Comprehensive Cancer Care: The Role for Palliative Care in Prostate Cancer Treatment. Heidi Blake, MD Beth Israel Deaconess Medical Center

Transcription

1 Comprehensive Cancer Care: The Role for Palliative Care in Prostate Cancer Treatment Heidi Blake, MD Beth Israel Deaconess Medical Center

2 None Disclosures

3 Outline What is palliative care? One man s story Evidence for palliative care how can it improve patients and families lives?

4 What is palliative care?

5 "Honey, I'm talking to a doctor she's a paleontologist."

6 HB: Hi. My name is Dr. Heidi Blake. I m a palliative care doctor Patient: Great. So, you re an ear, nose and throat doctor? HB: No. I m a palliative care doctor. Patient: Oh. I thought palate meant mouth What do you do?

7 You re with hospice. Right?

8 The Old Model: Either-Or Care Diagnosis Time

9 The New Model: Integrated Care Diagnosis Time

10 What is palliative care? Specialized medical care for people with serious illnesses Focused on providing relief from the symptoms, pain, and stress of a serious illness whatever the diagnosis The goal is to improve quality of life for both the patient and the family

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13 Physical Social Spiritual Mental

14 An extra layer of support Working with your doctor, palliative care teams provide: Expert management of pain and other symptoms Help navigating the healthcare system Guidance with difficult and complex treatment choices Emotional and spiritual support for patients and families

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16 One Man s Story Mr. T is a 67-year-old man with progressive prostate cancer Diagnosed 6 years earlier with prostate cancer: Gleason score 7, PSA 18 He pursued radical prostatectomy

17 One Man s Story Following prostatectomy, he returned to his job as a businessman He resumed his favorite hobby of bicycling His main post-treatment side-effects included urinary incontinence and erectile dysfunction, which improved over a few months

18 One Man s Story Six years post-surgery, Mr. T s PSA rose He also developed pain in his upper arm & ribs Evaluation revealed evidence of bone metastases

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20 One Man s Story Mr. T s oncologist prescribed anti-androgen therapy as well as and radiation to the bone Despite these measures, his pain remained difficult to control He was missing work due to the pain, causing both him and his wife distress

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22 One Man s Story Mr. T was admitted to the hospital to get his pain under better control His oncologist requested a palliative care consult for assistance in managing his pain

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24 Evidence for Specialty Palliative Care Improves pain & non-pain symptoms Improves mood > reduces depression Improves quality-of-life Improves patient & family satisfaction with care Prolongs survival?!... Yennurajalingam, et al. J Pain Symptom Mgt Follwell M, et al. J Clin Oncol Temel J, et al. NEJM

25 What does a palliative care consult entail? Physical - Pain - Shortness of breath - Fatigue - Constipation - Nausea/Vomiting - Appetite Mental Emotional -Coping with illness -Anxiety -Depression Social - Family / caregiver support - Financial concerns - Interpersonal relationships Spiritual - Spiritual well-being - Existential meaning

26 One Man s Story PC team worked with Mr. T to create an effective pain medication regimen PC team supported him & his wife as they grappled with anxiety about their future Mr. T was able to return to work, though he soon decided to retire to spend more time with his family

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28 One Man s Story A few years later Mr. T s PSA was noted to be rising, again He developed progressive back pain and weakness in his legs Evaluation revealed extensive metastases to his vertebrae, causing spinal cord compression He was rushed for emergency spinal surgery

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30 One Man s Story Mr. T and his wife met with his oncologist and palliative care doctor to discuss his course & to consider potential next steps His oncologist explained that his cancer was now hormone refractory His oncologist suggested that he consider chemotherapy once he recovered from the surgery

31 One Man s Story Mr. T struggled with the decision about whether to pursue chemo He worried about treatment-related sideeffects like those his father experienced His wife had difficulty understanding why he would ever consider foregoing chemo if it might give him more time to live and better QOL

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33 One Man s Story Mr. T s post-operative course was complicated by pneumonia and ongoing back pain He met regularly with his palliative care doctor and oncologist, who worked together to manage his pain He felt more fatigued and had difficulty motivating himself to engage in rehab

34 One Man s Story With ongoing pain management and the addition of an anti-depressant, Mr. T started feeling better He decided to try the chemotherapy

35 One Man s Story Mr. T experienced nausea, vomiting, and diarrhea with the chemo, though his pain improved His palliative care doctor helped him get control of the chemo-associated symptoms with medication and integrative therapies

36 One Man s Story Recalling how his father suffer horribly with advanced cancer, Mr. T wanted to be clear about what his wishes were in case his condition progressed His palliative care doctor facilitated discussions about this with Mr. T and his wife Although his wife found it hard to talk about him getting worse or dying, she appreciated knowing his wishes

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38 One Man s Reflections Mr. shared his feeling that working with his palliative care team helped him not only feel better physically and mentally but it also helped him feel more in control

39 At the heart of palliative care Understanding who a person is and what is most important to him, and, from that understanding, supporting him in pursuing care that aligns with his goals and values

40 Shouldn t all doctors provide palliative care? YES! Primary Palliative Care Secondary (or specialty) Palliative Care

41 Oncologic Care + Palliative Care = Comprehensive Cancer Care

42 When should someone with cancer pursue specialty palliative care? The American Society of Clinical Oncologists recommends that anyone with metastatic cancer or a high symptom burden receive specialty palliative care Smith TJ. J Clin Onc 2012

43 Where can a person find palliative care services? Start by asking your primary doctor Most commonly palliative care services are offered in hospitals There are some outpatient palliative care clinics

44 Summary Comprehensive prostate cancer care, particularly for men with advanced disease, should involve palliative care in some fashion When pain or symptoms become more burdensome, consider requesting a palliative care team to work in concert with your cancer clinicians

45 Summary (continued) Palliative care teams can improve pain and symptom control, decrease depression, enhance well-being and satisfaction with care Palliative care teams can also support patients and families as they face decisions about their care as the illness progresses and they near the end of life

46 Thank you. Questions? Heidi Blake, MD May 17 th, 2013 Beth Israel Deaconess Medical Center