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ESMO 2012 Report – Urgent need for integrated oncology and palliative care
The European Society for Medical Oncology (ESMO) has awarded ESMO Designated Center of Integrated Oncology and Palliative Care accreditation to 16 new oncology centres. The centres[1] will receive the acknowledgment at the ESMO 2012 Congress, in Vienna, Austria, 28 September – 2 October. The ESMO 2012 Congress will also highlight two new Italian studies demonstrating how palliative care works in practice in Italy. The first study explores use of analgesics; the second looks at different models for organization of the integration of palliative care with oncology.
First set up in 2003, this ambitious ESMO project aims to improve the infrastructure for the provision of palliative care globally. The initiative came partly in response to the World Health Organization (WHO) report “Cancer pain relief and palliative care”[2].
“This year’s awardees –13 based in Europe, one in Egypt, one in Singapore and one in India—demonstrate the truly international scope of ESMO’s work. It shows how ESMO wants to help humanity, not just European oncology patients,” says Raphael Catane, one of the founding members of the ESMO Palliative Care Working Group.
“In addition to making efforts to prolong the life of oncology patients, ESMO felt we needed to ensure that quality of life was good. We’ve made considerable efforts to change the mindset of doctors and patients that taking care of symptoms need not diminish efforts to prolong life. From the outset of diagnosis we wanted to integrate palliative care into the practice of medical oncology,” says Dr Catane, from the Institute of Oncology, Sheba Medical Center, Israel.
The award, judged anonymously by ESMO Palliative Care Working Group members, assesses centres according to 13 rigorous criteria[3]. Any oncology department or cancer centre can apply, with ESMO emphasizing that size is not important, what matters most is the quality and extent of integration of services.
The criteria have come to be regarded as a “roadmap” for how to build palliative care services. Unsuccessful applicants are invited to further develop their programs and reapply. “What’s really valuable is that we give feedback which works as a teaching tool, showing centres how they can improve,” says Dr Catane. “
Receiving the certification allows centres to use the title “ESMO Designated Center of Integrated Oncology and Palliative Care” and also be eligible to receive fellows in palliative medicine, supported by ESMO grants.
For successful applicants, however, there is no room for complacency, since awards need to be renewed every three years. Of the current 127 (including the 16 new centres) accredited centres, 50 have been reaccredited once (27 this year) and 21 twice (eight this year). “With personnel, policy and financial aspects changing all the time, we want to ensure that integration of palliative care continues,” says Dr Catane.
Dr. Matti Aapro, a member of the ESMO Supportive and Palliative Care Faculty, adds, “The program is laid out in a very ‘user-friendly’ manner which allows many centres to continue to improve their skills while already recognized as a ‘designated center’.”
Undoubtedly, the much sought after accolade has contributed to increasing the profile of palliative care within oncology units across the world. “ESMO’s initiative has certainly raised a lot of interest, as demonstrated by the growing list of centres that adhere to this program. It’s one of many ways to encourage the development of truly multidisciplinary cancer centres which look at the patient’s needs in all aspects of cancer treatment,” says Dr Aapro, from the Clinique de Genolier, Switzerland.
“While further penetration of ESMO’s palliative care policy[4] is still needed, the work of the ESMO Palliative Care Working Group has undoubtedly enhanced the lives of thousands of cancer patients in Europe and beyond,” says Dr. Catane.
ESMO 2012 abstracts reveal organization of palliative care in Italy
Two Italian abstracts presented at the ESMO 2012 Congress demonstrate the emphasis that Italian oncologists place on monitoring palliative care in a bid to further improve services delivered to patients. As a country, Italy has a strong tradition of palliative care, with 26 centres now awarded ESMO Designated Center of Integrated Oncology and Palliative Care status.
Underuse of adjuvant analgesics is highlighted in the first study, which evaluated the management of pain in eight Italian oncology centres. The study also emphasizes the importance of close patient follow-up.
“We set out to provide a snapshot of the management of cancer pain across Italy to see how we’re doing,” says Dr Sandro Barni, the principal investigator from Treviglio Hospital, Italy.
