radiology Appropriateness Criteria Expert Panel on Radiation Oncology

Bone metastases remain a therapeutic challenge because of the diversity of the problems they cause, the relative paucity of data regarding their treatment, and the necessity for management by a multidisciplinary palliative care team. The American College of Radiology convened an Appropriateness Criteria Expert Panel on Radiation Oncology for the treatment of bone metastasis to create representative clinical case scenarios and then rank the appropriate use of treatment modalities as well as the most reasonable radiotherapy dose schema and treatment planning methods. Here we present both the resulting Appropriateness Criteria and the rationale for making these decisions. The treatment recommendations are placed within the larger framework of the role of radiation in palliative care by discussing the efficiency of palliative radiotherapy schedules, cost effectiveness issues, and the need for additional research regarding the proper multidisciplinary care of patients with symptomatic bone metastasis.

Review Article: Goals of Care Toward the End of Life: A Structured Literature Review

Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.

Palliation and supportive care in radiation medicine

The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.

Clarifying the term 'palliative' in clinical oncology

The objective of this study was to clarify the term 'palliative' in clinical oncology. A qualitative study design with in-depth interviews was applied. The study sample included 30 cancer patients and 16 physicians. In clinical oncology, the use of the term 'palliative' to describe both anticancer treatments and palliative care may cause confusion and misunderstanding. Different aspects of palliative care, as expressed by the WHO definition, are not so easily recognizable with regard to palliative oncological treatments. Furthermore, the fact that the same anticancer treatments can be given to patients with palliative or curative intention is confusing. The distinction between curative and palliative oncological treatments is of crucial importance for the treatment decision-making process. Close consideration of the use of the term 'palliative' will help to clarify the various goals of treatment and care in oncological practice.

Palliative chemotherapy or best supportive care? A prospective study explaining patients' treatment preference and choice

In palliative cancer treatment, the choice between palliative chemotherapy and best supportive care may be difficult. In the decision-making process, giving information as well as patients' values and preferences become important issues. Patients, however, may have a treatment preference before they even meet their medical oncologist. An insight into the patient's decision-making process can support clinicians having to inform their patients. Patients (n=207) with metastatic cancer, aged 18 years or older, able to speak Dutch, for whom palliative chemotherapy was a treatment option, were eligible for the study. We assessed the following before they consulted their medical oncologist: (1) socio-demographic characteristics, (2) disease-related variables, (3) quality-of-life indices, (4) attitudes and (5) preferences for treatment, information and participation in decision-making. The actual treatment decision, assessed after it had been made, was the main study outcome. Of 207 eligible patients, 140 patients (68%) participated in the study. At baseline, 68% preferred to undergo chemotherapy rather than wait watchfully. Eventually, 78% chose chemotherapy. Treatment preference (odds ratio (OR)=10.3, confidence interval (CI) 2.8-38.0) and a deferring style of decision-making (OR=4.9, CI 1.4-17.2) best predicted the actual treatment choice. Treatment preference (total explained variance=38.2%) was predicted, in turn, by patients' striving for length of life (29.5%), less striving for quality of life (6.1%) and experienced control over the cause of disease (2.6%). Patients' actual treatment choice was most strongly predicted by their preconsultation treatment preference. Since treatment preference is positively explained by striving for length of life, and negatively by striving for quality of life, it is questionable whether the purpose of palliative treatment is made clear. This, paradoxically, emphasises the need for further attention to the process of information giving and shared decision-making.

Methodologic issues in collecting data from debilitated patients with cancer near the end of life

PURPOSE/OBJECTIVES

To report the experience of a group of researchers who have had a year of experience in a clinical trial with homecare hospice patients.

SAMPLE

150 hospice patients with cancer and their primary caregivers who were accrued to a National Cancer Institute-funded clinical trial focusing on quality of life.

METHODS

The investigative team kept careful records of the numbers of patient/caregiver dyads accrued to the study and the reasons for nonaccrual as well as reasons for attrition. Data were analyzed using descriptive statistics.

FINDINGS

During a nine-month period, the hospice admitted 2,517 patients; 75% had cancer and 95% had caregivers, making them eligible for the study. However, after further screening, only 19% were eligible for contact and only 5% finally were accrued to the study. For the 125 patient/caregiver dyads actually accrued to the study, baseline data were obtained on only 50% and evaluable follow-up data on only 50%.

CONCLUSIONS

Accruing patients to clinical trials and retaining them when they are critically ill and near death are extraordinarily difficult tasks. The inability to recruit and retain subjects for clinical trials has implications for integrity of data, data analysis, success of the project, and the cost of conducting such projects in the future.

Palliative chemotherapy or watchful waiting? A vignettes study among oncologists

PURPOSE

To determine the preferences of oncologists for palliative chemotherapy or watchful waiting and the factors considered important to that preference.

METHODS

Sixteen vignettes (paper case descriptions), varying on eight patient and treatment characteristics, were designed to assess the oncologists' preferences. Their strength of preference was rated on a 7-point scale. An orthogonal main effects design provided a subset of all possible combinations of the characteristics, allowing estimations of the relative weights of the presented characteristics. A written questionnaire was sent to a random sample of oncologists (N = 1,235).

RESULTS

The response rate was 67%, and 697 questionnaires were available for analysis. Eighty-one percent of the respondents were male. The mean age was 46 years. We found considerable variation among the oncologists. No major associations between physician characteristics and preferences were found. Of the patient and treatment characteristics affecting treatment preference, age was the strongest predictor, followed by the patient's wish to be treated and the expected survival gain. Other patient and treatment characteristics had a limited effect on preferences, except for psychologic distress, which had no independent impact.

CONCLUSION

Patients will encounter different decisions depending on their oncologists' preferences and their own personal background. Therefore, to ensure adequate information for decision-making processes, decision aids are proposed.

Treatment intention in hospitalized cancer patients in oncological wards in Norway: a national survey

Clinicians often do not agree whether a treatment is given with a palliative or curative intent. A common clear definition does not exist. This study has assessed the usefulness of dividing the goal of treatment into three distinct categories: curative treatment; palliative, symptom preventive treatment; and palliative, symptom relieving treatment. In a cross-sectional study among all cancer centres in Norway, a total of 629 patients were included into the study. Of these patients, 60% received palliative treatment, with an equal distribution between symptom preventive and symptom relieving. The definitions were found easy to use by the physicians. It gave important information of differences between cancer diagnosis with respect to the number of patients receiving palliative treatment. In order to refine the classification system, the authors will, in future studies, include a fourth category, life prolonging treatment, which is located between curative and palliative treatment with respect to treatment intensity.