Integrating palliative medicine into an oncology practice
Identifieur interne : 005F99 ( Istex/Corpus ); précédent : 005F98; suivant : 006000Integrating palliative medicine into an oncology practice
Auteurs : Mellar P. DavisSource :
- American Journal of Hospice and Palliative Medicine [ 1049-9091 ] ; 2005-11.
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DOI: 10.1177/104990910502200611
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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Davis</surname><given-names>Mellar P.</given-names></name><degrees>MD, FCCP</degrees><aff>The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>11</month><year>2005</year></pub-date><volume>22</volume><issue>6</issue><fpage>447</fpage><lpage>456</lpage><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Other</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>cover-date</meta-name><meta-value>November/December 2005</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value> Introduction Palliative care is the total care of patients whose illnesses are not responsive to curative treatment and whose health is deteriorating progres- sively and rapidly toward death. The aim of palliative care is the relief of symptoms, the maintenance of the best possible quality of life (QOL) for the patient, and support for the family before and after the patient's death.1 A part of palliative care is end-of-life care; however, palliative care is much broader, including collaborative care for patients receiving active antitumor therapy. Palliative medicine is the medical component of palliative care1,2 -- essentially, the science of symptom management. Oncology is the study of the biology and management of malig- nancies, and since its inception, it has had a disease-oriented approach to care. The evolution of modern oncology has been breathtaking. These develop- ments have been the fruit of extensive research in human pathophysiology and tumor biology. The concept of disease as an "experience" has been altered to disease as a "lesion" causing illness or disability. The language of oncology is, by necessity, cancer-ori- ented. Tumors regress or progress, and responses are seen in terms of rel- ative tumor burden. In addition, death is seen as the ultimate defeat and dying the result of less than optimal management rather than as a natural part of life. The first hospice (from the Latin hospitium, meaning welcoming inn or guest chambers) occurred in the 4th century and was established by Era Fabiola, a Roman matron.3 During the crusades and through the Middle Ages, monasteries carried the burden of caring for the sick and dying. At the time, hospitals were frequently unwilling to admit the dying. In the 17th century, a hospice specifically for care of the dying was developed in Lyon, France, under the direction of Mme. Jeanne Garnier. Her influence led to the foundation of six other establishments for the care of the dying between 1874, in Paris, and 1899, in New York. The Kaiserswerth, the first Protestant hospice, was founded in Germany in 1863, and St Joseph's of Dublin was established in 1879.3 Cicely Saunders, the founder of St. Christopher's Hospice in London, ushered in the modern era of palliative care by combining compas- sionate care, astute clinical observa- tion, and research. She and Robert Twycross accomplished the first trial in palliative medicine, a double-blind controlled study comparing morphine and diamorphine for cancer pain.3 Clinical studies in a vast array of symptoms have expanded the disci- pline to include psychosocial, spiritu- al, and QOL research. Palliative medicine and hospice developed as a protest against the neglect of the experience of disease.3 It was a reaction to positivist, reduc- tionist, technologically centered care--i.e., tumor management rather than patient management. In the United States, the movement evolved 447American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 Palliative oncology update Integrating palliative medicine into an oncology practice Mellar P. Davis, MD, FCCP Mellar P. Davis, MD, FCCP, Medical Director, The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio. as a grassroots effort outside of acade- mic centers. As a result, palliative care and oncology have been misaligned and, at times, feuding specialties. However, the philosophies of oncolo- gy and palliative medicine are more complimentary than contrary--or at least should be. The integration of both tumor-directed and patient- directed care can enhance overall quality of care in advanced cancer. Symptoms of advanced cancer Symptoms occur early in the course of disease but are generally under-recognized and undertreated.4 Symptom assessment in cancer is important, as it provides information about cancer pathophysiology and prognosis and directs palliative efforts by providing valuable information about treatment outcomes.4 In one study of 1000 patients, the median number of symptoms associ- ated with advanced cancer was 11.4 The 10 most frequently observed symptoms were pain, easy fatigue, weakness, anorexia, greater than 10 percent weight loss, lack of energy, dry mouth, constipation, dysphagia, and early satiety. All occurred in 50 percent or more of patients. All were clinically important and severe as judged by the patient. In a companion study, patients volunteered a median of two symptoms, indicated that, if symp- toms are not properly assessed through direct questioning, they will frequently be grossly underestimated.3 Therearegenderdifferencesinsymp- toms, severity, and type. Dyspnea and cough are more frequent with lung can- cer, while dysphagia is more common in head and neck and esophageal cancer. Bloating, nausea, and vomiting are most common among gynecological patients, and women in general have more gas- trointestinal symptom clustering (early satiety, nausea, and vomiting). Gastro- intestinal symptoms are also associated with significant weight loss. Dysphagia occurs more frequently in men. Women with gender-specific cancer survive the longest, while men with non-gender- associated cancer have the shortest sur- vival. The young experience sleep dis- turbances, pain, depression, anxiety, vomiting, and headaches more frequent- ly than the elderly. Symptom clusters and severity change with progression of illness. Poor prognostic symptoms are anorexia, dysphagia, bloating, and hallu- cinations. The National Hospice Study (NHS)6 found dyspnea, weight loss, dys- phagia, and dry mouth important deter- minants of outcome. Biological factors associated with reduced survival are high total white blood cell count, low lymphocyte count, and low pseudo- cholinesterase.7 Palliative prognostic indices have combined symptoms, per- formance scores, and biological factors as predictors of survival. Communicating the relationship between symptoms and prognosis pro- motes understanding and clinical deci- sion making for patients and families. In addition, it is important to assess each symptom and symptom cluster and direct treatment based on reversible causes and patient priorities. Symptom- assessment tools are readily available to aid in this practice.8 Once symptoms are adequately defined and prioritized, med- ical management options should be dis- cussed with the patient and family. Palliative pharmacological choices are based upon seven principles; one drug for multiple symptoms, lowest number of drug interactions, least drug side effects, drug versatility, drug efficacy, drug cost, therapeutic index. Reviews in the pharmacological management of symptoms are available in the litera- ture.9-13 Integrating oncology and palliative medicine Palliative chemotherapy and best supportive care Integrating palliative medicine into oncology can be difficult during anti- tumor therapy. Palliative specialists may prematurely refer patients to hos- pice without considering the therapeu- tic benefits of anticancer therapy. Chemotherapy is used with different intent. It may be used as a preventive or curative measure either alone or com- bined with other modalities or for pal- liation of symptoms. Chemotherapy is considered palliative in most situa- tions.4-6 Most metastatic cancer in adults is incurable with the antitumor therapies currently available.14-16 Chemother- apy is also associated with serious side effects and may add to symptom burden. Many cancers are poorly responsive to chemotherapy (by tumor measurement), and chemother- apy can be costly and inconvenient. Patients often lose opportunities to spend their remaining time meaning- fully because they are receiving mar- ginally effective antitumor therapy. Oncologists may fail to measure patient-centered outcomes appropri- ately, or they may follow the wrong parameters, such as tumor response rather than symptom relief or QOL.17 Time-to-treatment failure and short- term survival