In the prospective study, 265 consecutive cancer patients seen in eight Italian cancer centres over five days between Monday, 10 January and Friday 14, January 2011 were asked to fill in questionnaires concerning levels of pain experienced in the previous seven days, the site of pain and analgesics used. The questionnaires were then re-administered at one and two weeks later. The recruiting centres were in Treviglio, Florence, Rome, Pavia, Reggio Emilia and Palermo.
Of the enrolled subjects, 59% were female, the median age was 61 years, 72.8% had metastatic disease, 86.4% were undergoing chemotherapy and 88% had ECOG Performance status (0-1), indicating that they were ambulatory.
Results at baseline show 69.4% of patients used NSAIDs, 34% weak opioids, 34% strong opioids and 27.7% adjuvants (24.5% pregabain, 57.1% steroids and 18.4% other drugs). The baseline treatment was confirmed in 57.3%, adjusted in 34% and changed in 8.6%.
At one week follow-up analgesic therapy was confirmed in 72.2% and adjusted in 27.8%. New drugs prescribed were NSAIDS in 43.3%, weak opioids in 21.7%, strong opioids in 86.7% and adjuvants in 55%. At two weeks follow-up, therapy was adjusted in 19.1%, with an adjuvant prescribed in 85.7% of these patients.
Adjuvant analgesics (which include antidepressants, corticosteroids and bisphosphonates), are defined as drugs with a primary indication other than pain that have analgesic properties in some conditions.
“Our data suggests not enough cancer patients receive adjuvants. We have the impression that this is especially the case where therapies are not prescribed by oncologists. We’d like both doctors and patients to be better informed about the benefits of these drugs,” says Dr Barni.
The study, he adds, shows that clinicians frequently change and adjust pain treatments at follow-up visits. “The adjustments demonstrate that you need to follow patients very carefully. Healthcare professionals should be getting cancer patients to assess pain on visual scales every time they see them and adjusting treatments accordingly,” concludes Dr Barni.
The integrated care model of palliative care dominates Italian ESMO Designated Centres of Integrated Oncology and Palliative Care, reveals a survey of 20 Italian ESMO designated centres, but organization differs between centres.
In the second abstract, Dr Vittorina Zagonel and colleagues from the Task Force “Continuity of Care in Oncology” of the Italian Association of Medical Oncology (AIOM), set out to evaluate integration models for oncology and palliative care in the 20 Italian ESMO designated centres that were recognized at the time of the study. The task force, which was set up to bring together the ESMO designated centres in Italy, sent questionnaires to managers at each of the 20 centres.
“The intention was to reveal a picture of the different types of integration models operating in ESMO designated centres. We hope to inspire the Italian oncology units who have yet to be designated to consider applications,” says Dr Vittorio Franciosi, one of the investigators from the University Hospital of Parma, who is also secretary of the Task Force.
Results show that the integrated care model operated in 75% of centres. This is the model where the oncologist focuses on the management of the cancer and a supportive care team addresses the vast majority of physical and psychosocial concerns.
The questionnaire revealed that 90% (18) of the centres had an oncologist orientated to palliative care, 90% (18) had guidelines in place for symptomatic treatment, 70% (14) had palliative care beds and 70% (14) had palliative care offices.
Good integration with home care was demonstrated. Home care managed by palliative care physicians (PCPs) occurred in 45% (9), while in 30% (6) it was managed by general practitioners (GPs), in 15% (3) by oncologists and in 10% (2) jointly by PCPs and GPs.
Where home care was not managed by oncologists, the centres achieved integration through oncologist home visits in 35%, interdisciplinary meetings in 65% and guidelines sharing between oncologists, PCPs and GPs in 35%.
Good integration with hospices was demonstrated. Hospices were managed by PCPs in 79% of cases, PCPs together with GPs in 11%, GPs in 5% and oncologists in 5%. When not managed by oncologists, integration was achieved through hospice visits in 41%, interdisciplinary meetings in 65% and guidelines sharing between oncologists, PCPs and GPs in 41%. The study revealed that 60% (12) centres were based in Northern Italy, 30% (6) in the centre, 10% (2) in the Islands and none in the South[5].
