ASCO Calls for Open Discussions and Individualized Care for Patients with Advanced Cancer

Frank discussions with patients about their advanced cancer are challenging for physicians and their patients; however, avoiding such interactions is not a viable option, according to the American Society of Clinical Oncology (ASCO).

Building on its previous statements on end-of-life care and palliative care, ASCO has issued a new statement to oncologists, calling on them to recognize the value of an evidence-based individualized approach to cancer care for patients with advanced disease (Peppercorn JM, et al. J Clin Oncol. 2011; 29:755-760).

Unlike personalized medicine, which is based on the patient’s unique biologic characteristics, in the context of advanced disease that is often incurable (with increasing exceptions thanks to recently approved therapies for latestage cancer) ASCO is now urging oncologists to accept the need to properly inform patients with cancer about their prognosis, treatment challenges, and associated risks, and to institute a treatment plan that considers the clinical evidence, current guidelines for advanced disease, and the individual patient’s preferences that are based on well-informed parameters.

The authors highlight the need to change the paradigm of care for advanced cancer and overcome current barriers to individualized care at latestage disease, by tailoring care to the unique needs and preferences of the patient throughout the continuum of care, including in metastasized disease.

Quality of life (QOL) is always the primary consideration in cancer care, according to this statement. Explaining available therapeutic op tions and risks to patients based on the evidence and discussing the patient’s prognosis are inherently part of quality of care in oncology.

The statement outlines the following 6 major aspects of individualized care for patients with advanced cancer. Oncologists are advised to:

1. Ensure that patients are well informed about their prognosis and treatment options and have opportunities to express their preferences and concerns regarding treatment options and supportive care
2. Offer anticancer therapy when the evidence supports a meaningful clinical benefit
3. Develop a treatment plan when advanced cancer is diagnosed that outlines the goals of therapy and prioritizes and enhances the patient’s QOL throughout the course of illness, including late-stage disease
4. When discussing interventions, explain the nature of the potential response, any potential associated adverse events and risks, total direct costs to the patient, and impact on QOL
5. When appropriate, offer such patients the opportunity to participate in clinical trials or other research that may improve their outcome or that of future patients
6. Minimize the physical and emotional burden during treatment by encouraging patients to switch to symptom-directed palliative care when cancer-directed options have been exhausted.

Oncologists must become aware of when stopping disease-directed therapy is appropriate, based on current guidelines. The statement outlines specific strategies to enhance provider education, with the goal of achieving individualized care for patients with advanced cancer, through various provider initiatives.

These initiatives should include patient and family education, insurance reimbursement reform, and support for research that is designed to help oncologists to overcome their resistance to communication with their patients with cancer.

These initiatives are intended to increase oncologists’ awareness of the need to establish an open dialogue with their patients and provide an individualized treatment plan for patients and for their families.

The current system of reimbursement incentivizes disease-targeted therapies even at the end of life rather than encouraging direct conversations with patients to establish their preferences when all therapeutic options have failed. This new approach to the management of patients with advanced cancer has value for patients as well as for society.

Although this evidence-and guidelines-based approach has recently been politicized with the unfortunate “death panels” epithet, ASCO believes that it is time to overcome such barriers and embrace the need to provide appropriate quality of care for patients with advanced cancer.

“We need to move toward developing a treatment plan that is consistent with evidence-based options (including disease-directed and palliative care) and the patient’s informed preferences for how we pursue and balance these options throughout the course of illness,” the authors say.