The Role of Palliative Care in Gynecologic Oncology | Fredric V. Price, MD
November is National Hospice and Palliative Care Awareness Month
Among the most important advances in our specialty in the last five years has been the recognition of palliative care as an integral part of the practice of gynecologic oncology.
The landmark 2010 article by Temel, et al. showed in a randomized trial that early consultation with palliative care specialists with standard oncologic care after the diagnosis of metastatic non-small cell lung cancer resulted in better patient outcomes. It might have been predicted that quality of life indices would be better, but few expected that survival was 25% longer in the palliative care group with statistical significance. The fact that patients lived longer in the palliative intervention group raises many questions about the indications for aggressive and futile treatment in patients near the end of life. Few would argue that an intervention with such a significant overall survival improvement does not represent better patient care.
Symptom management has always played an important role in the practice of gynecologic oncology. Our specialty has been at the forefront of managing complications of progressive disease and side effects of therapy. In the last several years, many gynecologic oncologists have begun to integrate principles of palliative care into more traditional disease-directed therapeutic programs for patients with life-limiting illnesses. Research in palliative care as it applies to gynecologic oncology has resulted in a better understanding of our responsibility to provide these alternatives to patients near the end of life.
Forty-seven members of the Society of Gynecologic Oncology have been certified through the American Board of Obstetrics and Gynecology using the grandfather pathway in lieu of a one-year fellowship. Applicants were required to document 800 hours of experience in end-of-life care and 100 hours of hospice experience. They were recommended by a hospice medical director, and passed a rigorous written test. The test covered materials not otherwise part of the gynecologic oncology curriculum, including approaches to the grieving family, the spiritual needs of the dying, and religious rituals surrounding death. Preparation for board certification was a rewarding opportunity to reevaluate our approaches to the most challenging problems we face as clinicians. It also engendered new respect for our colleagues from other specialties, who are full-time palliative care specialists.
The number of hospitals in the US with palliative care programs has increased by more than 100% in the last few years. Growth in hospital-based programs can be attributed to a new understanding that palliative care reduces outlay of expensive resources on patients for whom aggressive treatment may be futile. The goals of relieving suffering, improving quality of life for patients and families, and reducing health care expenditures have become aligned. Palliative care programs emphasize not only symptom management, but also work to establish realistic goals for patients with serious illnesses.
Gynecologic oncology has made unprecedented progress as a specialty in the last decade. Patients now benefit from minimally invasive and robotic surgery, a new understanding of the pathogenesis of ovarian cancer, new treatment modalities based on genomic medicine and anti-angiogenesis, and intraperitoneal chemotherapy. None is more important than the new emphasis on palliative care for patients with advanced gynecologic malignancies.