“Our results show that the type of integration achieved depends to a large extent on local and regional factors. Such information could be useful as a starting point for discussions with other centres showing them how approaches for integration might work in their areas,” says Dr Franciosi.
Understanding the different models used in the Italian centres, he adds, opens the way for randomized clinical trials comparing the efficacy of integration of palliative and oncologic care with standard oncologic care.
While a study has already shown survival advantages in patients with advanced lung cancer[6], additional studies could now be undertaken on cancers such as advanced gastric cancer, pancreatic cancer and biliary cancer. The shortage of designated palliative care centres in Southern Italy, he adds, needs also to be addressed.
References and Notes
[1] The 2012 accredited centres are:
Campus Bio Medico, Rome, Italy
Prof. Giuseppe Tonini g.tonini@unicampus.it
Cancer Center, Ospedale San Pietro Fatenbenefratelli, Rome, Italy
Dr. Ida Pavese idapavese@yahoo.it
Centre Léon Bérard, Lyon, France
Dr. Gisèle Chvetzoff gisele.chvetzoff@lyon.unicancer.fr
Consorci Sanitari de Terrassa, Barcelona, Spain
Dr. Angels Arcusa I Lanza aarcusa@cst.cat
El-Qabbary Specialized Oncology and Palliative Care Center, Alexandria, Egypt
Dr. Waleed Hambdy Nafea ibnmasuod2006@yahoo.com
Instituto Oncologico Veneto – I.R.C.C.S., Medical Oncology 1, Padova, Italy
Dr. Vittorina Zagonel vittorina.zagonel@ioveneto.it
Oncologia Medica Policlinico Universitario Tor Vergata (Roma) & San Raffaele Hospices (Rocca di Papa – Montecompatri), Rocca di Papa, Italy
Dr. Matteo Vergati hospice.roccadipapa@sanraffaele.it
Oncology Center GZA Sint Augustinus, Wilrijk, Belgium
Dr. Luc Dirix luc.dirix@gza.be
Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
Dr. Kris Vissers k.vissers@anes.umcn.nl
Raffles Cancer Center, Singapore
Dr. Lynette Ngo ngo_lynette@rafflesmedical.com
Saroj Gupta Cancer Centre & Research Institute (SGCC&RI), Kolkata, India
Dr. Rakesh Roy rex4you@gmail.com
St. George’s Hospital NHS Trust, London, United Kingdom
Dr. Jens Smol jens.smol@stgreorges.nhs.uk
Struttura Complessa di Oncologia, Macroattività di Cure Palliative, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
Dott.ssa Chiara Broglia c.borglia@smatteo.pv.it
Tumor Zentrum, Hirslanden Medical Center, Aarau, Switzerland
Dr. Razvan Popescu razvan.popescu@hirslanden.ch
U.O.C. Oncologia Medica, Azienda Ospedaliera Sant’ Andrea, Sapienza Universita’ Di Roma, Rome, Italy
Dr. Paolo Marchetti paolo.marchetti@uniroma1.it
UOC Oncologia & Breast Unit – OSP. “A.Perrino”, Brindisi, Italy
Dr. Angelo Nacci angeloncc@gmail.com
[2] The WHO report “Cancer pain relief and palliative care” calls for the integration of efforts directed at maintaining the patient’s quality of life in all stages of cancer treatment. The report, published in 1990, emphasized that factors causing patient distress exist from the time of diagnosis and that supportive interventions are needed concurrently with efforts to control the underlying cancer.
[3] The criteria include close integration of oncology and palliative care services for all cancer patients; centres being committed to a philosophy of continuity of care and non abandonment; high levels of home care; support for family members; routine physical and psychological assessments; expert medical and nursing care in evaluation of pain relief; availability of emergency care; provision of respite care; in-patient end of life care; basic or clinical research related to quality of life; physician education around integration of oncology and palliative care.
