Supportive care in cancer
Why is supportive care critical to cancer management?
Dr Matti Aapro (Clinique de Genolier, Switzerland) and Dr Gary Lyman (Fred Hutchinson Cancer Center, Seattle, Washington, USA) discuss the definition and importance of supportive care in cancer management. View transcript
Many high-efficacy cancer treatments have been developed over the past decade, bringing with them new benefits as well as challenges for modern cancer therapy. Despite the advances, many patients still experience high rates of morbidity and adverse effects resulting from treatment1. The burden of adverse effects caused by cancer treatments plays a critical part in determining a patient’s clinical outcomes.
There is a growing body of evidence showing that providing supportive care to address the adverse effects of cancer treatment can lead to improvements in quality of life and survival2,3. However, worldwide variations in the definition of supportive care, a lack of clarity on who should provide these services, and lack of a universal clinical model have created barriers to implementation4, creating a significant need for ‘supportive oncology care’ to become a specialty in its own right. With the rising incidence of cancer worldwide5, and many patients living longer with improved treatments6, this need is becoming critical1.
What is supportive care in cancer?
Dr Aapro discusses the origins and definitions of supportive care in oncology. View transcript
What barriers are preventing implementation of supportive care models?
Dr Aapro discusses barriers preventing implementation of supportive care models. View transcript
The Multinational Association of Supportive Care in Cancer (MASCC) defines supportive care as:
The prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side effects across the continuum of the cancer experience from diagnosis through treatment to post-treatment care7
Supportive care manages the toxicities and side effects of cancer treatment, is evidence based and uses a patient-centred approach. With optimal supportive care models implemented into practice, there are numerous benefits for patients, families and healthcare providers (HCPs), including7-9:
- Reduced symptoms and complications of cancer
- Prevention and/or reduction of treatment toxicities and side effects
- Increased adherence to treatment due to better management of side effects
- Increased tolerance, and thus benefits, of cancer treatment
- Improved communication between patients, caregivers and HCPs
- Easing of the emotional burden for patients and caregivers
- Psychosocial support for cancer survivors
Role of the multidisciplinary team in supportive care
Dr Aapro details the structure and function of a proposed multidisciplinary team that could support people through their cancer treatment journey. View transcript
Supportive care covers the physical, emotional, social, spiritual and informational needs of the patient, and cannot be provided by a single clinical specialty alone10. As with other multidisciplinary teams (MDTs), a ‘core team’ is required to address everyday problems and concerns of the patient, while an ‘extended team’ will be involved as the need arises1,8. The core team usually consists of oncologists, surgeons, pathologists, radiotherapists, nurses and other specialists according to the type of cancer11. The core team requires regular specific and ongoing training in the principles of supportive care, to ensure the model is being implemented correctly, as well as appropriately engaging members of the extended team in a timely manner1,11. The supportive care team is illustrated in Figure 1.
Figure 1. Members of the supportive care team8,11.
Is supportive care synonymous with palliative care? What is the difference?
Supportive care emerged to specifically address the toxicities and side effects of cancer treatment throughout the entire cancer continuum12. Palliative care has historical roots in end-of-life and hospice care and, although it encompasses the same principles of supportive care, confusion among HCPs and patients between the use of the terms has created barriers to implementation13. Studies have shown that patients and HCPs are more responsive to the term ‘supportive care’ than ‘palliative care’, with many patients and HCPs hesitant to engage palliative care services because of the association with end-of-life and discontinuing treatment13.
It is a common misconception that supportive care and palliative care are separate, with the latter focused more on end-of-life care. It is important for HCPs to understand that, while these terms originated to address different concerns, they have evolved to encompass the same principles of supportive care and patient-centred care14 The European Society for Medical Oncology (ESMO) has suggested that the term ‘patient-centred care’ be used to cover both supportive and palliative care approaches during the continuum of cancer illness, while the World Health Organization (WHO) and the American Society of Clinical Oncology (ASCO) include the principles of supportive care in their definition of palliative care15. ASCO asserts that the two terms and types of care, though having different origins, are one and the same16. HCPs should therefore take time to dispel the negative connotations surrounding palliative care, while remaining conscious of its potential effect on patients and their families13. Supportive care could therefore be considered an overarching principle, with palliative care an integral part of that care.
