NcXHF

MARTINS, REYNOLDS, AND RIELY
vival of 11.6 months, compared with 8.9 months on the control
group (p 0.02).
It is unclear how this single-institution trial, with a specifıc
group of physicians, translates to general practice. Whether
these benefıts of early palliative intervention can only be
achieved by a specialized palliative care team is unknown, as
is how easily the results could be achieved in the community
oncology setting where access to such support services is often
limited. Indeed, in 2010 only 59% of National Cancer Institute–designated
comprehensive cancer centers and 22% of
community cancer centers had outpatient palliative care programs.
12 A more recent survey of California hospitals with
inpatient palliative care programs found that only one-fıfth
provided outpatient palliative services, and around the clock
outpatient services were available in only one-quarter of
those. 13 However, this work strongly suggests that more aggressive
therapy at the end of life is not associated with a better
survival.
Multiple studies have found that a signifıcant number of patients
with advanced NSCLC receive chemotherapy in the last
month of life. A 2001 review of almost 8,000 Medicare patients
found that 11% received chemotherapy in the last month of
life. 14 An Italian review of four cancer centers found 33% of patients
received chemotherapy in their last month of life (only
one-third of these had lung cancer). 15 Fifteen percent of patients
experienced grade 3 to 4 toxicity in the last month of life, and
there were two treatment-related deaths. A clinical benefıt was
observed in 10%. A more recent retrospective chart review was
conducted in 10 community oncology practices, which included
417 patients that were diagnosed with advanced NSCLC
in 2000 to 2003. 16 Chemotherapy was given within 1 month of
death in 43% and within 2 weeks of death in 20%. Of those receiving
chemotherapy in the last month of life, 39% were fırst
line, 28% second line, and 21% third line. The authors attributed
this high use of treatment at the end of life to the
availability of new agents and an increase in the length of
time patients receive treatment.
• Person-centered, family-oriented palliative care should
include extra efforts to manage transitions, avoid unneeded
hospitalizations, and support family caregivers.
• Clinician–patient communication and advance care
planning should be prioritized and improved to ensure
that patients have opportunities to articulate their preferences
while they are still able to.
• Professional education and development should extend
the new discipline of hospice and palliative medicine
into medical and nursing school curricula—across professional
silos—and it should include improving physician
communication skills.
• Policies and payment systems must be reorganized to incentivize
care coordination and palliative care provision
and to discourage excessive use of inpatient days and
multiple care transitions.
• Public education and engagement about end-of-life care
is crucial; efforts must be made to normalize conversations
about death and dying.
Medicare fails to adequately compensate long outpatient
discussions, typical of end-of-life care. Using the 2013 National
Medicare Fee Schedule, a physician who spends 35
minutes discussing the lack of benefıt of additional cancerdirected
therapy and hospice referral received 27% lower
compensation than he or she would by seeing two patients for
a 15-minute visit entirely dedicated to describing the schedule
of administration and side effects of a new line of therapy.
20 During the discussions about the approval and
implementation of the Affordable Care Act, there was a proposal
to compensate for end-of-life discussions. The goal was
to stimulate the counseling of patients and families to avoid
futile and expensive care near the end of life. Most medical
oncologists likely would agree that discussions about of endof-life
care are critical for our patients, their families, and society
in general. In a recent sign of progress, the American
Medical Association has released codes for advanced care
planning. 20 This is an important step for Medicare to consider
the coverage of end-of-life discussions.
ADVANCED CARE PLANNING
Emerging data suggest that interventions in community practice
can affect end-of-life care. The US Oncology Network’s My
Care My Wishes program (MCMW) gives formal counseling to
patients with advanced cancer, including discussions of prognosis
and desires regarding code status and end of life. A recent
analysis suggests that MCMW improves documentation of
code status in electronic medical records in the community setting,
perhaps reducing the likelihood of unwanted and futile
end-of-life interventions. 17 A study at this meeting suggests that
advanced care planning reduces hospitalization and increases
hospice referrals in patients with advanced cancer. 18
In 2014, the Institute of Medicine released “Dying in
America: Improving Quality and Honoring Individual Preferences
Near the End of Life.” 19 This document addresses all
patients with potentially terminal illness, not just oncology
patients. There were fıve main recommendations:
GUIDELINES
Choosing Wisely is an American Board of Internal Medicine
Foundation initiative supported by more than 60 medical
specialties. 21 It aims to promote discussions between providers
and patients to achieve care that is “supported by evidence;
not duplicative of other tests or procedures already
received; free from harm; truly necessary.” The American Society
of Clinical Oncology (ASCO) has joined Choosing
Wisely and proposed two lists with a total of 10 interventions
“whose common use and clinical value are not supported by
available evidence.” The very fırst of these listed procedures
applies to the discussion of palliative chemotherapy not supported
by existing evidence:
• “Do not use cancer-directed therapy for solid tumor patients
with the following characteristics: low performance
status (3 or 4), no benefıt from prior evidencebased
interventions, not eligible for a clinical trial, and
e416
2015 ASCO EDUCATIONAL BOOK | asco.org/edbook