[5] At the time of the study
[6] A landmark study by Jennifer Temel, from the Massachusetts General Hospital, Boston, USA, showed that patients with metastatic non-small cell lung cancer randomized to palliative care early after diagnosis survived longer, had better quality of life and also experienced less depressive symptoms than those receiving standard oncologic care alone (NEJM 2010, 363:733-42). The patients receiving palliative care had a median survival of 11.6 months versus 8.9 months for those receiving standard care (P=0.02). Additionally, the study showed that patients randomized to palliative care received less aggressive end of life care, including reduced chemotherapy and longer hospice care.
Disclaimer
Information contained in this press release was provided by the abstracts authors and reflects the content of the studies. It does not necessarily express ESMO’s point of view.
Session info
Abstract 1425 P (Poster) Monday, October 1, 2012 – 1:00 PM – 2:00 PM: – Room: Hall XL
Abstract 1436 P (Poster) Monday, October 1, 2012 – 1:00 PM – 2:00 PM: – Room: Hall XL
Abstract: 1425P
PAIN MANAGEMENT IN EIGHT ITALIAN ONCOLOGICAL CARE CENTRES
S. Barni1, K.F. Borgonovo1, F. Di Costanzo2, F. Cognetti3, G. Bernardo4, C. Boni5, B. Agostara6, P. Pronzato7, G. Colucci8, M. Mammucari9
1Medical Oncology Division, Azienda Ospedaliera Treviglio-Caravaggio, Treviglio, ITALY, 2Medical Oncology Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, ITALY, 3Division Medical Oncology A, Istituto Regina Elena, Roma, ITALY, 4Oncologia Medica 2, Fondazione S. Maugeri IRCCS, Pavia, ITALY, 5Oncology Dept., Arcispedale S. Maria NuovaDivisione di Oncologia, Reggio Emilia, ITALY, 6Oncology Division, A.O. Civico Palermo, Palermo, ITALY, 7Oncologia Medica A, IRCCS AOU San Martino – IST-Istituto Nazionale per la Ricerca sul Cancro, Genova, ITALY, 8Oncology Division, Istituto Tumori Ospedale Oncologico, Bari, ITALY, 9RMF, RMF, Roma, ITALY
Introduction:
Management of oncologic patients is different between treating centres, and in particular management of pain. We decided to perform a retrospective study to explore different approaches to oncological painful patients (pts) in different Italian Cancer Units.
Materials and methods:
We evaluated in 8 Italian cancer hospitals all consecutive pts during 5 days in order to investigate level of pain in the previous 7 days and in the following two weeks from the basal visit. Patients and oncologists filled up a questionnaire (type of pain, intensity, site of pain, and analgesic therapy).
Results:
265 pts were enrolled, 59% female and 41% male; median age 61.5. 88% of pts had ECOG PS 0-1; 72.8% of pts reported metastatic disease and 86.4% were under chemotherapy treatment. Pain measured with VAS (Visual Analogic Scale) at baseline was 2.9. Pain was somatic in 32.4%, visceral in 12.5% visceral, 13.9% neuropathic, 41.2% mixed. The current analgesic therapy at baseline had been prescribed by oncologist in 38.2%, by other specialist in 42.1%, by family doctor in 18.5% and by other doctor in 1.1%. The basal analgesic treatment was confirmed in 57.3%, adjusted in 34%, and changed in 8.6%. At baseline we detected NSAIDS in 69.4% pts, weak opioids in 34% of pts; strong opioids in 38.9%, and 27.7% of pts also had adjuvants (24.5% pregabalin, 57.1% steroids, 18.4% other drugs). At first weekly follow-up (216 pts) the intensity of pain was 2.6 (VAS). The analgesic therapy was confirmed in 72.2% and adjusted in 27.8%. New drugs prescribed at first follow-up were NSAIDS in 43.3%, weak opioids in 21.7%, strong opioids in 86.7%, adjuvants in 55%. At second weekly follow-up (131 pts): 80.9% of therapies were confirmed and 19.1% adjusted. 90.3% therapies of 72 pts coming to third follow-up were confirmed. In 85.7% of the adjusted therapies an adjuvant was prescribed.
Conclusions:
Our data suggest two important comments. First, we observed a poor utilization of adjuvants by physicians in oncologic patients, especially when therapies are not prescribed by oncologists. Second, our data confirmed the need for a close follow-up to improve analgesic therapy.
