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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 151-153

Palliative and symptom-directed care at diagnosis in hematologic malignancies: Need for hematology-oncology and anesthesia-pain services to join forces

Department of Clinical Hematology and Stem Cell Transplantation, Dayanand Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission18-Feb-2021
Date of Decision05-Mar-2021
Date of Acceptance05-Mar-2021
Date of Web Publication26-Mar-2021

Correspondence Address:
Suvir Singh
Department of Clinical Hematology and stem cell transplantation, Dayanand Medical college and hospital, Ludhiana, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_44_21

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How to cite this article:
Singh S. Palliative and symptom-directed care at diagnosis in hematologic malignancies: Need for hematology-oncology and anesthesia-pain services to join forces. Cancer Res Stat Treat 2021;4:151-3

How to cite this URL:
Singh S. Palliative and symptom-directed care at diagnosis in hematologic malignancies: Need for hematology-oncology and anesthesia-pain services to join forces. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Apr 22];4:151-3. Available from: https://www.crstonline.com/text.asp?2021/4/1/151/312104

Palliative care is defined by the World Health Organization (WHO) as any intervention that improves the quality of life (QOL) of patients and their families when faced with a life-threatening illness by identification and assessment of pain and other physical, psychosocial, and spiritual issues.[1] In clinical practice, however, this term has become synonymous with “end-of-life” care, with the intent of addressing patient symptoms at the last stage of the illness, in the setting of advanced disease.[2] In this setting, the wishes of the patients and their families often take a backseat, and minimal emphasis is placed on improving their QOL. While undergoing treatment for malignancies, patients often report feeling distressed when their QOL, symptoms, and wishes are not addressed adequately.[3],[4] This has inspired a number of studies addressing the routine integration of palliative care with oncology care services, leading to the concept of “primary palliative care.” Primary palliative care has come to be defined as care provided by the treating physician at the time of diagnosis and initiation of therapy, rather than in later stages.[5]

The importance of initiation of palliative care at an early stage in the disease course rather than at the end of life has been increasingly understood over the past decade. Three major trials have highlighted the importance of the early integration of palliative care with routine treatment in solid organ malignancies, and reported an improvement in various QOL measures. This is consistent with the WHO definition to provide multifaceted care for various issues that a patient or caregiver may face. One of these trials conducted by Bakitas et al. in 2009 included patients with newly diagnosed solid organ malignancies with expected survival <1 year; the study showed significant improvement in scores for QOL and mood.[6] Similar results were reported by Zimmerman et al., in terms of QOL measures.[7] Temel et al., in addition to the above measures, also reported an improvement in overall survival in patients with non-small cell lung cancer when palliative care was introduced early.[8] This has created an impetus for early integration of palliative care in clinical oncology services. In the USA, guidelines by the American Society of Clinical Oncology call for the integration of palliative care early in the management of the primary cancer.[9] An update in 2017 has emphasized the need for referral to specialized teams early in the disease course.[10]

However, specialized palliative care services are few and far between. Even in the developed countries, there is a significant shortage of palliative care physicians, infrastructure and the availability of palliative care, making it impossible for every patient to receive specialized care.[11],[12] In the Indian setting, there are very few specialized palliative care physicians or nurses, a fact which is further hampered by our variations in socioeconomic status, population density, and lack of national-level policies.[13] There is a huge unmet need in India in this setting.[14] In the absence of specialty physicians and nurses well versed with this subject, it is often the onus of the primary care physician to provide palliative care services. However, with the development of multidisciplinary cancer centers, it is often possible to enable these services with a team consisting of the anesthetist/pain specialist, oncologist, oncology nurse, and psychiatrist/psychologist in India.

Patients with hematologic malignancies have unique needs compared to those with solid organ malignancies, with a much higher incidence of symptoms due to neutropenia, mucositis, and bleeding.[15] The symptom burden in these patients due to primary disease and chemotherapy is distinctive. Different hematologic malignancies have varying rates of progression and require different intensities of chemotherapy. Many times, older patients with advanced malignancies are not candidates for intensive therapy and are on palliative chemotherapy alone. Older patients with advanced hematologic malignancies usually do not receive high-quality end-of-life care.[16] In addition, palliative chemotherapy and transfusions may play a unique role in hematologic malignancies, one that is not seen in other disorders.[17] A wide range of overall survival from a few weeks to many years for a hematologic cancer creates different palliative care needs for varying groups of patients. Preliminary data from our department (unpublished) have revealed a significant negative effect on QOL of hematology-oncology patients at diagnosis, as measured by the Functional Assessment of Cancer Therapy questionnaire; the manuscript is under prospective compilation.[18]

There are no studies evaluating the effects of early palliative care integration in patients with hematologic malignancies, particularly in the Indian setting. Patients with blood cancers and those undergoing a stem cell transplantation represent a unique patient population. An integrative approach, with inputs from anesthesiology/pain/palliative care services, neurology, psychiatry, and nursing along with the primary care physician, has the potential to improve the QOL of patients with hematologic cancers and should be high on the agenda for research.

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There are no conflicts of interest.

  References Top

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Bauman JR, Temel JS. The integration of early palliative care with oncology care: The time has come for a new tradition. J Natl Compr Canc Netw 2014;12:1763-71.  Back to cited text no. 2
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Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: A consensus report from the Center to Advance Palliative Care. J Palliat Med 2011;14:17-23.  Back to cited text no. 5
Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The Project ENABLE II randomized controlled trial. JAMA 2009;302:741-9.  Back to cited text no. 6
Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, et al. Early palliative care for patients with advanced cancer: A cluster-randomised controlled trial. Lancet 2014;383:1721-30.  Back to cited text no. 7
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733-42.  Back to cited text no. 8
Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012;30:880-7.  Back to cited text no. 9
Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol 2017;35:96-112.  Back to cited text no. 10
Lupu D; American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 2010;40:899-911.  Back to cited text no. 11
Schneider N, Mitchell GK, Murray SA. Palliative care in urgent need of recognition and development in general practice: The example of Germany. BMC Fam Pract 2010;11:66.  Back to cited text no. 12
Salins N. Health-related quality of life: Is it a missing feature in the Indian cancer setting? Cancer Res Stat Treat 2019;2:213-4.  Back to cited text no. 13
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McDermott E, Selman L, Wright M, Clark D. Hospice and palliative care development in India: A multimethod review of services and experiences. J Pain Symptom Manage 2008;35:583-93.  Back to cited text no. 14
Fadul NA, El Osta B, Dalal S, Poulter VA, Bruera E. Comparison of symptom burden among patients referred to palliative care with hematologic malignancies versus those with solid tumors. J Palliat Med 2008;11:422-7.  Back to cited text no. 15
El-Jawahri AR, Abel GA, Steensma DP, LeBlanc TW, Fathi AT, Graubert TA, et al. Health care utilization and end-of-life care for older patients with acute myeloid leukemia. Cancer 2015;121:2840-8.  Back to cited text no. 16
Uceda Torres ME, Rodríguez Rodríguez JN, Sánchez Ramos JL, Alvarado Gómez F. Transfusion in palliative cancer patients: A review of the literature. J Palliat Med 2014;17:88-104.  Back to cited text no. 17
Cella D, Jensen SE, Webster K, Hongyan D, Lai JS, Rosen S, et al. Measuring health-related quality of life in leukemia: The Functional Assessment of Cancer Therapy—Leukemia (FACT-Leu) questionnaire. Value Health 2012;15:1051-8.  Back to cited text no. 18


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