Integrating Palliative Care in Kidney Cancer

Limited data exists on the effects of palliative care in patients with kidney cancer, and more research is needed.

Palliative care integration should be a key goal when treating metastatic kidney cancer, with patient-centered care at the forefront of decision making, according to a presentation given at the 2021 International Kidney Cancer Symposium: North America.1

Evidence suggests that integrating palliative care into routine oncologic care can help to expand patient quality of life, improve mood, and decrease the use of intravenous chemotherapy. In lung cancer, it was also found to potentially improve survival. The American Society of Clinical Oncology included it in its practice guidelines in 2017 after a provisional clinical opinion was introduced in 2012. Palliative care can take several forms, such as the physical aspects of care like elevating pain and nausea, to the psychological, spiritual, and cultural aspects of care.2-4

However, limited data exists on the effects of palliative care in patients with genitourinary (GU) cancers. For example, the ENABLE III trial (NCT01245621), which looked at the effect of palliative care, only included 78 such patients.1

According to presenter Biren Saraiya, MD, a medical oncologist and associate professor of Medicine in the Division of Medical Oncology, and Section of Solid Tumor at the Rutgers Robert Wood Johnson Medical Center, open communication with the patient is key when integrating palliative care into clinical participation.

“When patients actually understand what's happening, they make different choices. When patients have accurate prognostication understanding, they chose differently,” said Saraiya.

Effective communication is where the physician’s worldview and the patient’s worldview meet, and the decision-making process should be shared, according to Saraiya. Patients should be invited to actively participate, be presented with all their options, and have adequate understanding of the risks and benefits of each treatment. Oncologists should help the patient assess their options based on their goals and concerns in order for deliberate decision making.5

Two frameworks for communication facilitation exist, according to Saraiya, there is the ASK-TELL-ASK framework and the SPIKES framework. In the ASK-TELL-ASK framework, the oncologist first asks for the patient’s story, then informs them on their knowledge, and then asks for input on what they have learned. In the SPIKES framework, the oncologist must first learn the patient perspective, invite input, provide knowledge and empathy, and then end by summarizing the conversation.6

According to Saraiya, the communication structure should have 4 parts: diagnosis, staging, prognosis or treatment goals, and treatment choices. Patients often want to jump to part 4, says Saraiya, but this cannot be done until there is a solid understanding of parts 1 through 3.

Accurate understanding of prognostication is key for informed decision making. In a study of early palliative care in non-small cell lung cancer, 50% of patients who had an inaccurate understanding of their prognosis received intravenous chemotherapy compared to the just 9.4% who had an accurate understanding of their prognosis.1

Additionally, research has found that oncologists also struggle with prognostication, especially with the introduction of immunotherapy. With immunotherapy, the complete response rate with immunotherapy for metastatic GU cancers is between 7% to 16%, however, questions remain around who those responders are.7

“The oncologists were overly optimistic about the prognosis. And there's nothing wrong with that… And newer therapies have created more challenges,” said Saraiya.

Despite challenges surrounding data availability, one potential next step is a pilot study looking at the early integration of palliative care in advanced kidney cancer. The aim of this study would be to find if patients are willing to participate, and the effect participation has on patient quality of life.1

“So how do you communicate that to patients? How do you communicate so they actually hear what we want them to be hearing, which is the uncertainty?” asked Saraiya. “Communicating uncertainty is a challenge. And so is helping them make a decision that's appropriate for them that is in alignment with their values and their goals.”

1.Saraiya B. “Enhancing patient-centered care in systemic therapy and clinical trials.” Presented at: IKCS 2021; Austin, Texas; November 5-6, 2021.
2.Smith T, Temin S, Alesi E, et al. American Society of Clinical Oncology Provisional Clinical Opinion: The integration of palliative care into standard oncology care. J Clin Oncol. 2012; 30(8):880-887. doi:10.1200/JCO.2011.38.5161.
3.Ferrell B, Temel J, Temin S, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017; 35(1):96-112. doi:10.1200/JCO.2016.70.1474.
4.Temel J, Greer J, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010; 363:733-742 doi:10.1056/NEJMoa1000678.
5.Kane H, Halpern M, Squiers L, et al. Implementing and evaluating shared decision making in oncology practice. CA: Cancer J. Clin. 2014. doi:10.3322/caac.21245.
6.Back A, Arnold R, Tulsky J, et al. Teaching communication skills to medical oncology fellows. J Clin Oncol. 2003;21(12): 2433-2436. doi:10.1200/JCO.2003.09.073.
7.Temel J, Greer J, Admane S, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol. 2011;29(17):2319-2326. doi:10.1200/JCO.2010.32.4459.
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