Disclosure: All authors have declared no conflicts of interest.
Keywords:
pain management, adjuvant, opioid
Abstract: 1436P
SURVEY ON MODELS OF INTEGRATION OF ONCOLOGY AND PALLIATIVE CARE (PC) IN ITALIAN ONCOLOGY UNITS ESMO DESIGNATED CENTRES
V. Zagonel1, C. Mastromauro2, M. Ciaparrone3, V. Franciosi4, L. Verna5, C. Moro6, Z.C. Di Rocco3, A.A. Martoni7, L. Cavanna8, G. Farina9
1Italian Association of Medical Oncology, Task Force Continuity of Care, Padova, ITALY, 2Italian Association of Medical Oncology, Task Force Continuity of Care, Venezia, ITALY, 3Italian Association of Medical Oncology, Task Force Continuity of Care, Roma, ITALY, 4Italian Association of Medical Oncology, Task Force Continuity of Care, Parma, ITALY, 5Italian Association of Medical Oncology, Task Force Continuity of Care, L’Aquila, ITALY, 6Italian Association of Medical Oncology, Task Force Continuity of Care, Bergamo, ITALY, 7Italian Association of Medical Oncology, Task Force Continuity of Care, Bologna, ITALY, 8Italian Association of Medical Oncology, Task Force Continuity of Care, Piacenza, ITALY, 9Italian Association of Medical Oncology, Task Force Continuity of Care, Milano – on behalf of Task Force Continuity of Care in Oncology – Italian Association of Medical Oncology (AIOM), ITALY
Background:
The early integration of cancer treatment and palliative care (PC) is effective but the current state of integration in Italian Cancer Centres is unknown.
Aims:
To determine the models of integration of PC in Italian Oncology Units ESMO Designated Centres of Integrated Oncology and Palliative Care (ESMO-DCs).
Methods:
A questionnaire was sended by e-mail to the executives of the 20 Italian ESMO-DCs.
Results:
Twenty questionnaires were sent with a response rate of 100%. The geographical distribution of the ESMO-DCs is unbalanced: 12 (60%) in North-Italy, 6 (30%) in the Center, 2 (10%) in the Islands and none in the South. The ESMO-DCs organization is oriented to integration of PC through at least one oncologist oriented to PC in 18 (90%) Centres; guidelines (LG) of symptomatic treatment in 18 (90%); PC beds in 14 (70%) and PC offices in 14 (70%). The name “PC office” is used only in 4/14 (29%) centres; in 10 (71%) Centres alternative names were chosen. ESMO-DCs showed a good integration with Home Care (HC): in 9 (45%) Centres HC is managed by Palliative Care Physicians (PCPs); in 6 (30%) by General Practitioners (GPs); in 3 (15%) by oncologists and in 2 (10%) by PCPs with GPs. When HC is not directly managed by oncologists, the ESMO-DCs achieve the integration through home visits in 6/17 (35%), meetings and/or GL sharing with PCPs and GPs in 11/17 (65%) and 6/17 (35%), respectively. The ESMO-DCs showed a good integration with the Hospices (Hs): in 14 (79%) Centres Hs are managed by PCPs; in 2 (11%) by PCPs with GPs, in 1 (5%) by GPs and in 1(5%) by oncologists. When Hs are not directly managed by oncologists the ESMO-DCs achieve the integration through hospice visits in 7/17(41%), meetings and GL sharing with PCPs and GPs in 11/17 (65%) and 7/17 (41%), respectively. The integration model of reference for 15/20 (75%) ESMO-DCs is Integrated Care Model (see E.Bruera. JCO 2010).
Conclusions:
ESMO-DCs are not representative of Italian situation and lack in the South of Italy. The Integrated Care model of ESMO-DCs is Simultaneous Care-oriented but its achievement is different by Center. The “ESMO-DCs” experience is challenging for Oncology Units to improve early integration of palliative care, continuity and quality of assistance of cancer patients.
Disclosure:
All authors have declared no conflicts of interest.
Keywords:
simultaneous care, models of integration of oncology and palliative care, palliative care, symptom control 