are poor markers of ben- efit in a palliative setting.8 Treatments are sometimes continued without regard for diminished QOL. Third- and fourth-line palliative chemothera- py regimens may be falsely assumed to have survival benefit both by the patient and the treating oncologist. Tumor response can be mistaken for symptom response. The marginal sur- vival benefits are not necessarily equal in value to palliation of symp- toms.8 Oncologists frequently state that QOL considerations lead to modi- fication of palliative chemotherapy, but the primary reason for modifying treatment is drug toxicity and tumor progression. Only 10 percent of oncologists report basing their deci- sions to modify chemotherapy on patient QOL.19 448 American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 Important to the patient is symptom relief and QOL; however, cancer chemotherapy is valued by oncolo- gists for tumor response and, at times, as a means of extending hope to patients, even though the primary intent may be symptom control. This can lead to miscommunication. Patients with non-small cell lung can- cer frequently believe treatment is curative when the intent is actually palliative.15-17 This, in part, is related to the reluctance of physicians to explain that the chemotherapy is a means of symptom control rather than cure due to personal disappointment about the outcome, aversion to the emotional response such a conversa- tion engenders, and fear of destroying hope. On the other hand, chemotherapy can still be of value to patients by pal- liating symptoms associated with advanced cancer.14-18,20 It has the potential to improve QOL unrelated to survival benefit and tumor response. Salvage chemotherapy for recurrent tumors is less likely to be palliative, and the palliative equation may then shift toward single-agent chemothera- pies with reduced toxicity. Age, comorbidity, and performance scores should be considered in this equation, as should tumor characteristics (biolo- gy, response characteristics, previous treatment, and extent of disease). The use of palliative chemotherapy requires a palliative/toxicity tradeoff favoring symptom relief. This balance has been significantly affected by the development of supportive care, par- ticularly 5HT3 antagonists for nausea and hematopoietic growth factors for myelosuppression. Randomized trials of palliative chemotherapy and best supportive care (BSC) have been important in promoting the concept of palliative chemotherapy. These trials are diffi- cult to accomplish if there is no treat- ment arm, however. BSC in palliative trials is often not clearly defined and, by usual outcome measures, it is not known whether BSC influences palli- ation. If pain is a sentinel symptom to control, then BSC among oncologists will be suboptimal symptom manage- ment. Positive trials with a BSC arm may reflect the adverse effects of poor nonchemotherapy palliation rather than the benefits to palliative chemo- therapy. Most patients with an Eastern Cooperative Oncology Group (ECOG) performance status score of 2 or greater (Karnofsky score of 60) will not tolerate chemotherapy, and cer- tainly patients with an ECOG score of 3 or 4 (Karnofsky score of 50 or less) should not receive palliative chemo- therapy but should receive other pal- liative modalities.14-16 Patients tend to overestimate their performance scores, which is complicated further by individual variability among physi- cians in grading performance scores. QOL as the final common denomina- tor in determining treatment benefit is a subjective, patient-derived parame- ter.21-25 Supplementing self-reported QOL through multidimensional as- sessment tools such as the Quality of Life Questionnaire--Cancer (QLQC- 30) can provide a more accurate per- formance score. Oncologists may consider single- agent chemotherapy (e.g., gemc- itabine and vinorelbine for non-small cell lung cancer, capcitabine for colon cancer, and mitoxantrone or taxanes for prostate cancer); alternative sched- ules of drugs, such as infusion 5FU for colon cancer; or drug substitutions such as carboplatin for cisplatin for palliative purposes, particularly in patients with marginal performance scores, incurable illnesses, or comor- bidity.14-16,26,27 Multiagent chemother- apy, radiation, and single-agent gemc- itabine in non-small cell lung cancer can reduce cough, pain, dyspnea, and anorexia without conventionally defined complete or partial responses, which emphasizes the importance of considering chemotherapy within the palliative context. Palliative chemotherapy and quality of life Multiple QOL scales of varying complexity have been developed and validated.22-26 Most contain individual symptom assessments either by numerical scale, Likert scale, or visual analog scale (VAS). QOL instruments assess performance of activities of daily living; drug toxicity; and eco- nomic, social, and psychological bur- den associated with disease or treat- ment. Patients are usually asked to assess their QOL. It is imperative that physicians use a validated QOL tool that includes a patient self-assessment of symptom relief achieved with a given therapy. Patient surrogate and physician views of acceptable QOL not infrequently diverge from the patient's; thus, patient self-assess- ments are more accurate. Perceptions of QOL shift over time as patients adjust to the limitations imposed by their illnesses. They accept more limitations as they survive longer and rate their QOL higher than do their caregivers. Pre-existing disability, a premorbid sedentary lifestyle, and gen- der also influence patient assessment of QOL.14-16 Tradeoffs between QOL and survival are weighed by personal val- ues and altered risks and benefits based on patient perceptions. Benefits of initi- ating chemotherapy in an asymptomatic but incurable patient are balanced against perceptions of risk related to delayed treatment, QOL, tumor type, treatment toxicity, economic burden, and delay of cancer-related symp- toms.14-16 A "watch and wait" ap- proach, however, can miss the window of opportunity for a palliative chemo- therapy trial when unexpected compli- cations require alternative approaches such as surgery or radiation.14-16 Prospective trials do not provide a firm recommendation as to the best 449American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 treatment approach, nor do they pro- vide guidelines for predicting individ- ual patient responses, tumor respons- es, toxicity, satisfaction with treatment, economic burden, or QOL. Tumor response alone is not a suffi- cient justification for palliative chemotherapy in an asymptomatic patient with good QOL. Trials have failed to take all these parameters into account.28 Therapies touted to be ben- eficial have measured only a few--or even one--outcome. Chemotherapy, on the other hand, has been shown to provide symptom relief, improve QOL, and reduce economic burden by reduction in hospitalizations without objective tumor response.18 Mito- xantrone in prostate cancer, gemc- itabine in pancreatic cancer, and mul- tiagent cisplatin in lung cancer are examples.29-32 Hospice referral and aggressive nonchemotherapeutic pal- liative measures should be considered for those patients with poorly respon- sive cancer (< 25 percent) low ECOG or Karnofsky score, and poor QOL. Patients with borderline performance scores (i.e., ECOG score of 2, Karnofsky score of 60) and a reason- able chance of response may want to undergo a trial of palliative chemo- therapy once the purpose is under- stood.14,16 Measures of QOL and symptom response with each cycle of chemotherapy will guide therapy more than objective reduction of tumor. Oncologists need to be circumspect about treating responsive cancers in untreatable patients and treating unre- sponsive cancers in treatable patients. No universal approach to such diffi- cult clinical situations can be recom- mended, and an honest discussion between patient and physician is nec- essary for informed decision making. In practice, two cycles of treatment are followed by assessment of tumor size, symptom response, toxicity, and QOL. A mutual decision about the value of ongoing therapy should be a balance between multiple outcomes. If most parameters are improved, treatment continues until maximum efficacy is achieved (usually not more than six cycles).14,16,33 Physicians should avoid making decisions guided by anecdotal experiences of dramatic responses in isolated patients with poor performance status that are not apropos to general oncology experi- ence and that are contrary to usual practices or guidelines. Any reduction in QOL requires reassessment, for either the treatment or the tumor is the cause whether or not palliation is achieved, and chemotherapy should be discontinued. Palliative radiation therapy Radiation therapy is quite effective in relieving local