Post on 14-Feb-2019
transcript
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