Lynn Howie

Early palliative care in cancer treatment: rationale, evidence and clinical implications.

Patients with advanced cancer often experience symptoms of disease and treatment that contribute to distress and diminish their quality of life (QOL). Care that is aimed at control of these symptoms, whether or not the patient is undergoing ongoing disease-directed therapy to control the cancer, is thus a key feature of high-quality patient-centered care. In standard oncology practice, it is easy for focus on this type of care to be obscured by discussions and management of anticancer therapy and adequate attention to QOL, patient preferences, and goals of care often occur only days to weeks from the patient’s death. The initiation of palliative care and discussion of the patients’ goals and preferences earlier in the course of disease can lead to improved symptom control, reduced distress throughout the disease-directed therapy, and care delivery that matches the patients’ preferences. This review discusses the evolving evidence for early initiation of palliative care in patients with advanced cancer and ongoing barriers to care in this setting. We highlight challenges for research and care delivery and the potential for broader awareness of the demonstrated benefits of palliative care to help translate known benefits into improved outcomes for patients facing advanced cancer.

Neoadjuvant use of ipilimumab in locally advanced melanoma

Recent advances in immune modulating therapies show great promise for patients with advanced melanoma, however optimal strategies for achieving long‐term disease control in locally advanced melanoma are unclear. We present two cases of neoadjuvant ipilimumab, one case in combination with isolated limb infusion (ILI) followed by surgical resection and one followed by surgery alone. Both patients have had durable responses. These cases highlight the ongoing need for prospective trials in the neoadjuvant setting. J. Surg. Oncol. 2015;112:841–843.

The Ethics of Clinical Trials for Cancer Therapy

Cancer clinical trials are intended to evaluate novel interventions and to improve outcomes. Such research depends on the participation of patients seeking the best options for care. The design, conduct, and analysis of trials must therefore be grounded in an ethical framework that respects and protects the interests of clinical trial participants.

There Is a Mismatch Between the Medicare Benefit Package and the Preferences of Patients With Cancer and Their Caregivers

PURPOSE To identify insured services that are most important to Medicare beneficiaries with cancer and their family caregivers when coverage is limited. METHODS A total of 440 participants (patients, n = 246; caregivers, n = 194) were enrolled onto the CHAT (Choosing Health Plans All Together) study from August 2010 to March 2013. The exercise elicited preferences about what benefits Medicare should cover for patients with cancer in their last 6 months of life. Facilitated sessions lasted 2.5 hours, included 8 to 10 participants, and focused on choices about Medicare health benefits within the context of a resource-constrained environment. RESULTS Six of 15 benefit categories were selected by > 80% of participants: cancer care, prescription drugs, primary care, home care, palliative care, and nursing home coverage. Only 12% of participants chose the maximum level of cancer benefits, a level of care commonly financed in the Medicare program. Between 40% and 50% of participants chose benefits not currently covered by Medicare: unrestricted cash, concurrent palliative care, and home-based long-term care. Nearly one in five participants picked some level of each of these three benefit categories and allocated on average 30% of their resources toward them. CONCLUSION The mismatch between covered benefits and participant preferences shows that addressing quality of life and the financial burden of care is a priority for a substantial subset of patients with cancer in the Medicare program. Patient and caregiver preferences can be elicited, and the choices they express could suggest potential for Medicare benefit package reform and flexibility.

A decision exercise to engage cancer patients and families in Deliberation about Medicare Coverage for advanced Cancer Care

BackgroundConcerns about unsustainable costs in the US Medicare program loom as the number of retirees increase and experiences serious and costly illnesses like cancer. Engagement of stakeholders, particularly cancer patients and their families, in prioritizing insured services offers a valuable strategy for informing Medicare coverage policy. We designed and evaluated a decision exercise that allowed cancer patients and family members to choose Medicare benefits for advanced cancer patients.MethodsThe decision tool, Choosing Health plans All Together (CHAT) was modified to select services for advanced cancer patients. Patients with a cancer history (N = 246) and their family members (N = 194) from North Carolina participated in 70 CHAT sessions. Variables including participants’ socio-demographic characteristics, health status, assessments of the exercise and results of group benefit selections were collected. Routine descriptive statistics summarized participant characteristics and Fisher’s exact test compared group differences. Qualitative analysis of group discussions were used to ascertain reasons for or against selecting benefits.ResultsPatients and family members (N = 440) participated in 70 CHAT exercises. Many groups opted for such services as palliative care, nursing facilities, and services not currently covered by the Medicare program. In choosing among four levels of cancer treatment coverage, no groups chose basic coverage, 27 groups (39%) selected intermediate coverage, 39 groups (56%) selected high coverage, and 4 groups (6%) chose the most comprehensive cancer coverage. Reasons for or against benefit selection included fairness, necessity, need for prioritizing, personal experience, attention to family needs, holistic health outlook, preference for comfort, freedom of choice, and beliefs about the proper role of government. Participants found the exercise very easy (59%) or fairly easy (39%) to understand and very informative (66%) or fairly informative (31%). The majority agreed that the CHAT exercise led to fair decisions about priorities for coverage by which they could abide.ConclusionsIt is possible to involve cancer patients and families in explicit discussions of their priorities for affordable advanced cancer care through the use of decision tools designed for this purpose. A key question is whether such a conversation is possible on a broader, national level.