symptoms related to cancer, although the duration of benefit and QOL is rarely measured in routine medicine. In locally advanced non-small cell lung cancer, high-dose palliative radiation improves QOL over the first 86 days, which then retreats to base- line by day 266.34 Days of improved QOL are added by treatment.24 Radiation works best for localized symptoms and rarely for anorexia and cachexia, and it may temporarily worsen fatigue. Radiation usually does not improve performance score and largely fails to influence survival, at least in lung cancer.20 In lung cancer patients, 60 to 80 percent who experi- ence thoracic pain or hemoptysis will respond to hypofractionated radia- tion.20,34 Hypofractionation schemes are preferable in patients with limited survival, since palliation with single fractions reduces time under treat- ment, at reduced cost, with the ability to re-treat the patient in the future.20 Disadvantages include location (sin- gle-fraction should not be used for epidural disease metastases, although gamma knife techniques for brain metastasis are usually hypofractionat- ed); response duration (which is less than with multiple fractionation schemes); and a narrow tumor-to-tis- sue toxicity ratio and therapeutic index. Therefore, radiation therapists have the freedom to choose the frac- tionation scheme that best benefits the patient's symptoms within the course of his or her illness. Local symptom relief achieved in less time and at lower cost (to a capitated reimburse- ment system) are particularly apropos to hospice patients. Less time under- going treatment is meaningful for patients with weeks to survive. Radiation therapists may choose longer (multifraction) treatments to improve duration of symptom control for patients with some longevity. Unfortunately, radiation therapy trials have rarely included QOL scales. It is unlikely that randomized trials comparing BSC with hypofrac- tionation radiation will ever be done, for ethical reasons. Combined chemo- therapy and radiation therapy is rarely justified in a palliative setting, partic- ularly in frail patients with a short expected survival. Toxicity increases, and symptom control and QOL are unlikely to be enhanced when com- pared with radiation alone. Advantages of early referral to palliative care Early referrals of patients undergo- ing palliative antitumor therapy to a cancer center's palliative care unit may bolster family structures severely taxed by the patient's failing health. Referral can be made to appropriate community resources for ongoing support. The value of such services can be properly established if the patient has some longevity. Symptom control during active antitumor treat- ment allows the patient to focus on meaningful activities. Late referrals mean that patients are exposed to a new care team during a crisis or transi- tion period, increasing their anxiety and sense of abandonment. Early 450 American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 referrals also provide an opportunity for targeted, specific research studies on various treatment modalities and educational opportunities through case studies within the cancer center. The need for palliative medicine in oncology Burnout is the internal desolation of idealism, enthusiasm, and pur- pose.35,36 In oncology, it is the accu- mulated effect of multiple stressors including: · loss of and grief over long-term relationships; · guilt over failed treatment; · emotional labor with other peo- ple's psychosocial burdens; · fiscal constraints by managed care and evolving medical eco- nomics; · the glut of medical information; · existential stress over the fear of one's own death; · organizational conflicts and communication problems; · medicolegal liabilities for mis- diagnosis or treatment-related toxicity; · high patient expectations engen- dered by premature and overly optimistic reports of medical advancements; · teaching and research responsi- bilities; and · an unbalanced lifestyle (the tyranny of the ill or dying patients).36 Burnout is emotional bankruptcy, depersonalization, negativity, and dis- satisfaction with accomplishments. In a study of job satisfaction among oncologists and palliative specialists, four categories were identified that determined professional satisfaction: dealing with patients and families, having professional status and esteem, intellectual stimulation, and adequate resources to perform one's role.26 Oncologists had the lowest rating of satisfaction in all four categories but derived the greatest satisfaction from intellectual stimulation.36 Palliative specialists had the highest satisfaction dealing with patients and relatives and adequate resources to do so. Among the items cited as creating job dissatis- faction for oncologists were negative relationships with families and patients, dealing with dying patients, ineffective treatments, and lack of emotional resources necessary to sus- tain patients and families.36 Therefore, there is the potential for a complemen- tary relationship between palliative specialists and oncologists that can enhance job satisfaction, foster improved care, reduce stress, and limit burnout. The role of the palliative specialist in cancer care Controversy exists about the respective roles of palliative special- ists and oncologists in the management of advanced cancer.37 Oncologists may adopt the role of chemotherapist and defer symptom management and psy- chosocial care to family physicians (internists, cancer pain specialists, and palliative specialists). Ideal manage- ment of severe symptoms would com- bine, in coordinated fashion, both effective nontumor-directed palliative pharmacotherapy and antitumor treat- ment. Hopefully, the combination will favorably influence patient and cancer outcomes, respectively. Communi- cation needs to be sensitive to the ethi- cal principles of beneficence and autonomy. Compassionate communi- cation is a necessity for establishing goals of care and is usually more appropriate to palliative specialists who are trained in communication and culturally sensitive decision making. At some point in the trajectory of ill- ness, palliative specialists should be primarily responsible for care (but in close communication with the treating oncologist), even though palliative antitumor therapy is continued. Continuity of patient care within a cancer center can be problematic, mainly due to poor transfer of infor- mation.39 Eventually, chemotherapy and radiation will no longer be appro- priate, and hospice or palliative care in the cancer center community will become the proper goal of care. Palliative specialists are well-posi- tioned to refer their patients to com- munity hospices, home care, or chron- ic care facilities, thus ensuring continuity of symptom management and psychosocial support. Those patients who wish to return to the cancer center may continue to receive supportive ser- vices through the palliative medicine department. Meanwhile, the treating oncologist is freed by palliative medi- cine to see additional patients for clinical research. Cancer control programs in cancer centers are organized on four princi- ples: prevention, early detection, treatment for cure or prolongation of life, and prevention of suffering through symptom management.38,40 Cancer control, however, is generally seen as a biological problem (genes, oncogenes, and toxins). Anatomical/ biological alterations in tumor remain the primary focus of palliative chemotherapy; QOL is secondary in cancer control trials.40 Placing pallia- tive medicine departments within can- cer centers will enhance the fourth principle of cancer control. In return, the academic machinery of cancer centers will be able to further pallia- tive research. Palliative specialists 451American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 will gain an understanding of tumor biology and treatment, while oncolo- gy trainees will experience palliative models of care and learn QOL assess- ment skills that are, in general, poorly done by oncologists.41 Emergency consults for highly symptomatic cancer patients are another benefit to palliative services within a cancer center. Educational objectives for trainees and regulatory issues for cancer programs can be met by palliative specialists. Proper as- sessments can be observed and, hope- fully, incorporated into practice by oncology trainees.42 Interdisciplinary training and combined research trials that include tumor response and symptom research are likely to occur within a palliative medicine-oncology matrix.38,40 Specialists in palliative medicine can also train physicians from other medical or surgical subspecialties in the palliative care philosophy. Structuring palliative medicine within a cancer center Integrating palliative medicine into existing cancer care programs occurs at several levels