Comprehensive Cancer Care: The Role for Palliative Care in Prostate Cancer Treatment

Heidi Blake, MD Beth Israel Deaconess Medical Center

Disclosures • None

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

What is palliative care?

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

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

do?”

mouth… What do you

“You’re with hospice. Right?”

The “Old” Model: Either-Or Care

Diagnosis

Time

The “New” Model: Integrated Care

Diagnosis

Time

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

http://www.hms.harvard.edu/pallcare/Other/Rounds.htm

Physical Spiritual

Social Mental

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 www.capc.org/building-a-hospital-based-palliative-careprogram/case/definingpc

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

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

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

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

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

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. 2011. Follwell M, et al. J Clin Oncol. 2009. Temel J, et al. NEJM. 2010.

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

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

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

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

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

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

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

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

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

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”

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

Shouldn’t all doctors provide palliative care? • YES! – Primary Palliative Care – Secondary (or specialty) Palliative Care

Oncologic Care + Palliative Care = Comprehensive Cancer Care

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

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 • www.getpalliativecare.org/providers

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

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

Thank you. • Questions?

Heidi Blake, MD May 17th, 2013 Beth Israel Deaconess Medical Center