Providing Palliative Care for Patients With Gastrointestinal Cancers

Rajiv Agarwal, MD, Vanderbilt University Medical Center, Nashville, Tennessee, explains the role of palliative care in the treatment of patients with gastrointestinal cancers, a topic he presented at the 2022 Great Debates and Updates in Gastrointestinal Malignancies virtual meeting.

In his presentation, Dr Agarwal stressed the importance of integrating palliative care early in a patient’s treatment, and that palliative care should change as the patients’ physical and nonphysical needs evolve throughout their disease course. Dr Agarwal also noted that helping a patient to understand their disease is an integral part of palliative and supportive care.

Transcript:

Hi, my name is Dr. Rajiv Agarwal and I'm an assistant professor of medicine in the Division of Hematology/Oncology at Vanderbilt University Medical Center. And I'm also one of the palliative care physicians at Vanderbilt University. At the last Great Debates and Updates in GI Malignancies meeting, I gave a talk on palliative care and GI malignancies, and this recording is to help summarize some of the key topics and key points of that talk.

In general, when we talk about palliative medicine and palliative care, it is a discipline in medicine that helps support people and families and loved ones as they cope and live with a serious illness. And in GI oncology, we really think of palliative care and supportive care as something that should begin at diagnosis and should be delivered concurrently with disease-directed, life-prolonging therapies. Palliative care is an integral part of comprehensive cancer care. As patients' needs evolve, care adapts to address those evolving needs throughout each patient's disease course. Therefore, palliative care at the beginning of a cancer diagnosis may be one thing, and that may change throughout the disease trajectory.

We really don't think of palliative care as something of a sequel to when cancer treatments fail anymore. The current thought of palliative care and supportive care with cancer treatment is that it is something that should be based off need, and not prognosis. For our patients with GI malignancies, we really are addressing the whole person. The goal of palliative care and palliative medicine is to address sources of suffering, whether that's physical suffering and physical symptoms, [or] nonphysical symptoms, such as psychosocial symptoms, emotional, spiritual, or even existential distress.

As we develop further cancer treatments for our GI cancers, what we need in palliative medicine and its incorporation into GI oncology is a dynamic model that integrates with modern therapies and adapts to ongoing drug discovery. In GI oncology, we have a heterogeneous patient population with unique biological and disease characteristics, and so the supportive care that's provided to patient population must be unique as well.

Most of the evidence that we have for early integration of palliative care stems [from] the early 2000s among patients with non-small cell lung cancer, where there was about a 2-month survival benefit for patients with newly diagnosed non-small cell lung cancer stage 4 disease who received concurrent palliative care. The GI population, it's been much harder to really prove this benefit in subsequent studies. There's really been no difference in studies about using early palliative care intervention for quality of life at 12 weeks or at 24 weeks from a newly diagnosed metastatic or advanced GI cancer. Part of that has to do with resources, timing, and also attrition, due to how patients are clinically doing with their advanced malignancy. We also don't know as much about the role and effect of early palliative care for patients with earlier stage disease as well, and so this is an ongoing area that needs further investigation.

In addition to delivery of palliative care earlier on, part of what we do as GI oncologists is to help patients understand their illness. And in a key study that was presented in 2012, patients with newly diagnosed metastatic colorectal cancer were asked, what do they expect from their treatment? And about 81% of those patients reported that they expected a cure from their treatment for metastatic stage colorectal cancer. Why might that be the case? That might be due to a lack of information, use of optimism, [and/or] not believing that their disease is incurable.

Subsequent studies when looking at earlier versus later stage disease, again, confirms that patients with later stage disease have a more inaccurate disease understanding compared to patients with earlier stage disease. It's important for us as oncologists to help patients navigate their disease trajectory and understand their illness, particularly to help patients achieve closure and create legacy and be able to say goodbyes to their family members and loved ones. It's also really hard to do this, to communicate this, as oncologists. And even when patients do receive life expectancy statistics, they still may expect and hope to live longer than what's anticipated.

Overall, when we think about the integration of palliative care in GI oncology, we are really hoping to integrate palliative care and supportive care earlier to help mitigate total suffering and navigate uncertainty throughout disease trajectories. We have to acknowledge that each patient population within GI oncology may be different, and so there may be different needs for psychosocial support and anticipatory guidance. And as we are developing new cancer treatments and drug development, it's important that we also focus on quality-of-life outcomes of our clinical trials. I think one of the biggest challenges for palliative care integration is that it must also adapt to the evolution of how we monitor and treat GI cancers. Changes in cancer care impact the changes [in] how we integrate palliative and supportive care to help guide decision making.

Source:

Agarwal R. Palliative Care in GI Malignancies. Presented at: Great Debates and Updates in Gastrointestinal Malignancies; November 16-18, 2022; Virtual.