simultaneously: via advice to primary physicians without direct patient contact ("curbside con- sult"); through a single physician- patient encounter for direction in care; between oncologists and palliative specialists who share care; and during transitional care, when patient respon- sibility is transferred from oncologists to palliative specialists. Salient features of the palliative medicine program should include an inpatient unit, an inpatient consulta- tion service, outpatient clinics, com- munity (hospice) services, support- ive/advisory disciplines, training and education activities, and research. The basic principle guiding palliative- medicine program development is providing continuity of care through- out the trajectory of illness. Patient care should not suffer by fragmented and limited palliative services. They should be available as needed. Limited services and delayed referrals limit patient access at the time of greatest need, provide few educational or research opportunities, and fail fiscally. Models of palliative medicine programs within cancer centers There is no single appropriate pal- liative medicine model. Such pro- grams can be successfully located within different departments and still successfully provide service. The location and formation of palliative services will depend upon the particu- lar institution. The Cleveland Clinic palliative medicine program A three-month pilot study conduct- ed within the oncology department at the Cleveland Clinic established the need for palliative services.43-45 A three-year plan to establish a compre- hensive program lead to a consultation service (1987), an outpatient clinic (1988), an inpatient service (1988), a hospice service (1990), and palliative home care (1992). The Cleveland Clinic program became a designated World Health Organization Demon- stration Project in 1991. The Harry R. Horvitz Center for Palliative Medi- cine inpatient unit was established by philanthropy in 1994 and maintained through standard diagnosis-related group (DRG) reimbursement. The hospital-based multidiscipli- nary team includes four full-time staff, three of whom are boarded in oncolo- gy; two palliative medicine nurse clin- icians, case managers, five clinical fellow physicians, one physician assistant, two monthly rotating inter- nal medicine trainees, one social worker, one full-time nurse discharge coordinator, two part-time music ther- apists, chaplains, physical and occu- pational therapists, and a dietician. Service rotations occur monthly between outpatient clinics and hos- pice, the inpatient consulting service, and the inpatient palliative medicine unit. A designated palliative physi- cian-nurse team maintains continuity of care for each patient, and a 24-hour physician-nurse on-call system is available for emergencies. Weekly conferences by staff and fellows as well as invited lecturers and an annual national conference are part of the educational opportunities. Two dedi- cated research fellows along with staff members carry on a variety of research projects within the program. The National Cancer Institute of Milan A pain therapy division was origi- nally established by philanthropy at the National Cancer Institute in Milan (NCI-Milan). The program included four physicians responsible for in- and outpatient care, a nurse who provided pain assessments, and a physician responsible for home care.46 Services and financial support expanded, and the name of the program was changed to the Pain Therapy and Palliative Care Division. This new section was incorporated into the rehabilitation division and led to the formation of the Rehabilitation and Palliative Care Operative Unit in 1998. Personnel expanded to six full-time physicians on staff at the Institute and six others financed by grants. Other services in the division include nurses, physiothera- pists, social workers, and volunteers. A day hospital (10 patients per day, five days per week) provides support- ive therapy including hydration, nutri- tion, transfusion, infusion analgesics, and bisphosphonates. Outpatient clinics receive advanced cancer or terminally ill patients who would undergo symptom assessment and symptom management. Proportions of patients receive chemo- therapy and radiation therapy and are followed collaboratively. Different 452 American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 subspecialties are used when neces- sary including radiation therapy, neu- rology, neurosurgery, psychology, hematology, and psychiatry. The home-care arm of the unit was initially financed through a charity (The Florien Foundation) and was expanded by additional support through the National Health Care Service. The goals are to assist patients and their families in symptom control, to provide psychological sup- port and assistance, to coordinate assistance programs, to coordinate existing services, to reduce hospital- ization, and to provide financial sup- port and bereavement services. Most deaths occur at home or in the local inpatient hospice. The inpatient consulting service of the unit responds to requests for pain therapy and symptom management within the cancer wards of NCI- Milan. Rehabilitation services include pre- and post-surgical physical evalua- tion, perioperative ambulatory physical therapy, outpatient ambulatory therapy, physicalmodalitiesforpaincontrol(e.g., ultrasound), lymphedema therapy, swal- lowingrehabilitation,andevaluationand education of prosthetic requirements. The Italian Association for Palliative Care finances cancer research, and col- laboration occurs through the European Association for Palliative Care. The University Hospital of Essen A pilot project sponsored by the Mildred Scheel Foundation within the department of internal medicine at the University of Essen started in 1989.47 In 1991, the project was expanded from one physician with an interest in pain management to a team pursuing four aims: optimal pain and nonpain symptom control for in- and outpa- tients, undergraduate physician edu- cation in pain management, research in pain and supportive services, and audit of outcomes related to pain ther- apy. An Interdisciplinary Pain Ambulatorium (IPA) is open eight hours a day, five days a week. The clinic receives patients either from outpatient or inpatient areas and coor- dinates care within the institution. An assigned physician within the IPA is responsible for the same individual patient throughout the course of ill- ness and collaborates on his or her care with specialists in different departments. If the patient is hospital- ized, the admission is to the individual subspecialty department with coordi- nated care between that department and the IPA physician. Multidis- ciplinary meetings take place regular- ly. Social workers and chaplains are invited to participate as needed. An Interdisciplinary Pain Conference (IPC) consists of a standing commit- tee of physicians from nearly every department involved with the care of cancer patients. The IPC physician offers lectures and monthly rotations within the IPA. Each subspecialty department has one member trained in supportive (palliative) care. Research projects involve symptom checklist development, analgesic trials, and patient satisfaction with pain-treat- ment modalities. Palliative services are, in general, decentralized and inte- grated into the various departments involved in cancer care. The US National Institutes of Health The National Institutes of Health (NIH) is an agency of the US Department of Health and Human Services with programs directly fund- ed by Congress.48 The purpose of the NIH is to conduct intramural research, support extramural research by non- federal scientists, train research inves- tigators, and facilitate communication of medical information. It is com- prised of 23 institutes and centers including the National Cancer Institute (NCI). The Warren Grant-Magnuson Clinical Center houses the Pain and Palliative Care Service (PPCS) within the NIH.48 The guiding principles of the PPCS are as follows: · palliative care not limited to EOL (all patients are undergo- ing active treatment); · optimization of palliative ser- vices through early intervention and implementation; · continuity of care throughout the illness trajectory; · parallel (collaborative) aggres- sive antitumor research and comprehensive palliative mo- dalities (drug, nondrug and mul- tidisciplinary); · combinations of active and com- passionate (humanizing and individualized) therapies focused on physical, psychological, so- cial, and spiritual suffering; · comprehensive palliation not limited to pain; and · comprehensive intensive man- agement of symptoms affecting QOL, and prospective research in outcomes related to palliative services. An initial performance-improve- ment process at the NIH revealed clin- ical gaps within existing programs in