The critical role of supportive care in cancer management
Dr Aapro highlights the impact of cancer treatment and the related toxicities on patient quality of life and treatment outcome. View transcript
Numerous studies have demonstrated that implementing a supportive care model as part of cancer management improves the outcome in many different aspects of a patient’s life2,3,17-19
Systemic treatments have rapidly evolved from being predominantly cytotoxic chemotherapy and radiotherapy, to immunotherapies and targeted therapies9. Despite the advances in cancer therapy, tolerance to treatment remains a key issue. The emergence of novel treatments has seen an increase in new toxicities and side effects, necessitating alternative management approaches9. MASCC has created guidelines for supportive care strategies addressing many of these toxicities, to ensure optimal outcomes for patients that HCPs can familiarise themselves with.
Patients undergoing cancer treatments often experience a high burden from the side effects of treatment (Figure 2). Unmanaged side effects can lead to patient discomfort, treatment non-adherence and suboptimal cancer management. This can subsequently increase the cancer burden through dose delays, dose reductions and treatment withdrawal. Management of side effects is therefore a critical component of providing supportive care that has a direct impact on treatment outcomes20.
Figure 2. Impact of cancer treatment and side effects on the patient *Treatment side effect rates based on a multicentre study of patients in Australia (N=441) with breast, colorectal or lung cancer receiving chemotherapy22
There is evidence to show that a lack of supportive care is associated with profoundly detrimental outcomes. Evidence gathered from populations with limited access to supportive care for reasons of socioeconomic, geographical and racial barriers have shown that survival, secondary complications arising from treatment, and health-related quality of life are all negatively impacted26-29.
In the UK, a national initiative to implement supportive care into existing cancer management plans has been trialled with great success3. Studies have returned positive results including3:
- Improved symptom control and quality of life
- Reduced 30-day mortality
- Improved overall survival
- Reduced healthcare costs
Similarly, initiatives to implement early supportive care in US clinics showed improved overall survival and quality of life30.
Advance care planning
Advance care planning (ACP) is a process that ‘supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care’31. ACP informs treatment decisions that can be documented in an advance directive (AD). Palliative care specialists are skilled in providing ACP support for patients but are a limited resource. To address this limitation, the CONNECT study was undertaken to investigate the impact of a nurse-led intervention on ACP uptake among patients with advanced cancer. Given that oncology nurses often have special relationships with their patients, they may be well suited to providing ACP support31.
The CONNECT study involved a secondary analysis of a cluster randomised controlled trial examining the impact of nurse-based primary palliative care32. Patients with advanced cancer were randomly assigned to receive either monthly primary palliative care visits with trained nurses within their cancer centre or standard care. Nurses in the intervention arm received special training in ACP32.
ACP uptake was assessed at enrolment and 3 months later, evaluating whether an end-of-life conversation (EOLC) occurred with the oncologist, and whether an AD was completed32. Multivariable logistic regression tested differences in ACP uptake by treatment arm adjusted for various factors.
Of the 672 patients enrolled, 54% (182/336) patients in the intervention arm and 58% (196/336) in the standard care arm lacked an EOLC at baseline and completed the 3-month assessment32. In the intervention arm, 45.1% (82/182) of patients had an EOLC after 3 months, compared with 14.8% (29/196) in the standard care arm. Regarding ADs, 33% (111/336) of patients in the intervention arm and 31% (105/336) in the standard care arm did not have ADs initially but completed the 3-month assessment. Among these, 43.2% (48/111) in the intervention arm and 18.1% (19/105) in the standard care arm completed an AD during the study32.
The study concluded that nurse-led primary palliative care increased ACP uptake among patients with advanced cancer32. Training oncology nurses within community cancer centres to provide primary palliative care may help improve ACP access. These findings highlight the potential of specialist HCPs, including oncology nurses, to provide primary palliative care and contribute to improving the quality of care for patients with advanced cancer32.
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