Prognostication, Palliative Care and Patient Outcomes (Reply to Rossi et al.)

Dear Editor

We appreciate the comments from Rossi and colleagues on the importance of prognostication and palliative care in the radiation oncology setting.¹ In a recent study, radiation oncologists were found to be overly optimistic in estimating survival of cancer patients undergoing palliative radiation.² Moreover, over-estimation of survival by radiation oncologists was associated with more aggressive care at the end-of-life. We are thus eager to learn if use of validated prognostic tools and/or early integration of palliative care could impact outcomes in the Prognostication in Palliative Radio Therapy (ProPaRT) study once it is complete.

In addition to prognostic tools, palliative care may also improve prognostic accuracy. In the Temel randomized clinical trial, integrated oncologic palliative care resulted in better illness understanding than oncologic care alone.³ Among patients assigned to the integrated oncologic palliative care group, those with better illness understanding were less likely to receive chemotherapy at the end- of-life compared to patients without a good understanding. In contrast, the rate of chemotherapy at the end-of-life did not differ by illness understanding for patients assigned to the oncologic care group. This interaction suggests that palliative care played a critical role not only in enhancing illness understanding but also in helping patients to take advantage of the prognostic information to make healthcare decisions.

Taken together, these studies and others underscore the important role that palliative care plays for many patients seen by radiation oncologists. However, palliative care referral currently occurs in a haphazard manner with significant heterogeneity among oncologists. To facilitate timely palliative care referral, an international project identified 11 consensual criteria to trigger outpatient palliative care involvement.⁴ Nine of the 11 criteria were needs-based and the remaining 2-criteria were time based. Many patients with advanced cancer seen by radiation oncology clinic may be appropriate for referral, such as those with high symptom distress (e.g. severe mucositis, dyspnea, and/or bone pain) or undergoing palliative radiation for central nervous system involvement (e.g. multiple brain metastases, spinal cord compression). These criteria, coupled with systematic screening and automatic referral,⁵ may help to triage patients in need of palliative care, standardize care, improve timely referral to palliative care by several months,⁶ and ultimately improve patient outcomes. We look forward to more research findings on other integrated models of palliative care delivery, such as the Radiotherapy and Palliative Care Outpatient Clinic.