which patients' needs were not being met. This led to the formation of the PPCS in August of 2000. Key improvement areas were identified, i.e., continuity of care and discharge from the NIH, symptom management related to treatment (and disease), and addressing undertreatment of pain within hospital settings.48 The clinical center of the PPCS initially consisted of a palliative specialist physician and a nurse practitioner. A formal intro- duction to palliative care principles 453American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 and practice was introduced through grand rounds; a palliative consultation team accompanied each research team, providing bedside teaching and formal and informal consultations. A collaborative, nonadversarial relationship developed between de- partments, leading to extensive con- sultations and inclusion of palliative care services as part of research proto- cols. This approach avoided the "either palliative medicine or oncolo- gy" conflict, and the perception of pal- liative care as EOL (transitional) care was avoided. Outpatient clinics were established as the team became involved in continuity and discharge. Holistic treatment approaches were accomplished through collaboration with other departments. Inter- disciplinary liaisons committed to two half-days in the clinic and attended weekly interdisciplinary team meet- ings. The plan of care for each consult was established and reviewed weekly. Team members do daily rounds, and referral is made to the member with a particular expertise in problems the patient is experiencing. Improved com- munication between researcher and patient is one of the purposes of the team. The PPCS does not have a sepa- rate inpatient service but acts in an advi- sory, educational, and facilitative role on all inpatient service wards. In-ser- vices for nurses extends the program's influence, with a nurse liaison group formed from each unit. Each liaison nurse attends an eight-hour seminar and is the resource person for unit col- leagues. The PPCS has expanded recently to include a second physician and additional healthcare members. Present research includes a randomized three-year study evaluating palliative interventions in patients treated on sur- gical services. Other examples of integrated pallia- tive medicine models exist, but all have common factors. Each model involves an organization of cancer care that rec- ognized a need for palliative medicine, pilot projects, planned development, philanthropy, multidisciplinary teams, collaborative care, and patient-cen- tered, referral-friendly access to care. Identification of a physician special- ist/nurse team for individual patients enhances continuity of care. Most pro- grams involve education and research, inpatient units, outpatient clinics, and inpatient consulting services. Patients are collaborative managed with oncolo- gists during the time they receive chemotherapy or radiation therapy. Differences include department location (e.g., within oncology or pain management departments or as part of rehabilitation services). Some have developed extensive inpatient units within acute care settings, while oth- ers have emphasized more home or outpatient care. Decentralized models with collaborative initiatives are char- acteristic of other centers. Home care palliative services and utilization of an inpatient hospice unit outside of the cancer center are found in two of the models. A 24-hour on-call system is important to most programs. There are important advantages to a centralized inpatient palliative medicine unit within a cancer center. Complex symptoms can be managed effectively and quickly. Palliative units foster nurs- ing expertise in palliative skills and pro- vide an environment conducive to edu- cation, research, multidisciplinary team development, and coordinated care. Such units bridge care seamlessly from cancer center to community services. Patient respite admissions and patient preferred choice for terminal care are additional benefits of inpatient palliative units. Drawbacks include the potential for "de-skilling" other medical and sur- gical units in the art of symptom relief and terminal care and the potential of becoming known as the "dying unit." Problems with collaboration Referral to palliative medicine is based on the oncologist's conception of care, which may be collaborative (continuous), transitional (discontinu- ous), or terminal (dying). The pallia- tive specialist is at the mercy of his referral source. Medications prior to referral may produce a financial bur- den on the program, since expensive medications are frequently prescribed based on marketing or need to be modified due to drug class redundan- cies, interactions, or altered pharma- cokinetics as a result of organ failure. Conflicts in goals of care can arise between palliative specialists and referring oncologists. Patients may see palliative specialists as lacking hope and referral as an indicator of impending death. Palliative specialists may be cast in the role of a gatekeeper due to differences in reimbursement structures (DRG versus capitated reimbursement). Prescribing in pallia- tive medicine needs to be sensitive to the financial restraints of affiliated hospices, since many patients will eventually be referred to them. Palliative medicine is usually not an advertising point for tertiary cancer centers, and for some patients, pallia- tive medicine is not the answer they were seeking. Finally, there are few prospective studies that measure out- comes (symptom control, QOL, patient satisfaction, and financial fea- sibility) in palliative medicine pro- grams, which would provide the evi- dence necessary to justify services, improve performance, and make com- parisons with other conventional (nonpalliative) services. Conclusion Palliative medicine services and the philosophy of palliative care can be successfully incorporated into pre- existing comprehensive cancer cen- ters, but benefit outcomes need to be established though prospective trials. Both oncology and palliative medi- cine need to shed the either/or mental- ity and the perception of palliative 454 American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 care as end-of-life care if effective integration is to occur. Compre- hensive palliative services within can- cer centers should follow the patient throughout the trajectory of disease, since symptom burden occurs early in the disease. Inpatient units, inpatient consulting services, outpatient clinics, hospice, education, and research are all important elements of a compre- hensive palliative medicine depart- ment. Pilot studies and philanthropy are important at the start as is the need for planned expansion of services. Palliative specialists need to under- stand the symptom management and QOL benefits of palliative chemo- and radiation therapy and not limit their views to their own specialty. Collaboration, communication, and cooperation are key to integrating oncology and palliative medicine into the best care for advanced cancer patients. Acknowledgment The author would like to acknowledge the help of Janet Hardy BSc, FRACP, The Royal Marsden Hospital, United Kingdom; Nora Janjan, MD, MD Anderson Cancer center, Houston, Texas; and Tony O'Brien, MD, Marymont Hospice and Consultant in Palliative Medicine, Cork University Hospital, Cork, Ireland. The Harry R. Horvitz Center of the Cleveland Clinic is a World Health Organization Demonstration Project in Palliative Medicine. References 1. World Health Organization: Cancer Pain Relief and Palliative Care. Technical Report Series 804, Geneva, Switzerland, 1990. 2. Cairns W: The problem of definitions. Prog Pall Care. 2001; 9(5): 187-189. 3. Saunders C: The evolution of palliative care. Patient Educ Couns. 2000, 41:7-13. 4. Donnelly S, Walsh D: The symptoms of advanced cancer. Semin Oncol. 1995; 22(2): 67-72. 5. Homes J, Walsh D, Nelson KA, et al.: The impact of a palliative medicine consultation service in medical oncology. Support Care Cancer. 2001; 10(4): 1-11. 6. Reuben DB, Moor V, Hires J: Clinical symptoms and length of survival in patients with terminal cancer. Arch Intern Med. 1988; 148(7): 1586-1591. 7. Miltonic M, Proven M, Nanny O, et al.: Biological indices predictive of survival in 519 Italian terminally ill cancer patients. J Pain Symptom Manage. 1997; 13(1): 1-9. 8. Cleeland CS, Mendoza TR, Wang XS, et al.: Assessing symptom distress in cancer patients. The MD Anderson Symptom Inventory. Cancer. 2000; 89(7): 1634-1646. 9. Waller A, Carolyn N (eds.): Handbook of Palliative Care in Cancer (2nd ed.). Woburn, MA: Butterworth-Heinemann, 2000. 10. Faull C, Carter Y, Woolf R (eds.): Handbook of Palliative Care. Oxford, UK: Blackwell Science Ltd., 1998. 11. Twycross R (ed.): Symptom Management in Advanced Cancer (2nd ed.) Oxon, UK: Radcliff Medical Press, 1997. 