Breakthrough Cancer Pain

Breakthrough pain is a relatively new concept, first coined by Portenoy and Hagen in 1990 [1], and anecdotal observation suggests that awareness of breakthrough pain as a distinct clinical entity remains relatively low [2]. Cancer pain is often variable, with a waxing and waning course throughout a day. For example, variations in activity level may be associated with exacerbations of pain that are somewhat predictable. On the other hand, sudden and significant changes in pain intensity may also occur spontaneously. While these are both examples of breakthrough pain, the strategy for addressing each scenario may be quite different. Breakthrough pain may also have variable pathophysiologic underpinnings, sometimes from a neuropathic process, while at other times from more nociceptive or mixed etiologies. Given the complexity and heterogeneity of breakthrough cancer pain (BtCP) as a distinct clinical entity, a separate chapter dedicated to its assessment and management is appropriate. BtCP can have a dramatic impact on the quality of a patient’s life, as well as key pain-related outcomes, and therefore warrants focused attention and expert management.

Polls and Policy: Signals or Substance

Costs of cancer care in the United States are projected to rise from

Early Stage HER2-Positive Breast Cancers Not Achieving a pCR From Neoadjuvant Trastuzumab- or Pertuzumab-Based Regimens Have an Immunosuppressive Phenotype

124.6 billion in 2010 to approximately

Title: Development and Refinement of a Learning Health Systems Training Program

174 billion in 2020, contributing to an emerging consensus that health care spending is on an unsustainable trajectory. With the annual cost of novel therapies often exceeding twice the US median household income of

Abstract P4-14-16: T-cell clonality increases after neoadjuvant treatment with trastuzumab and pertuzumab

50,000, access to quality care for individual patients is threatened. Costs of care can lead to financial distress and even bankruptcy. For the health system as a whole, health care spending consumes a growing proportion of federal and state budgets. Rising costs threaten the viability of public health insurance programs, including Medicare and Medicaid, as well as spending on other social priorities, including cancer research. Controlling costs while improving access to quality care and continuing to support innovation thus poses a critical challenge. In considering this problem, it is important to recognize that concerns over cost and access to health care are not new. These concerns were behind efforts at reform under Presidents Nixon in the 1970s and Clinton in the 1990s. Previous reform efforts have been subject to labels of socialized medicine and branded anti-American. Recent efforts to expand access and control costs under the Affordable Care Act have met the same discord and demagoguery. The US public has long endorsed the concept of health care reform, but it has been divided over the nature of reform and how it should be achieved. Writing in 1984 about the “schizophrenia” of the nation over health care costs, and summarizing multiple public opinion polls from that time, Blendon and Altman explained that although controlling costs was viewed as the number one health care priority for the nation, it was not viewed as a top national priority, compared with unemployment, government spending, defense, and other areas. Furthermore, they found that although Americans were deeply concerned with the rising costs of health care for themselves as individual patients, they were not particularly troubled by rising societal spending on health care, and some favored greater national spending on health. We hope to control costs along with improving access and quality; however, it is not clear that cost control can be achieved without facing hard choices. The proportion of the US gross domestic product spent on health care costs has been steadily rising since the enactment of Medicare in 1965. This rise has been driven by multiple factors, including the growth and development of new technologies, an aging population, increased use of tests and scans, and reimbursement policies for physicians, hospitals, and other providers that incentivize delivery of more services. Although many countries struggle with high costs of health care, the United States is somewhat unique in that we prohibit consideration of cost effectiveness in our public health insurance system. At its inception, Medicare was established with a statutory obligation to cover any care deemed reasonable and necessary, but precisely how this should be defined is the subject of ongoing political debate. In this context, Gogineni et al sought to understand current concerns over health care costs among physicians, patients with cancer, and members of the general public, with a focus on Medicare and potential methods to control Medicare spending. They achieved response rates consistent with expectations in similar populations (at roughly three quarters of eligible patients and 50% of selected oncologists and members of public). Some response bias must be considered when interpreting results, with 50% of patients and oncologists self-identifying as Democrats versus roughly one third identifying as Republicans. Approximately three quarters of respondents agreed that Medicare spending was a substantial national problem, and roughly two thirds thought Medicare spending could be reduced without harming health outcomes. The vast majority of each group felt that both pharmaceutical industry and private health insurance company behaviors contributed to high costs. Roughly 80% of the public and approximately 70% of patients and oncologists also believed that unnecessary treatments contributed to high costs. Not surprisingly, larger differences emerged over the question of excessive physician charges, with approximately 80% of the public, 67% of patients with cancer, and only 19% of oncologists viewing this as an important factor. These data highlight the extent to which multiple stakeholders are concerned about costs of care and suggest that there is consensus on potential to reduce unnecessary health care spending without restricting high-value care. Indeed, this is the premise behind the American Board of Internal Medicine Choosing Wisely campaign, through which the American Society of Clinical Oncology and other specialty organizations have identified practices that should be eliminated to lower costs with no adverse impact on quality (and, in some cases, improvement). The challenge of drawing firm policy conclusions from survey work becomes apparent when considering the question of Medicare adopting reference pricing for cancer drugs. Gogineni et al found that 75% of respondents agreed that Medicare should not pay for more expensive treatments when equally effective alternatives were available. They then argue that this indicates widespread support for reference pricing, in which reimbursement for an intervention is set at the rate of the lowest cost equivalent. One might question why 100% JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L VOLUME 33 NUMBER 8 MARCH 1