The Role of Integrated Palliative Care in Radiation Oncology

A Conversation With Tracy A. Balboni, MD, MPH


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Tracy A. Balboni, MD, MPH

We saw this program as an opportunity to establish integrated models of palliative services in radiation oncology care, so our Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care worked together to create a system to provide these services.

—Tracy A. Balboni, MD, MPH

Three years ago, Dana-Farber Cancer Institute and Brigham and Women’s Hospital in Boston, launched a Supportive and Palliative Radiation Oncology (SPRO) program to integrate generalist palliative oncology services, including the physical, psychosocial, and spiritual aspects of care, into radiation therapy for patients with advanced cancers. The goals of the program are to improve clinical care for patients and the system of care, including its departmental structure and interface with collaborating services, and to advance palliative cancer care within radiation oncology through education and research.

The ASCO Post talked with Tracy A. Balboni, MD, MPH, Clinical Director of the Supportive and Palliative Radiation Oncology Service and Researcher at the Center for Outcomes and Policy Research at Dana-Farber Cancer Institute and Brigham and Women’s Hospital, and Associate Professor in Radiation Oncology at Harvard Medical School, about the program and the integration of palliative services within radiation oncology.

Palliative Care Integration

Please talk about the Supportive and Palliative Radiation Oncology service and how radiotherapy for palliation has been integrated into your radiotherapy clinic.

Within the practice of radiation oncology, we encounter many patients living with advanced cancer who require palliation for symptom relief and to improve their quality of life. Approximately one-third of treatments that radiation oncology departments deliver are for this purpose, and while there is a growing interest in integrating palliative care and radiation oncology now, palliative care has not been a focus within radiation oncology historically.

We saw this program as an opportunity to establish integrated models of palliative services in radiation oncology care, so our Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care worked together to create a system to provide these ­services.

We see patients at every stage of the trajectory of their disease, from the time of initial diagnosis to the end of life. Care within each stage presents opportunities to communicate with patients and family members and aid them in their understanding of where they are in their diagnosis, as well as how to intervene with radiation therapy to improve symptoms and control disease.

Program Staff

How is the program staffed?

We have a team consisting of two nurse practitioners, one attending physician, and one resident. It’s a busy service, and having a dedicated team in place affords us the ability to treat the needs of the whole patient. Attending physicians and residents rotate on the service on a weekly basis and are solely dedicated to SPRO and related patient care for that week. Our nurse practitioners are core members of the SPRO service week-to-week and have training in both palliative care and oncology, which is a critically important combined level of expertise for the service.

One of the reasons we decided to launch this service was that by the standard care model, advanced cancer patients with urgent issues were added to an attending physician’s already full schedule. The physician may not only have inadequate time, but also might not have the support of a resident or nurse practitioner with a dedicated interest in palliative care. This type of isolated care is not an adequate model for patients facing complex issues related to symptomatic advanced cancers, whether those issues arise at the time of initial diagnosis, at disease progression, or at end of life.

New Technologies

Are there new radiotherapy technologies available to improve radiotherapy for palliation?

Yes, there are. These technologies include the use of more focal therapies to treat regions of symptomatic tumors such as in the brain or within the spine. These technologies can afford greater dose intensity and tumor control of lesions at critical sites while minimizing dose to nearby normal structures.

However, technologic advancement within palliative radiotherapy not only includes the application of sophisticated technologies, such as high-dose, stereotactic treatments, but also the more judicious use of radiotherapy, particularly in light of a patient’s disease trajectory. One example is greater use of conventional radiation therapy with a hypofractionated approach (higher dose per treatment, fewer treatment regimens, eg, 8 Gy × 1 for bone metastases) to spare patients protracted time on therapy, especially when life expectancy is short.

Furthermore, technologic advancements are needed to better define patients who won’t benefit from palliative radiotherapy based on a short life expectancy. Understanding and disseminating these critical nuances of palliative radiation oncology care requires research as well as the education of radiation oncology clinicians. Along with optimizing patient care, these are the primary goals of the SPRO service.

Spirituality and Religion

What role does spirituality and religion play in palliative care?

Spirituality frequently plays a critical role for patients in both the curable and incurable setting. Whether in religious or nonreligious forms, spirituality is an avenue by which many patients and family members cope with the stressful circumstances of cancer and find meaning in the midst of the trial of illness.

Our studies1,2 of spirituality after an advanced cancer diagnosis have included examining the roles such beliefs play in patient quality of life and medical decision-making, as well as the spiritual struggles patients and families can face as they encounter an illness. Such efforts are one example of palliative care research that attempts to understand patients and families as they face a life-threatening illness and how we as caregivers can provide care in a more holistic way. ■

Disclosure: Dr. Balboni reported no potential conflicts of interest.

References

1. Vallurupalli M, Lauderdale K, Balboni MJ, et al: The role of spirituality and religious coping in the quality of life of patients with advanced cancer receiving palliative radiation therapy. J Support Oncol 10:81-87, 2012.

2. Phelps AC, Maciejewski PK, Nilsson M, et al: Religious coping and use of intensive life-prolonging care near death in patients with advanced cancer. JAMA 301:1140-1147, 2009.

 

Addressing the evolving needs of cancer survivors at various stages of their illness and care,
Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is Senior Director of Education, Science and Professional Development Department at ASCO.

 



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