12. Woodruff R: Palliative Medicine: Symp- tomatic and Supportive Care for Patients with AdvancedCancerandAIDS(2nded.).Victoria, AU: Asperula Pty Ltd, 1996. 13. Walsh D, Doona M, Molnar M, et al.: Symptom control in advanced cancer: Important drugs and routes of administra- tion. Semin Oncol. 2000; 27(1): 69-83. 14. Ellison NM: Palliative chemotherapy. In Berger A, Portenoy R, Weissman DE (eds.): Principles and Practice of Supportive Oncology. Philadelphia: Lippincott-Raven, 1998: pp. 667-669. 15. Ellison NM: Palliative chemotherapy. Am J Hosp Palliat Care. 1998; 15(2): 93-103. 16. Archer VR, Billingham LJ, Cullen MH: Palliative chemotherapy: No longer a con- tradiction in terms. Oncologist. 1999; 4(6): 470-477. 17. Mead GM: Chemotherapy for solid tumours. Routine treatment not yet justified. BMJ. 1995; 310(6974): 246-247. 18. Ahmedzai SH, Walsh D: Palliative medi- cine and modern cancer care. Semin Oncol. 2000; 27(1): 1-6. 19. Detmar SB, Muller MJ, Schornagel JH, et al.: Role of health-related quality of life in palliative chemotherapy treatment decisions. J Clin Oncol. 2002; 20(4): 1056-1062. 20. Gianmauro N, Russi E, Merlano M: Best supportive care in non-small cell lung can- cer: Is there a role for radiotherapy and chemotherapy? Lung Cancer. 2001; 32: 213- 226. 21. Doyle C, Crump M, Pintilie M, et al.: Does palliative chemotherapy palliate? Evaluation of expectations, outcomes, and costs in women receiving chemotherapy for advanced ovarian cancer. J Clin Oncol. 2001; 19(5): 1266-1274. 22. Donnelly S, Rybicki L, Walsh D: Quality of life measurement in the palliative man- agement of advanced cancer. Support Care Cancer. 2001; 9(5): 361-365. 23. Coates A: Quality of life and supportive care. Support Care Cancer. 1997; 5(6): 435- 438. 24. Cella DF: Methods and problems in mea- suring quality of life. Support Care Cancer. 1995; 3(1): 11-22. 25. Feld R: Endpoints in cancer clinical tri- als: Is there a need for measuring quality of life? Support Care Cancer. 1995; 3(1): 23- 27. 26. Jassem J, Krzakowski M, Roszkowski K, et al.: A phase II study of gemcitabine plus cisplatin in patients with advanced non- small cell lung cancer: Clinical outcomes and quality of life. Lung Cancer. 2002; 35(1): 73-79. 27. The Elderly Lung Cancer Vinorelbine Italian Study Group: Effects of vinorelbine on quality of life and survival of elderly patients with advanced non-small cell lung cancer. J Natl Cancer Inst. 1999; 91(1): 66- 72. 28. Bonomi PD, Finkelstein DM, Ruckdeschel JC, et al.: Combination chemotherapy versus single agents followed by combination chemotherapy in stage IV non-small-cell lung cancer: a study of the Eastern Cooperative Oncology Group. J Clin Oncol. 1989; 7(11): 1602-1613. 29. Thatcher N, Anderson H, Betticher DC, et al.: Symptomatic relief from gemcitabine and other chemotherapy in non-small cell lung cancer: Changes in performance and cancer related symptoms. Anticancer Drugs. 1995; 6(suppl6): 39-48. 30. Tannock IF, Osoba D, Stockler MR, et al.: Chemotherapy with mitoxantrone plus prednisone or prednisone alone for sympto- matic hormone-resistant prostate cancer: a Canadian randomized trial with palliative end points. J Clin Oncol. 1996; 14(6): 1756- 1764. 31. Moore MJ, Osoba D, Murphy K, et al.: Use of palliative end points to evaluate the effects of mitoxantrone and low-dose pred- nisone in patients with hormonally resistant prostate cancer. J Clin Oncol. 1994; 12(4): 689-694. 32. Glimelius B, Hoffman K, Graf W, et al.: 455American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 Cost-effectiveness of palliative chemothera- py in advanced gastrointestinal cancer. Ann Oncol. 1995; 6(3): 267-274. 33. Socinski MA, Schnell MJ, Peterman A, et al.: Phase III trial comparing a defined duration of therapy versus continuous therapy followed by second-line therapy in advanced-stage IIIB/IV non-small-cell lung cancer. J Clin Oncol. 2002; 20(5): 1335-1343. 34. Schaafsma J, Coy P: Response of global quality of life to high-dose palliative radio- therapy for non-small-cell lung cancer. Int J Radiat Oncol Biophys. 2000; 47(3): 691- 701. 35. Whippen DA, Canellos GP: Burnout syndrome in the practice of oncology: Results of a random survey of 1,000 oncolo- gists. J Clin Oncol. 1991; 9(10): 1916-1920. 36. Vachon MLS: Stress and burnout in oncolo- gy. In Berger A, Portenoy R, Weissman DE (eds.): Principles and Practice of Supportive Oncology. Philadelphia: Lippincott-Raven, 1998: pp. 833-843. 37. Bruera E, Neumann C: Respective limits of palliative care and oncology in the sup- portive care of cancer patients. Support Care Cancer. 1999; 7(5): 321-327. 38. Maltoni M, Amadori D: Palliative medi- cine and medical oncology. Ann Oncol. 12(4): 443-450. 39. Dumont I, Dumont S, Turgeon J: Continuity of care for advanced cancer patients. J Palliat Care. 2005; 21(1): 49-56. 41. Von Roenn JH, Cleeland CS, Gonin R, et al.: Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group. Ann Intern Med. 1993; 119(2): 121-126. 42. Porzio G, Valenti M, Aielli F, et al.: Assessment and treatment of symptoms among Italian medical oncologists. Support Care Cancer. 2005; Apr 29 [E-pub ahead of print]. 43. Goldstein P, Walsh D, Horvitz L: The Cleveland Clinic Foundation Harry R. Horvitz Palliative Care Center. Support Care Cancer. 1996, 4(5): 329-333. 44. Tropiano P, Walsh D: Organization of services and nursing care: Hospice and pal- liative medicine. Semin Oncol. 2000; 27(1): 7-13. 45. Walsh D: The Harry R. Horvitz Center for Palliative Medicine (1987-1999): Development of a novel comprehension integrated program. Am J Hosp Palliat Care. 2001; 18(4): 239-250. 46. DeConno F, Ripamonti C, Caraceni A, et al.: Palliative care at the National Cancer Institute of Milan. Support Care Cancer. 2001; 9(3): 141-147. 47. Kloke M, Scheidt H: Pain and symptom control for cancer patients at the University Hospital in Essen: Integration of specialists' knowledge into routine work. Support Care Cancer. 1996; 4(6): 440-447. 48. Berger A, Baker K, Bolle J, et al.: Establishing a palliative care program in a research center: Evolution of a model. Cancer Invest. 2003; 21(2): 313-320. 456 American Journal of Hospice & Palliative Medicine Volume 22, Number 6, November/December 2005 Call for Papers American Journal of Hospice & Palliative Medicine invites the submission of hospice-related articles in the following areas: research, case studies, literature reviews, policy examination, and opinion & commentary. Suggested topics include, but are not limited to, the following: · Complementary hospice therapies · Hospice nursing · International hospice efforts · Pain management · Pediatric hospice care · Spirituality in hospice For more information, contact: Editorial Department American Journal of Hospice & Palliative Medicine 470 Boston Post Road Weston, Massachusetts 02493 Tel: 781-899-2702 Fax: 781-899-4900 E-mail: hospice@pnpco.com Web site: www.hospicejournal.com </meta-value></custom-meta></custom-meta-wrap></article-meta></front><back><ref-list>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>World Health Organization</surname></name>: <source>Cancer Pain Relief and Palliative Care</source>. <series>Technical Report Series 804</series>, <publisher-loc>Geneva, Switzerland</publisher-loc>, <year>1990</year>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Cairns W</surname></name>: <article-title>The problem of definitions</article-title>. <source>Prog Pall Care</source>. <year>2001</year>; <volume>9</volume>(<issue>5</issue>): <fpage>187</fpage>-<lpage>189</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Saunders C</surname></name>: <article-title>The evolution of palliative care</article-title>. <source>Patient Educ Couns</source>. <year>2000</year>, <volume>41</volume>:<fpage>7</fpage>-<lpage>13</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Donnelly S</surname></name>, <name name-style="western"><surname>Walsh D</surname></name>: <article-title>The symptoms of advanced cancer</article-title>. <source>Semin Oncol</source>. <year>1995</year>; <volume>22</volume>(<issue>2</issue>): <fpage>67</fpage>-<lpage>72</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Homes J</surname></name>, <name name-style="western"><surname>Walsh D</surname></name>, <name name-style="western"><surname>Nelson KA</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>The impact of a palliative medicine consultation service in medical oncology</article-title>. <source>Support Care Cancer</source>. <year>2001</year>; <volume>10</volume>(<issue>4</issue>): <fpage>1</fpage>-<lpage>11</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Reuben DB</surname></name>, <name name-style="western"><surname>Moor V</surname></name>, <name name-style="western"><surname>Hires J</surname></name>: <article-title>Clinical symptoms and length of survival in patients with terminal cancer</article-title>. <source>Arch Intern Med</source>. <year>1988</year>; <volume>148</volume>(<issue>7</issue>): <fpage>1586</fpage>-<lpage>1591</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Miltonic M</surname></name>, <name name-style="western"><surname>Proven M</surname></name>, <name name-style="western"><surname>Nanny O</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Biological indices predictive of survival in 519 Italian terminally ill cancer patients</article-title>. <source>J Pain Symptom Manage</source>. <year>1997</year>; <volume>13</volume>(<issue>1</issue>): <fpage>1</fpage>-<lpage>9</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Cleeland CS</surname></name>, <name name-style="western"><surname>Mendoza TR</surname></name>, <name name-style="western"><surname>Wang XS</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Assessing symptom distress in cancer patients. The MD Anderson Symptom Inventory</article-title>. <source>Cancer</source>. <year>2000</year>; <volume>89</volume>(<issue>7</issue>): <fpage>1634</fpage>-<lpage>1646</lpage>.</citation>
