It was mid-March when a tweet from @Pallimed piqued my interest: “ASCO has plans for a new ASCO Symposium on Palliative Cancer Care scheduled for fall 2014. Stay tuned for details!”
Well indeed I did stay tuned and I headed for Boston in October for the inaugural ASCO Palliative Care in Oncology symposium.
Vision of the meeting
The symposium started with steering committee chair, Dr Michael Fisch of MD Anderson Cancer Centre, setting the scene for the event and reminding us of the ASCO 2009 vision: ‘Concurrent palliative care and oncology care should be “usual” care by 2020.’
This was followed by the 2012 consensus statement “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”.
There is insufficient space to give more than brief highlights of my most enjoyed moments, but more details plus all abstracts and posters are available via the ASCO meeting library.
Scientific programme highlights
The Three Ms of Symptom Science – Mechanism, Measurement, and Management were the topic of the first paper presented. These included toxicity side effect management, animal models for understanding pain and Patient Reported Outcome Measures in routine care.
Dr Stephen Sonis from Dana Faber gave a most impressive display of how to make genomics understandable when considering risk prediction for cancer treatment toxicity.
Amongst six talks in the Oral Abstract Session – Symptom Management and End of Life Care, Dr YuJung Kim presented a study on the association between tobacco use, symptom expression, alcoholism and illicit drug use in advanced cancer, with smoking associated with negative impacts on symptoms and opioid misuse.
Survivorship received due attention with sessions on definitions plus symptom management of fatigue, cognitive changes after childhood cancer and aromatase inhibitor induced musculoskeletal symptoms.
‘Skills for Addressing the End of Life’, delivered by Dr Anthony Back of the Seattle Cancer Care Alliance and Dr BJ Miller from Zen Hospice, San Francisco, stole the day for me.
Even as a palliative care clinician who works in the setting of challenging discussions every day, I learned valuable tips here to share with colleagues and to consider when teaching others.
These included Dr Back’s cautionary but humorous tail of three common mistakes when discussing difficult issues: “bad stuff won’t be quite so bad if you don’t talk about it”, “delaying talking about bad stuff until you absolutely have to” and “cutting to the chase will save you time and decrease their distress.”
He called on oncologists to start conversations about end of life sooner and to develop skills to do this.
Dr Back encouraged tapping into one’s own life experience to connect at a human level to the person in front of you and to consider “roadmaps” to help find a way through challenging discussions, until your skills are more honed.
Examples of these include skills such as ‘PAUSE’ and ‘REMAP’. Please do look at vitaltalk.org for more details.
Make palliative care more beautiful and meaningful
Dr BJ Miller stopped me in my tracks and made me recall what drew me towards palliative care many years ago. This was the fact that “the job of palliative care is to make things less horrible, so make it more beautiful, more meaningful” and reflect on the “resonant moments” between clinicians and patients.
In discussing suffering, he also examined one form I had never previously considered – logistical suffering – caused by the systems of which our patients are victims, and for which we often spend much time apologising.
‘Early Integration of Palliative Care in Cancer Care’ kicked off Day Two. Part of this dealt with the need for earlier palliative care in cancer care, models of improved integration, challenges of crafting medical care against patient care goals when the systems in the US have been about billing and reimbursement.
Dr Jennifer Temel provided a superb review of the three major studies on early palliative care – Project ENABLE, 2004, Temel et al, 2010 , Zimmerman et al, 2014 and considered what we can learn and extrapolate and how we can direct future research.
She asked: What is the appropriate timing of an early palliative care intervention? What is the appropriate frequency of longitudinal out-patient palliative care intervention? How should the characteristics of the patient population impact the timing, frequency and nature of the palliative care intervention?
Dr Temel’s talk was closely followed in the Keynote session by Dr Ira Byock’s: ‘Opportunities at the Intersession of Palliative Care, Supportive Care and Oncology’ during which where he cautioned “we exist to take care of patients and families” and we must consider our work and future research not just from the healthcare professional and provider perspectives.
The final abstract session: ‘Early Integration of Palliative Care, Burnout Issues and Mindfulness’ also consisted of six fantastic presentations, including Dr Richard Riedel on the positive impact on length of stay and readmission by joint ward rounds between oncologists and palliative care doctors on the in-patient unit at Duke university.
Also, Dr Joseph Greer presented a comprehensive cost analysis on the study by Dr Temel and colleagues.
The dangers of burnout
Dr Arif Kamal whipped up huge interest and subsequent discussion with an evaluation of burnout prevalence and predictors in US palliative care clinicians.
Dr Kamal suiggested that there is a crisis looming, with higher rates than other physician groups, and in those aged <50, working in teams of <4 and working longer hours. A suggested resource 3 good things is worth taking a look at.
Connections in providing care
The final session: ‘Psycho-oncology’ was concluded by the inimitable Dr Max Chochinov, discussing dignity conserving care and the importance and impact of a simple question: “What do I need to know about you as a person to help me to take the best care of you that I can?”
I am already reaping the benefits of reconnecting with this phrase and wondering why I haven’t been using it earlier and more consistently before now.
Much of what I reflected upon was about connections. We need each other – oncologists and ‘palliatricians’.
One team cannot do it all, but we need to learn how to work better and smarter together and learn from each other, particularly around symptom management and communication and the non-physical needs of patients and their families. We also need to support one another for a sustainable team, sustainable service, improved research agenda and a better patient experience.
Palliative care as more than ‘the alternative approach’
Until we start normalising our working together in a truly integrated way, with palliative care not seen as the “alternative approach”, the positive public declaration that oncology care goes hand in hand with palliative care will not be standard by 2020.
You can read my Storify from the event here.
Find out more on the symposium website.