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Addressing End-of-Life Quality Gaps in Hematologic Cancers: The Importance of Early Concurrent Palliative Care.

Invited Commentary Addressing End-of-Life Quality Gaps in Hematologic Cancers: The Importance of Early Concurrent Palliative Care Although many patients with hematologic cancers are cured, many are not. It is estimated that more than 55 000 Americans will die of leukemia, lymphoma, or multiple myeloma in 2015, many more than the annual deaths from common cancers such as breast cancer.1 Despite this, surprisingly little attention is given to palliative and end-of-life (EOL) issues in hematologic cancers. Yet the quality gap is clear: these patients are less likely to use hospice services, more likely to die in the hospital, and less likely to see a palliative care specialist.2 Now, however, after many years of relative silence there is hope on the horizon. Several key studies, including the article by Odejide et al,3 have recently appeared in the literature, each illuminating unique palliative and EOL issues in hematologic cancers. First, it is increasingly clear that patients with hematologic cancer differ from those with solid tumors. For example, many may not actually want to die at home, despite common assumptions and contrary to knowledge about patients with solid tumors. A population-based survey of more than 300 decedents with hematologic cancer found that more than 28% of those reporting a preference wanted an inhospital death, and that another 5.6% preferred a nursinghome death.4 With the development of improved models of care for patients with hematologic cancer, it is necessary to consider that they may have different perspectives than patients with solid tumors. Because the treatments for these 2 kinds of cancers are often quite different, it is likely that the experiences of patients who have them are probably also different. We must consider these perspectives as we address end-of-life quality gaps. Second, the physicians who treat hematologic cancers differ from those who treat solid tumors. For example, specialists in hematologic cancers think differently about tradeoffs in risks and benefits of aggressive cancer care. A survey of 182 oncologists at a tertiary care center found that hematologic oncologists were more likely than solid-tumor oncologists to favor chemotherapy with moderate toxic effects and no survival benefit for patients with poor function and a 1-month life expectancy.5 Similarly, hematologic oncologists reported less comfort discussing EOL issues and were more likely to report a sense of failure on disease progression than were solidtumor oncologists. Given that hematologic malignancies are often quite different in their responsiveness to chemotherapy and intensity of treatment (stem-cell transplantation, high-dose chemotherapies, etc), it makes sense that oncologists who treat these diseases would also have a different perspective. Evidence also suggests that hematologic oncologists are more likely to view palliative care as only late-stage terminal care or hospice care, whereas solid-tumor specialists more often recognize palliative care as a specialty that provides additional support to those facing a serious illness.6 To date, however, the unique features of these specialists remain underexplored. In this issue, Odejide et al3 shed more light on this subject, enriching the understanding of hematologic oncologists’ perspectives. In their national survey of hematologic oncologists in the United States, 3 important findings emerged. First, 56% of hematologic oncologists believed that EOL discussions occur too late. Second, respondents at tertiary care centers were even more likely to report late discussions than those in the community. Third, many respondents reported waiting until a patient’s death was imminent before discussing EOL issues. These findings are important. They provide a better sense of hematologic oncologists’ awareness of gaps in the quality of EOL care, confirming that hematologic oncologists generally do not have their “heads in the sand” about how they tend to practice. Even more importantly, these findings suggest that hematologic oncologists are uncertain about how to actually change the status quo of EOL issues, thereby highlighting a practice gap in need of an intervention. As a practicing hematologic oncologist and a palliative care physician, I believe that the field of hematology should look to specialty palliative care for the answer to this need. A robust literature demonstrates that early, concurrent palliative care yields many benefits for patients and caregivers facing advanced cancer, including improved prognostic awareness, better quality of life, and less depression.7 It is increasingly clear that the mechanism of action of palliative care has much to do with adding a uniquely skilled expert to further support the patient and family beyond the support provided through standard cancer care. Although some oncologists worry that this amounts to an abrogation of their personal responsibility to address important issues with their patients, data show that patients prefer to talk about different issues with their oncologist than with their palliative care specialist.8 Together, everyone accomplishes more, and each team member complements the others. Unfortunately, landmark studies of early palliative care have largely excluded patients with hematologic cancers. If palliative care is the answer to the problems in the quality of EOL care in hematologic cancers, researchers must study and better understand the unique needs of patients with hematologic cancers and their oncologists. For example, comparatively little is known about the symptom burden and palliative care needs of patients with hematologic cancers, which are a remarkably heterogeneous collection of diseases. Similarly, hematologic oncologists and palliative care specialsts together must better understand the unique needs of the speRelated article