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The management of symptomatic bladder cancer in patients who are either too frail for curative treatment or have end stage disease from advanced metastasis is one of the harder clinical problems in our area. The importance of respecting quality of life in the patient, their caregivers and quality of death, as well as reducing patient anxiety, improving their understanding of their disease state and providing patient support was highlighted in her discussion.
Dr. Temel was able to share with the Bladder Cancer community her experience with early involvement palliative care in the management of end stage cancer patients. She was lead author in a New England Journal of Medicine study looking at early Palliative care involvement in lung cancer patients which showed improved QOL, decreased depression, decreased anxiety, improved understanding of prognosis, and early hospice service involvement (NEJM Temel 2010). This has been supported in other diseases and the message is clear that patients and care givers do better from a quality of life standpoint with early palliative involvement.
With increased therapeutic options for end stage disease, end of life will likely get more complex. And in the treatment options, it is important to think of early palliative care as patients and families are suffering. Prognostication of disease and assessing possible cure is a difficult barrier to referral to palliative care. As often clinicians do not want to give up hope unless they know for certain. However, Temel highlights, receiving aggressive desperation care is often done due to uncertainty. And aggressive care near the end of life may have negative consequences for patient and their family. Patients with advanced disease have psychological, depressive and physical symptoms increase with increasing disease burden. And despite full care in hospital setting issues such as pain, constipation, nausea, hematuria, painful LUTS, dyspnea are significant. This results in significant distress in the patient and care givers. These issues need to be addressed and can be addressed even while active therapy is being given. Whereas palliative care will have improved quality of life at end of life and quality of death. Furthermore, family members can have decreased bereavement outcomes (Wright JAMA 2008).
Dr. Temel highlighted an integrated palliative care and oncology care model as well as the role of “primary palliative care” where every care giver is encouraged to provide palliative care treatments and the early intervention from primary physicians, surgeons and oncologist will improve patient outcomes. However, an integrated palliative and oncology care is an appealing model. Transitioning the timing and focus of palliative care toward patients earlier will allow them and their caregivers to get the most benefit. Necessary elements of comprehensive care that palliative care can provide is symptom management, psychosocial support, assistance with treatment decision making for patients. Emphasizes the well-being of patients and their families. Delivery of care options such as telephone call to patients may have some benefit with more intensive in hospital or clinic setting may have more benefit. Barriers are disseminating palliative care to patients, and creation of appropriate models specific to bladder cancers, and work force issues. However, what is clear, is that early involvement of palliative care in patients with advanced untreatable disease in many cancers is beneficial to their quality of life, and this should be explored in bladder cancer.
Presented By Jennifer Temel, MD. Massachusetts General Hospital
Written by: Michael J Metcalfe, MD. Fellow of Urologic Oncology Urology, MD Anderson Cancer Center, Houston TX.
Ashish M. Kamat, MD, MBBS, FACS
President, International Bladder Cancer Network
Chair, Society of Immunotherapy for Cancer (SITC), BCTF
Director of Urologic Oncology Fellowship
Professor of Urology
Attending Surgeon, Division of Surgery
The University of Texas, MD Anderson Cancer Center