</ref>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Waller A</surname></name>, <name name-style="western"><surname>Carolyn N</surname></name> (eds.): <source>Handbook of Palliative Care in Cancer</source> (<edition>2nd ed.</edition>). <publisher-loc>Woburn, MA</publisher-loc>: <publisher-name>Butterworth-Heinemann</publisher-name>, <year>2000</year>.</citation>
</ref>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Faull C</surname></name>, <name name-style="western"><surname>Carter Y</surname></name>, <name name-style="western"><surname>Woolf R</surname></name> (eds.): <source>Handbook of Palliative Care</source>. <publisher-loc>Oxford, UK</publisher-loc>: <publisher-name>Blackwell Science Ltd.</publisher-name>, <year>1998</year>.</citation>
</ref>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Twycross R</surname></name> (ed.): <source>Symptom Management in Advanced Cancer</source> (<edition>2nd ed.</edition>) <publisher-loc>Oxon, UK</publisher-loc>: <publisher-name>Radcliff Medical Press</publisher-name>, <year>1997</year>.</citation>
</ref>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Woodruff R</surname></name>: <source>Palliative Medicine: Symptomatic and Supportive Care for Patients with Advanced Cancer and AIDS</source> (<edition>2nd ed.</edition>). <publisher-loc>Victoria, AU</publisher-loc>: <publisher-name>Asperula Pty Ltd</publisher-name>, <year>1996</year>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Walsh D</surname></name>, <name name-style="western"><surname>Doona M</surname></name>, <name name-style="western"><surname>Molnar M</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Symptom control in advanced cancer: Important drugs and routes of administration</article-title>. <source>Semin Oncol</source>. <year>2000</year>; <volume>27</volume>(<issue>1</issue>): <fpage>69</fpage>-<lpage>83</lpage>.</citation>
</ref>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Ellison NM</surname></name>: <article-title>Palliative chemotherapy</article-title>. In <name name-style="western"><surname>Berger A</surname></name>, <name name-style="western"><surname>Portenoy R</surname></name>, <name name-style="western"><surname>Weissman DE</surname></name> (eds.): <source>Principles and Practice of Supportive Oncology</source>. <publisher-loc>Philadelphia</publisher-loc>: <publisher-name>Lippincott-Raven</publisher-name>, <year>1998</year>: pp. <fpage>667</fpage>-<lpage>669</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Ellison NM</surname></name>: <article-title>Palliative chemotherapy</article-title>. <source>Am J Hosp Palliat Care</source>. <year>1998</year>; <volume>15</volume>(<issue>2</issue>): <fpage>93</fpage>-<lpage>103</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Archer VR</surname></name>, <name name-style="western"><surname>Billingham LJ</surname></name>, <name name-style="western"><surname>Cullen MH</surname></name>: <article-title>Palliative chemotherapy: No longer a contradiction in terms</article-title>. <source>Oncologist</source>. <year>1999</year>; <volume>4</volume>(<issue>6</issue>): <fpage>470</fpage>-<lpage>477</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Mead GM</surname></name>: <article-title>Chemotherapy for solid tumours. Routine treatment not yet justified</article-title>. <source>BMJ</source>. <year>1995</year>; <volume>310</volume>(<issue>6974</issue>): <fpage>246</fpage>-<lpage>247</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Ahmedzai SH</surname></name>, <name name-style="western"><surname>Walsh D</surname></name>: <article-title>Palliative medicine and modern cancer care</article-title>. <source>Semin Oncol</source>. <year>2000</year>; <volume>27</volume>(<issue>1</issue>): <fpage>1</fpage>-<lpage>6</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Detmar SB</surname></name>, <name name-style="western"><surname>Muller MJ</surname></name>, <name name-style="western"><surname>Schornagel JH</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Role of health-related quality of life in palliative chemotherapy treatment decisions</article-title>. <source>J Clin Oncol</source>. <year>2002</year>; <volume>20</volume>(<issue>4</issue>): <fpage>1056</fpage>-<lpage>1062</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Gianmauro N</surname></name>, <name name-style="western"><surname>Russi E</surname></name>, <name name-style="western"><surname>Merlano M</surname></name>: <article-title>Best supportive care in non-small cell lung cancer: Is there a role for radiotherapy and chemotherapy?</article-title>
<source>Lung Cancer</source>. <year>2001</year>; <volume>32</volume>: <fpage>213</fpage>-<lpage>226</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Doyle C</surname></name>, <name name-style="western"><surname>Crump M</surname></name>, <name name-style="western"><surname>Pintilie M</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Does palliative chemotherapy palliate? Evaluation of expectations, outcomes, and costs in women receiving chemotherapy for advanced ovarian cancer</article-title>. <source>J Clin Oncol</source>. <year>2001</year>; <volume>19</volume>(<issue>5</issue>): <fpage>1266</fpage>-<lpage>1274</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Donnelly S</surname></name>, <name name-style="western"><surname>Rybicki L</surname></name>, <name name-style="western"><surname>Walsh D</surname></name>: <article-title>Quality of life measurement in the palliative management of advanced cancer</article-title>. <source>Support Care Cancer</source>. <year>2001</year>; <volume>9</volume>(<issue>5</issue>): <fpage>361</fpage>-<lpage>365</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Coates A</surname></name>: <article-title>Quality of life and supportive care</article-title>. <source>Support Care Cancer</source>. <year>1997</year>; <volume>5</volume>(<issue>6</issue>): <fpage>435</fpage>-<lpage>438</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Cella DF</surname></name>: <article-title>Methods and problems in measuring quality of life</article-title>. <source>Support Care Cancer</source>. <year>1995</year>; <volume>3</volume>(<issue>1</issue>): <fpage>11</fpage>-<lpage>22</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Feld R</surname></name>: <article-title>Endpoints in cancer clinical trials: Is there a need for measuring quality of life?</article-title>
<source>Support Care Cancer</source>. <year>1995</year>; <volume>3</volume>(<issue>1</issue>): <fpage>23</fpage>-<lpage>27</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Jassem J</surname></name>, <name name-style="western"><surname>Krzakowski M</surname></name>, <name name-style="western"><surname>Roszkowski K</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>A phase II study of gemcitabine plus cisplatin in patients with advanced non-small cell lung cancer: Clinical outcomes and quality of life</article-title>. <source>Lung Cancer</source>. <year>2002</year>; <volume>35</volume>(<issue>1</issue>): <fpage>73</fpage>-<lpage>79</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>The Elderly Lung Cancer Vinorelbine Italian Study Group</surname></name>: <article-title>Effects of vinorelbine on quality of life and survival of elderly patients with advanced non-small cell lung cancer</article-title>. <source>J Natl Cancer Inst</source>. <year>1999</year>; <volume>91</volume>(<issue>1</issue>): <fpage>66</fpage>-<lpage>72</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Bonomi PD</surname></name>, <name name-style="western"><surname>Finkelstein DM</surname></name>, <name name-style="western"><surname>Ruckdeschel JC</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Combination chemotherapy versus single agents followed by combination chemotherapy in stage IV non-small-cell lung