Cure simultanee in oncologia

Vittorina Zagonel

Dipartimento OncologiaIstituto Oncologico Veneto, IRCCS, Padova

Regione del Veneto

The goal of care in oncology has changed

Jordan K et al, Ann Oncol 2018;29:36-43.

Early integration of palliative care- EIPC -

Several randomized controlled trials provided level I evidence that supports EIPC for patients withadvanced stage/incurable cancer

EIPC is associated with improved QoL, symptomscontrol, patient and cargiver satisfaction, best qualityof end of life care, reduced depression, use more appropriate care settings, and in some case, improvedsurvival*.

WHO, ESMO, ASCO, EAPC, NCCN guidelines integratedEIPC as an essential goal to guarantee a comprehensivecancer care.

*Ferrell BR et al .JCO 2017, 35:96-112.

Traditional versus early palliative care

Kaasa S. et al. Lancet Oncology online 18 oct 2018

Conceptual model of palliative care delivery based on provider expertise

Kaasa S. et al. Lancet Oncology online 18 oct 2018

Proposed model of optimal oncology palliative care provision

Kaasa S. et al. Lancet Oncology online 18 oct 2018

The challenge: the silos must be connected

share the patient's care path

OncologistPalliative

care team

PrimaryCare

Physician

Tertiary palliative care on the basis ofreferral to palliative care clinic

Kaasa S. et al. Lancet Oncology online 18 oct 2018

Open questions

1. How to define the timing of PC access?

2. How oncology & palliative-care teams can better integrate? What is recommendedintegration level?

3. How integration should be tailored to the characteristics of the health care systems, hospital setting, and local resourceavailability?

Timing of EIPC

The timing to EIPC depends on the type of tumor and the level of palliative care provided by the oncologist and the primary care physician

The results obtained in NSCLC of a significant improvement at 12-weeks of QoL score for the EIPC has not been confirmed in all cancers.

Furthermore, immunotherapy and targeted therapies are drastically lengthening the survival of some patients with particular tumor subtypes; so the prognosis in the metastatic phase is now to difficult to define.

2008: 4 centers2018: 40 centersItaly, the nation with the largest number of ESMO Designated Centers

Il modello ESMO di integrazione dal 2003

EARLY PALLIATIVE CARE: temporaneità(rispetto ai bisogni del paziente) dellaattivazione delle cure palliative, concomitantialle terapie oncologiche attive.

SIMULTANEOUS CARE: modalità dierogazione delle cure palliativeprecoci (ambulatorio condiviso traoncologo e team di cure palliative-modello integrato-).

STUMENTI PER RILEVARE I BISOGNI

ORGANIZZAZIONE

Screening for EIPC for oncologyoutpatients in Italy

Sharing a document by AIOM and SICP, in which a consensus list of criteria for palliative care assessment is defined

Routinely screening of patient needsperformed by oncologists at everyconsultation

When unmet needs emerged, oncologistfill out the list to send the patient to the simultaneous care clinic

• Performance Status

• Sintomi

• Prognosi

• Terapie con impatto sulla

sopravvivenza

• Tossicità attesa dai

trattamenti

• Problemi psico- socio-

assistenziali

SCORE

>10 visita entro

10 gg

Tra 5-9 entro

1 mese

Tra 0-4 entro

2 mesi

2 ambulatori/sett. per

pazienti ambulatoriali;

2 breefing /sett. per

pazienti ricoverati

Somministrazione del termometro del distress

Inquadramento dello stato fisico /funzionale del paziente (PS,

MUST,ESAS, EO)

Confronto tra oncologo e palliativista sulle prospettive di cura e

sulla prognosi

Inquadramento psicologico (consapevolezza e prognosi, ansia,

depressione, capacità di coping, risorse familiari, caregiver,

DAT)

Definizione del PAI (terapia antalgica, nutrizionale, supporto

psicologico, pianificazione controlli successivi , compilazione

SVAMA, segnalazione delle criticità ai MMG, o Servizi Sociali)

Feedback all’oncologo inviante

Ambulatorio Cure Simultanee

Visita: oncologo e team di cure palliative

1818

Electronic Medical Record

Palliative care specialist

Nutritionist Psychologist

Actors and Services

Setting

First visit Prep. & admin of Rx

Therapeutic plan

Diagnosis Exams

PharmacistNurseOncologist

Outpatient clinic Day Hospital / In-patient ward Outpatient clinic

Communication to Primary Care Physician

Open questions

1. How to define the timing of access to PC?

2. How oncology & palliative-care teams can better integrate? What is recommendedintegration level?

3. How integration should be tailored to the characteristics of the health care systems, hospital setting, and local resourceavailability?

