Palliative Care in Advanced Cancer Patients: How and When? And Where?

Abstract

A study by Bruera et al. published in a recent issue of The Oncologist is discussed.

Eduardo Bruera et al. [1] recently published an exhaustive paper in which they underscore the importance of the integration between oncology and palliative care, suggesting how and when to provide palliative care in advanced cancer patients.

We agree that this integrative model allows prompt evaluation and treatment of symptoms, a reduction in costs resulting from inappropriate hospitalization, and better survival outcomes.

In their conclusion, Bruera et al. [1] affirm that the two most important resources for palliative care delivery are outpatient palliative care centers and inpatient palliative care units.

Although we are on the same wavelength as Bruera et al. [1], we would like to point out some considerations. First, in many countries a large majority of patients prefer to spend the last phase of their disease at home [2–4]. Second, the availability of new drugs and the development of innovative therapeutic strategies have changed cancer into a chronic disease; as with all chronically ill patients, oncological patients spend most of their clinical history at home, and at home they and their relatives experience distressing symptoms. In the end, in many countries (i.e.. U.S., Canada, England, and Wales) an increase in home deaths and a reduction in deaths in a hospital or a nursing home have been registered [5].

Indeed, some governments are promoting programs to support home care in order to reduce the high costs of hospitalization.

Based on these considerations, we believe that it is mandatory that cancer centers incorporate palliative care delivery, even high-quality home care services, into their own resources to allow symptom control, to support the family everywhere, and to reduce inappropriate admission to hospitals.

Home care should be activated early in the disease trajectory, even during active treatment, to avoid the major concern of late referral to palliative care. In our view, a cancer center should provide home care services directly, possibly employing the same team involved in palliative care at the hospital, or implement protocols closely integrated with home care providers.

The integration between hospital and home care could play a pivotal role in realizing the aim of a gradual transition of care, warranting continuity of care and avoiding abandonment.

Home care teams with solid expertise in palliative care can also treat complex clinical conditions at home (e.g., malignant bowel obstructions or refractory symptoms requiring palliative sedation), fulfilling patient preferences and avoiding expensive hospitalization [6, 7].

Moreover, new technologies, including Internet connections and the management of data online, may allow a dramatic improvement in information exchange between patients at home and their palliative care teams.

In the near future, as a result of patient wishes, government policy, and changes in the characteristics of cancer, home care will be a priority of palliative care and, more generally, of health services. It's time to highlight home care in our agenda, adding another point to the question of Bruera et al. [1]: not only palliative care how and when, but also where.

Author Contributions

Provision of study material or patients: Federica Aielli

Manuscript writing: Giampiero Porzio, Sebastiano Mercadante, Federica Aielli, Lucilla Verna

Final approval of manuscript: Sebastiano Mercadante, Corrado Ficorella