cancer: a study of the Eastern Cooperative Oncology Group</article-title>. <source>J Clin Oncol</source>. <year>1989</year>; <volume>7</volume>(<issue>11</issue>): <fpage>1602</fpage>-<lpage>1613</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Thatcher N</surname></name>, <name name-style="western"><surname>Anderson H</surname></name>, <name name-style="western"><surname>Betticher DC</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Symptomatic relief from gemcitabine and other chemotherapy in non-small cell lung cancer: Changes in performance and cancer related symptoms</article-title>. <source>Anticancer Drugs</source>. <year>1995</year>; <volume>6</volume>(<issue>suppl6</issue>): <fpage>39</fpage>-<lpage>48</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Tannock IF</surname></name>, <name name-style="western"><surname>Osoba D</surname></name>, <name name-style="western"><surname>Stockler MR</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Chemotherapy with mitoxantrone plus prednisone or prednisone alone for symptomatic hormone-resistant prostate cancer: a Canadian randomized trial with palliative end points</article-title>. <source>J Clin Oncol</source>. <year>1996</year>; <volume>14</volume>(<issue>6</issue>): <fpage>1756</fpage>-<lpage>1764</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Moore MJ</surname></name>, <name name-style="western"><surname>Osoba D</surname></name>, <name name-style="western"><surname>Murphy K</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Use of palliative end points to evaluate the effects of mitoxantrone and low-dose prednisone in patients with hormonally resistant prostate cancer</article-title>. <source>J Clin Oncol</source>. <year>1994</year>; <volume>12</volume>(<issue>4</issue>): <fpage>689</fpage>-<lpage>694</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Glimelius B</surname></name>, <name name-style="western"><surname>Hoffman K</surname></name>, <name name-style="western"><surname>Graf W</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Cost-effectiveness of palliative chemotherapy in advanced gastrointestinal cancer</article-title>. <source>Ann Oncol</source>. <year>1995</year>; <volume>6</volume>(<issue>3</issue>): <fpage>267</fpage>-<lpage>274</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Socinski MA</surname></name>, <name name-style="western"><surname>Schnell MJ</surname></name>, <name name-style="western"><surname>Peterman A</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Phase III trial comparing a defined duration of therapy versus continuous therapy followed by second-line therapy in advanced-stage IIIB/IV non-small-cell lung cancer</article-title>. <source>J Clin Oncol</source>. <year>2002</year>; <volume>20</volume>(<issue>5</issue>): <fpage>1335</fpage>-<lpage>1343</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Schaafsma J</surname></name>, <name name-style="western"><surname>Coy P</surname></name>: <article-title>Response of global quality of life to high-dose palliative radiotherapy for non-small-cell lung cancer</article-title>. <source>Int J Radiat Oncol Biophys</source>. <year>2000</year>; <volume>47</volume>(<issue>3</issue>): <fpage>691</fpage>-<lpage>701</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Whippen DA</surname></name>, <name name-style="western"><surname>Canellos GP</surname></name>: <article-title>Burnout syndrome in the practice of oncology: Results of a random survey of 1,000 oncologists</article-title>. <source>J Clin Oncol</source>. <year>1991</year>; <volume>9</volume>(<issue>10</issue>): <fpage>1916</fpage>-<lpage>1920</lpage>.</citation>
</ref>
<ref>
<citation citation-type="book" xlink:type="simple"><name name-style="western"><surname>Vachon MLS</surname></name>: <article-title>Stress and burnout in oncology</article-title>. In <name name-style="western"><surname>Berger A</surname></name>, <name name-style="western"><surname>Portenoy R</surname></name>, <name name-style="western"><surname>Weissman DE</surname></name> (eds.): <source>Principles and Practice of Supportive Oncology</source>. <publisher-loc>Philadelphia</publisher-loc>: <publisher-name>Lippincott-Raven</publisher-name>, <year>1998</year>: pp. <fpage>833</fpage>-<lpage>843</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Bruera E</surname></name>, <name name-style="western"><surname>Neumann C</surname></name>: <article-title>Respective limits of palliative care and oncology in the supportive care of cancer patients</article-title>. <source>Support Care Cancer</source>. <year>1999</year>; <volume>7</volume>(<issue>5</issue>): <fpage>321</fpage>-<lpage>327</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Maltoni M</surname></name>, <name name-style="western"><surname>Amadori D</surname></name>: <article-title>Palliative medicine and medical oncology</article-title>. <source>Ann Oncol</source>.<volume>12</volume>(<issue>4</issue>): <fpage>443</fpage>-<lpage>450</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Dumont I</surname></name>, <name name-style="western"><surname>Dumont S</surname></name>, <name name-style="western"><surname>Turgeon J</surname></name>: <article-title>Continuity of care for advanced cancer patients</article-title>. <source>J Palliat Care</source>. <year>2005</year>; <volume>21</volume>(<issue>1</issue>): <fpage>49</fpage>-<lpage>56</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Von Roenn JH</surname></name>, <name name-style="western"><surname>Cleeland CS</surname></name>, <name name-style="western"><surname>Gonin R</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology Group</article-title>. <source>Ann Intern Med</source>. <year>1993</year>; <volume>119</volume>(<issue>2</issue>): <fpage>121</fpage>-<lpage>126</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Porzio G</surname></name>, <name name-style="western"><surname>Valenti M</surname></name>, <name name-style="western"><surname>Aielli F</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Assessment and treatment of symptoms among Italian medical oncologists</article-title>. <source>Support Care Cancer</source>. <year>2005</year>; Apr 29 [E-pub ahead of print].</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Goldstein P</surname></name>, <name name-style="western"><surname>Walsh D</surname></name>, <name name-style="western"><surname>Horvitz L</surname></name>: <article-title>The Cleveland Clinic Foundation Harry R. Horvitz Palliative Care Center</article-title>. <source>Support Care Cancer</source>. <year>1996</year>, <volume>4</volume>(<issue>5</issue>): <fpage>329</fpage>-<lpage>333</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Tropiano P</surname></name>, <name name-style="western"><surname>Walsh D</surname></name>: <article-title>Organization of services and nursing care: Hospice and palliative medicine</article-title>. <source>Semin Oncol</source>. <year>2000</year>; <volume>27</volume>(<issue>1</issue>): <fpage>7</fpage>-<lpage>13</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Walsh D</surname></name>: <article-title>The Harry R. Horvitz Center for Palliative Medicine (1987-1999): Development of a novel comprehension integrated program</article-title>. <source>Am J Hosp Palliat Care</source>. <year>2001</year>; <volume>18</volume>(<issue>4</issue>): <fpage>239</fpage>-<lpage>250</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>DeConno F</surname></name>, <name name-style="western"><surname>Ripamonti C</surname></name>, <name name-style="western"><surname>Caraceni A</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Palliative care at the National Cancer Institute of Milan</article-title>. <source>Support Care Cancer</source>. <year>2001</year>; <volume>9</volume>(<issue>3</issue>): <fpage>141</fpage>-<lpage>147</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Kloke M</surname></name>, <name name-style="western"><surname>Scheidt H</surname></name>: <article-title>Pain and symptom control for cancer patients at the University Hospital in Essen: Integration of specialists’ knowledge into routine work</article-title>. <source>Support Care Cancer</source>. <year>1996</year>; <volume>4</volume>(<issue>6</issue>): <fpage>440</fpage>-<lpage>447</lpage>.</citation>
</ref>
<ref>
<citation citation-type="journal" xlink:type="simple"><name name-style="western"><surname>Berger A</surname></name>, <name name-style="western"><surname>Baker K</surname></name>, <name name-style="western"><surname>Bolle J</surname></name>, <name name-style="western"><surname>et al.</surname></name>: <article-title>Establishing a palliative care program in a research center: Evolution of a model</article-title>. <source>Cancer Invest</source>. <year>2003</year>; <volume>21</volume>(<issue>2</issue>): <fpage>313</fpage>-<lpage>320</lpage>.</citation>
</ref>
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