Integration of oncology and palliative care: a Lancet Oncology Commission - 02/11/18

Doi : 10.1016/S1470-2045(18)30415-7

Stein Kaasa, ProfPhD ^a,^⁎,^{^{†
Contributed equally}} , Jon H Loge, ProfPhD ^a,^b,^{^{†
Contributed equally}}, Matti Aapro, MD ^c, Tit Albreht, PhD ^d, Rebecca Anderson, MSc ^f, Eduardo Bruera, ProfMD ^g, Cinzia Brunelli, PhD ^h, Augusto Caraceni, ProfMD ^h, Andrés Cervantes, ProfPhD ⁱ, David C Currow, ProfPhD ^j,^k, Luc Deliens, ProfPhD ^l,^m, Marie Fallon, ProfMD ⁿ, Xavier Gómez-Batiste, ProfPhD ^o, Kjersti S Grotmol, PhD ^p, Breffni Hannon, MD ^q,^r, Dagny F Haugen, ProfPhD ^u, Irene J Higginson, ProfPhD ^v, Marianne J Hjermstad, PhD ^a, David Hui, MD ^g, Karin Jordan, ProfMD ^w, Geana P Kurita, PhD ^x,^y, Philip J Larkin, ProfPhD ^aa, Guido Miccinesi, MD ^ab, Friedemann Nauck, ProfPhD ^ac, Rade Pribakovic, MD ^e, Gary Rodin, ProfMD ^q,^s,^t, Per Sjøgren, ProfPhD ^x,^z, Patrick Stone, ProfMD ^f, Camilla Zimmermann, ProfPhD ^q,^r,^t, Tonje Lundeby, PhD ^a

^a European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway

^b Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway

^c Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland

^d Centre for Health Care, National Institute of Public Health, Ljubljana, Slovenia

^e Centre for Promotion and Prevention Programme Management, National Institute of Public Health, Ljubljana, Slovenia

^f Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK

^g Department of Palliative, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA

^h Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milan, Milan, Italy

ⁱ Department of Medical Oncology, Biomedical Research Institute INCLIVA, CiberOnc, University of Valencia, Valencia, Spain

^j IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia

^k Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK

^l End-of-Life Care Research Group, Vrije Universiteit Brussel and Ghent University, Brussels, Belgium

^m Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium

ⁿ Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK

^o WHO Collaborating Center for Palliative Care Public Health Programs, Catalan Institute of Oncology, University of Vic/Central Catalonia, Barcelona, Spain

^p Regional Advisory Unit for Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway

^q Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada

^r Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada

^s Institute of Medical Science, University of Toronto, Toronto, ON, Canada

^t Department of Psychiatry, University of Toronto, Toronto, ON, Canada

^u Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway

^v Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK

^w Department of Medicine, Haematology, Oncology and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany

^x Palliative Research Group, Department of Oncology, Rigshospitalet–Copenhagen University Hospital, Denmark

^y Multidisciplinary Pain Centre, Department of Neuroanaesthesiology, Rigshospitalet–Copenhagen University Hospital, Denmark

^z Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark

^aa Centre Hospitalier Universitaire Vaudoise and Institut Universitaire de Formation et de Recherche en Soins, University of Lausanne, Switzerland

^ab Clinical Epidemiology Unit, Oncological Network, Prevention and Research Institute, Florence, Italy

^ac Department of Palliative Medicine, University Medical Center Göttingen, Georg-August-Universität Göttingen, Göttingen, Germany

^* Correspondence to: Prof Stein Kaasa, European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo 0424, Norway European Palliative Care Research Centre Department of Oncology Oslo University Hospital and Institute of Clinical Medicine University of Oslo Oslo 0424 Norway

Summary

Full integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Early delivery of patient-directed care by specialist palliative care teams alongside tumour-directed treatment promotes patient-centred care. Systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of health-care resources. The absence of international agreements on the content and standards of the organisation, education, and research of palliative care in oncology are major barriers to successful integration. Other barriers include the common misconception that palliative care is end-of-life care only, stigmatisation of death and dying, and insufficient infrastructure and funding. The absence of established priorities might also hinder integration more widely. This Commission proposes the use of standardised care pathways and multidisciplinary teams to promote integration of oncology and palliative care, and calls for changes at the system level to coordinate the activities of professionals, and for the development and implementation of new and improved education programmes, with the overall goal of improving patient care. Integration raises new research questions, all of which contribute to improved clinical care. When and how should palliative care be delivered? What is the optimal model for integrated care? What is the biological and clinical effect of living with advanced cancer for years after diagnosis? Successful integration must challenge the dualistic perspective of either the tumour or the host, and instead focus on a merged approach that places the patient’s perspective at the centre. To succeed, integration must be anchored by management and policy makers at all levels of health care, followed by adequate resource allocation, a willingness to prioritise goals and needs, and sustained enthusiasm to help generate support for better integration. This integrated model must be reflected in international and national cancer plans, and be followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated. Patient-centred care should be an integrated part of oncology care independent of patient prognosis and treatment intention. To achieve this goal it must be based on changes in professional cultures and priorities in health care.

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