By Matti Aapro
Supportive care and palliative care: two terms that I often use when talking about cancer care. Without consulting the dictionary one might say that palliation means alleviation, or decrease, while supportive means sustaining. Apparently contradictory terms? Really? Come on, be creative and follow me. It is time for us to stop placing these concepts in opposition to each other.
Many have, for too long, tried to divide medical care into isolated compartments. The present politically correct world says that one should have a “holistic” and “multidisciplinary” approach. What is your opinion? Mine is that good medicine has always been about taking care of the patient, in all the areas where help is needed. In some fortunate countries there has been a multitude of possibilities for this, without exclusivity. But in these same countries some medical practitioners are happy to isolate themselves in their specialty, excellent in their micro-environment but forgetting that the patient is not simply a disease, but a human being.
So what is the difference between the two aspects of patient care I mention? Where in cancer care does “support” end and “palliation” begin?
This topic has been an area of debate for a long time, but one has to realize that there is a continuum in patient care and that it is unacceptable to stay in an ivory tower. Even if historical reasons have led to the development of separate specialist groups that have dedicated their expertise more towards issues frequent at the end of life (often called palliative care), or more towards issues around treatment management and post-treatment issues (often called supportive care), this is not a reason to continue looking at each other with diffidence, like chiens de faïence, as we would say in French (like disdainful China dogs). According to the Multinational Association for Supportive Care in Cancer (MASCC), of which I had the honour of being president a few years ago, supportive care includes management of physical and psychological symptoms and side effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care.
Annals of Oncology is the official journal of The European Society for Medical Oncology (ESMO) which has also recognized the importance of these approaches for a long time and encourages the development of integrated centers of excellence. So, if ESMO supports this concept, why is it not more widely embraced? What are we waiting for?
The word used to designate these activities is not trivial. Obviously translations in various languages and cultures renders the discussion even more complex, but for several years there has been a negative perception of palliation. Many have felt that palliation is synonymous with patient abandonment by the “active” treatment team. Thus simply a name change from palliative unit to supportive care unit has been reported to be associated with more inpatient referrals and earlier referrals in the outpatient setting.
There has been much recent interest in palliative care as a means to support patients and have an impact on survival, an interest sparked by the publication of a study evaluating patients with advanced non small-cell lung cancer, which reported that early palliative care in these patients improves quality of life, mood, and survival despite less aggressive end-of-life care compared with standard oncology care alone. The American Society of Clinical Oncology (ASCO) panel’s expert consensus on this matter concluded not long ago that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.
In the end, but not just in the end, it is patient care that is important.
Dr. Matti Aapro is Dean of the Multidisciplinary Oncology Institute, Genolier, Switzerland. He serves as Executive Director of the International Society for Geriatric Oncology (SIOG). Dr. Aapro is Editor-in-Chief of Critical Reviews in Oncology/Hematology, Associate Editor of Annals of Oncology and founding editor of the Journal of Geriatric Oncology. Dr. Aapro’s recent editorial, Supportive care and palliative care: a time for unity in diversity has been made freely available for a limited time by the Annals of Oncology Journal.
Annals of Oncology is devoted to the rapid publication of editorials, reviews, original articles and letters related to oncology, particularly medical oncology. Annals of Oncology is the official journal of the European Society for Medical Oncology. Since 2008 the Journal is also affiliated with the Japanese Society of Medical Oncology.
Image credit: Doctor with senior female patient discussing treatment. Photo by monkeybusinessimages, iStockphoto.