Early palliative care integration has increased in oncologic settings but remains less common − and often misunderstood − in hematologic malignancies, especially for patients undergoing hematopoietic cell transplant.
When Dame Cicely Saunders founded the first modern hospice in 1967 and established the culture of palliative care, the focus of this new medical discipline was almost exclusively on end-of-life care. Since then, however, physicians in many fields have begun to recognize that palliative care specialists have much more to offer than specific types of symptom relief for patients who are close to death.1 Researchers and clinicians have made substantial progress in recent years integrating palliative care early on in the oncology patient experience, for example, and now palliative care is regularly combined with standard treatment approaches for patients with solid tumors.
In the context of hematologic malignancies, however, palliative care remains less commonly used. Barriers to palliative care in the hematological malignancy context are partly cultural and include lack of access to transfusions in patients enrolled in hospice programs, as well as the availability of a high number of active therapies that can effectively treat even critically ill patients and rapid change in the clinical status of patients.
Hematopoietic cell transplant (HCT) may be the “final frontier†for palliative care in the hematology-oncology setting. HCT is one of the most intensive procedures in hematology oncology, and while it has the potential to cure a substantial proportion of patients with hematologic malignancies, HCT is associated with high morbidity (which may continue for years if chronic graft-versus-host disease becomes established) and mortality. Even when transplantation is successful, patients experience a variety of symptoms such as pain, nausea, depression, loneliness while isolated, and anxiety.
Palliative care specialists are currently rarely consulted in the HCT setting, but many feel that this should change and that their expertise can help mitigate some of the symptoms patients experience. Increasingly, palliative care physicians are urging transplant teams and insurers to recognize that palliative care can serve an important role for transplant patients by reducing symptoms throughout the disease process and helping patients and their families cope with the experience.
“Palliative care provides an extra layer of support for patients facing a life-limiting or life threatening illness, regardless of prognosis,†said Areej El-Jawahri, MD, an oncologist at Massachusetts General Hospital.
In 2015, the Centers for Medicare and Medicaid Services (CMS) established a payment schedule for advance-care planning discussions and services, which has prompted a larger discussion about palliative care in a variety of settings, including responding to the needs of transplant patients. Thomas LeBlanc, MD, an oncologist and palliative care physician at Duke University Hospital in Durham, North Carolina, called the move a “small but significant part of a much bigger picture†in an ASH Clinical News article published in December 2016.2
ASH Clinical News spoke with Drs. El-Jawahri, LeBlanc, and others about integrating palliative care into the treatment of patients with hematologic malignancies and those undergoing HCT.