AREASOF

INTEGRATION

Administration(9)

Processes(13)

Education(8)

Research(4)

ClinicalStructures

(4)

Integrazione: un lungo e complesso processo

Hui D & Bruera E, Nat Rev Clin Oncol 2016;13:159-171

Interdisciplinarietà implica

Condivisione degli obiettivi

Riconoscimento e reciproco rispetto delle competenze e del ruolo

Valorizzazione delle differenze individuali

Relazioni simmetriche e flessibili

Decisioni attraverso il consenso

Gestioni dei conflitti attraverso il confronto

Kaa

saS.

et

al. L

ance

tO

nco

logy

on

line

18

oct

20

18

Three levels of integration

Regione del Veneto

DGR 553/2018

Cure palliative precoci e simultaneeRegione del Veneto

DGR 553/2018

Regione del Veneto

Colon-retto

Melanoma

Mammella

Prostata

Percorsi Diagnostici Terapeutici ed Assistenziali

Vescica

Polmone

Sarcomi

Ovaio

Stomaco

Tumori ereditari

Rene

Tumori Neuroendocrini

Fegato

Pancreas

Tumoriendocrini

Esofago

Testa-Collo

Metastasi scheletricheSNC

Testicolo

I nodi strategici

Ambulatori condivisi di cure simultaneeProcedura condivisa per l’accesso agli ambulatori

integratiCondividere test validati per il rilievi sistematico

dei sintomi/prognosiCondividere percorsi di

formazione/aggiornamento Coinvolgere il team di cure palliative nel GOM Inserire le cure simultanee e palliative definitive

nei PDTA dei vari tipi di tumore

In tutte le linee guida di patologia

Il modello integrato (cure palliative precoci e simultanee, concomitanti alle terapie oncologiche attive) dovrebbe essere sempre preso in considerazione come prima opzione per i pazienti in fase metastatica o sintomatici, ove disponibile un team di cure palliative (RACCOMANDAZIONE POSITIVA FORTE).

Ove non disponibile un team di cure palliative, l’oncologo medico deve garantire un controllo adeguato dei sintomi a tutti i pazienti in fase metastatica in trattamento oncologico attivo , e promuovere l’attivazione di ambulatori integrati, per garantire a tutti i pazienti le cure palliative precoci e simultanee (RACCOMANDAZIONE POSITIVA DEBOLE).

1. Presence of Palliative Care (PC) inpatient consultation team 2. Presence of PC outpatient clinic 3. Presence of interdisciplinary PC team

7. Proportion of outpatients with pain assessed before death 8. Proportion of patients with 2 or more emergency room visits in last 30 days of life (negative indicator) 9. Proportion of place of death consistent with patient's preference

4. Routine symptom screening in the outpatient oncology clinic 5. Early referral to PC (> 6 months)6. Proportion of routine documentation of advance care plan

10. Didactic PC curriculum for oncology 11. Continuing medical education in PC for attending oncologists 12. Combined PC & oncology educational activities 13. Routine rotation in PC for oncology fellows

Hui D et al Ann Oncol 26:1953, 2015

STRUCTURE(3)

PROCESS(3)

OUTCOME(3)

EDUCATION(4)

Indicators of Integration at ESMO-DCs:resultsST

RU

CTU

RE

PR

OC

ESS

OU

TCO

ME

EDUCATION

Median PCOI-13 index:7.8 A higher PCOI-13 index was significantly associated withpresence of dually trained palliative oncologists (median 8.4 vs7.0;p=0.01)

Palliative Care Oncology Integration Index (PCOI)

Livelli di integrazione: ESMO vs ITALIA

78

63

85

8275

85

20554283

98

88

88

EDUCATION

OU

TCO

ME

STR

UC

TUR

EP

RO

CES

S

G. Lanzetta, G. Farina, V. Franciosi, V. Zagonel.Poster AIOM 2017, SLBA2620