Despite increasing palliative care resources, significant gaps in care delivery remain

JAMA and Archives JournalsMar 17 2010

Palliative care services are available at most U.S. cancer centers, although the scope of services offered and the degree of integration between palliative care and oncology care varies widely among centers, according to a study in the March 17 issue of JAMA, a theme issue on cancer.

David Hui, M.D., M.Sc., of the University of Texas M. D. Anderson Cancer Center, Houston, presented the findings of the study at a JAMA media briefing.

Although significant progress has been made in cancer treatment, approximately half of all patients with cancer eventually die of their disease, and one-third of cancer deaths happen within 6 months of diagnosis, according to background information in the article. "Palliative care outpatient clinics, inpatient consultation teams, palliative care units (PCUs), and hospices all play an integral role providing symptom control, psychosocial support, and transition of care for patients with cancer and their families along the cancer care continuum. Based on this understanding, multiple national and international organizations support early incorporation of palliative care into oncology practice," the authors write. Despite this support, little is known about the current state of palliative care in cancer centers in the U.S. "A more thorough picture of the level of palliative care that currently exists in these cancer centers would identify deficiencies and barriers to comprehensive cancer care and allow development of specific strategies to improve care delivery."

Dr. Hui and colleagues conducted a study to determine the availability and degree of integration of palliative care services in U.S. cancer centers. The study consisted of a survey, between June and October 2009, of 71 National Cancer Institute (NCI)-designated cancer centers and a random sample of 71 non-NCI cancer centers, of both executives and palliative care clinical program leaders, where applicable, regarding their palliative care services. A total of 142 and 120 surveys were sent to executives and program leaders, with response rates of 71 percent and 82 percent, respectively.

The researchers found that the NCI cancer centers were significantly more likely to have a palliative care program (50/51 [98 percent] vs. 39/50 [78 percent]), at least 1 palliative care physician (46/50 [92 percent] vs. 28/38 [74 percent]), an inpatient palliative care consultation team (47/51 [92 percent] vs. 28/50 [56 percent]), and an outpatient palliative care clinic (30/51 [59 percent] vs. 11/50 [22 percent]). Few centers had an institution-operated hospice (37/101 [37 percent]) or dedicated palliative care beds (23/101 [23 percent]).

The median (midpoint) duration from referral to death was 7 daysOur survey revealed that palliative care patients were referred too late in the disease trajectory, a marker of limited access and integration," the authors write.

Cancer center executives, supportive of stronger integration and increasing palliative care resources, cited reasons such as poor reimbursement and limited institutional resources as barriers to delivery of palliative care. The researchers also found that research programs, palliative care fellowships and mandatory rotations for oncology fellows were uncommon.

"Although most cancer centers now have a palliative care program, significant gaps and delays in the delivery of care remain. To fulfill American Society of Clinical Oncology's vision of full integration of palliative care as a routine part of comprehensive cancer care by 2020, we urgently need to consolidate infrastructure such as outpatient clinics and PCUs, increase training of palliative care professionals and oncologists, conduct research on novel integration models and quality improvement measures, educate patients and their families, and advocate for public health policy changes. Oncologists, palliative care specialists, executives, and political leaders need to work closely together to ensure access to high-quality palliative care for all patients with cancer in the United States," the authors conclude.