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  Volume 95
Numero 6
novembre-dicembre 2009 		I documenti sono in formato PDF, consultabili utilizzando Acrobat Reader
 
The medical oncologist’s role in palliative care: AIOM’s position

Vittorina Zagonel, Luigi Cavanna, Gianluigi Cetto, Marco Ciaparrone, Cristiana Di Rocco, Vittorio Franciosi, Marco Maltoni, Paolo Marchetti, Andrea Martoni, Cataldo Mastromauro, Marta Mazzoli, Cecilia Moro, Carmine Pinto, Giampiero Porzio, Leonardo Trentin, Francesco Boccardo

1UOC Oncologia, Ospedale SG Calibita, Rome; 2UOC Oncologia Medica, AO Civile, Piacenza;
3Divisione Clinicizzata Oncologia Medica, Policlinico GB Rossi, Verona; 4UOC Oncologia, IDI, IRCCS, Rome; 5UOC Oncologia Medica, AO Universitaria, Parma; 6UOC Oncologia, AO Morgagni-Pierantoni, Forlì; 7UOC Oncologia, AO S. Orsola Malpighi, Bologna; 8UOC Oncologia,
Ospedale SS. Giovanni e Paolo, Venice; 9DH Oncologia, Policlinico Umberto I, Rome;
10UOC Oncologia, Ospedali Riuniti, Bergamo; 11UOC Oncologia Medica, Ospedale S. Salvatore, L’Aquila; 12Terapia del dolore e cure palliative, Dip Oncologia, ULSS6, Vicenza; 13AIOM’s President. *Coordinator

Key words: medical oncologist’s training, palliative care in oncology, simultaneous care.


Progress made in the treatment and better management of cancer patients has significantly improved overall survival, with 75% of the patients alive 5 years after the first diagnosis and 50% over a follow-up of 10 years. Therefore, cancer often becomes a chronic illness with a deep impact on the quality of life of the patients and their families. In fact, taking care of patients with cancer means not only to offer them the best therapeutic options but also to understand and anticipate their physical, functional, psychological, social and spiritual needs throughout the course of the disease. The quality of life of a cancer patient, thought of as the fundamental end point to achieve at every step of the disease, recognizes in supportive palliative care and rehabilitation the most important aspects.
AIOM recently established a task force “Palliative care in oncology”, with three main targets:
1) to assure medical oncologist’ humane and professional growth in the context of palliative care;
2) to focus on the quality of life of all cancer patients admitted to oncology units and oncology departments;
3) to suggest operative solutions in order to assure to all cancer patients the best palliative support.

AIOM believes that the mission of medical oncology should follow the “nonabandonment” culture, guaranteeing quality of life and continuity of care to all cancer patients at every step of the disease, always considering the patient instead of the disease as the most important target.
According to ASCO1-3, ESMO3-5 and AIOM’s previous document6, AIOM has defined its position about palliative care in oncology with regard to the Italian Health Organization and scientific knowledge.

Clarifications
As the definition and the distinction between supportive, palliative and end-of-life care are still lacking, AIOM wants to specify the meaning of these terms, identifying the real and the distinct needs of cancer patients as well as the oncologist’s required skills.
Supportive care includes the prevention and treatment of the adverse effects of anticancer therapies in addition to the complications of cancer. Symptom control and therefore quality-of-life are the end points of supportive care, when the main outcome is patient survival.
Palliative care concerns the prevention, identification, assessment and treatment of physical, functional, psychological, social and spiritual needs of cancer patients in the setting of advanced-terminal disease, when the aim can no longer be patient survival but is represented by the quality of life of the patient and his/her family. Hence, end-of-life care is included in palliative care7. Therefore, supportive, palliative and end-of-life care represent a “continuum” towards the course of the disease for all cancer patients (Figure 1).





Training of the medical oncologist
The training of a medical oncologist should include the assessment and treatment of symptoms, throughout the evolution of the disease, and supportive care during the antineoplastic treatment. AIOM supports the inclusion of specific palliative care training in Medical School as well as in Oncology Postgraduate School. According to AIOM, acknowledgement by the National Health Service of “palliative care” as a subject matter is considered necessary in order to regulate leadership in palliative care organization.
In accord with ESO8, AIOM recognizes two levels in palliative care: a basic one for all medical oncologists and an advanced one for physicians working in palliative care areas for advanced-terminal disease. The training of a medical oncologist should include the organizational ability of coordination and integration with other physicians to define a unique supportive plan, which is shared and defined according to patient needs.
Before such specific professional training becomes effective, AIOM will support and promote a training stage and practical courses held at Italian centers certified by ESMO (as centers for integration of oncology and palliative therapies), towards a specific task force of palliative care in oncology, in order to support the acquisition of skills by medical oncologists. Furthermore, AIOM will define relationships with Italian and international scientific associations to support attendance by medical oncologists in the palliative care stage, also in foreign centers. AIOM will guarantee an adequate and updated presence of palliative care and rehabilitation in national congresses, conferences and interregional meetings.

The role of the medical oncologist
The medical oncologist has to guarantee the best quality of life to the patient and constant and continuous care at every moment of the illness, in addition to the anticancer medical treatment9. The medical oncologist should consider prevention and treatment of symptoms of the disease, as well as evaluating response to anticancer therapy. Assessment of symptoms with validated instruments is necessary during every visit regardless of disease stage or anticancer treatment. Symptoms and therapy should be easily found in the medical chart. The medical oncologist has to be able to prevent and treat symptoms regardless of their nature or current treatments. The medical oncologist should be able to establish an effective communication and a care’s relationship with the patient, giving correct and clear information during all steps of the disease. Moreover, the medical oncologist should be able to discuss the prognosis with the patient, anticipating such information in the early stages of the disease and assuring the patient’s understanding to actually share in treatment decisions10-15.
The medical oncologist should be able to recognize psychological, rehabilitative, spiritual and social needs of patients and their families. Furthermore, the medical oncologist has to guarantee that intervention by such specialists is timely in all phases of the disease in order to resolve every symptoms.
The medical oncologist has to assure optimum supportive care and the best palliative care for the patients enrolled in clinical trials on new drugs and new anticancer treatments, with the assessment of patient symptoms and quality of life. The medical oncologist has to be able to coordinate the treatment in all phases of the disease, finding the solutions which best fit all a patient’s needs. The medical oncologist has to be able to manage the end of life, from a humane and professional point of view, including the guidelines for palliative sedation.

The role of a medical oncology unit
Medical oncology units need to include symptom assessment and treatment in daily clinical practice. Continuous care and the “non-abandonment” approach need to be included in the culture and in the activities of all oncology units. A medical oncology unit needs to define palliation processes and guidelines of the main symptoms, i.e., pain, dyspnea, bowel occlusion, palliative sedation. Assessment and treatment of symptoms have to be specified in medical charts as part of a patient’s file. According to the World Health Organization, pain assessment needs to be considered as a vital sign and consequently reported daily on a patient’s medical chart.
AIOM supports the development of clinical trials on palliative treatment and considers them as important as anticancer drug studies.
Medical oncology units should include specialists able to support psychological, spiritual and social needs of patients and families. Each oncology unit should include at least one physician with specific palliative care training or an expert consultant.
The nurses of medical oncology units should consider symptom assessment and care of priority in daily practice. Medical oncology units need to plan training and updated courses on symptom assessment and care for nurses.
Medical oncology units have to be able to look after every disease stage and, in case they cannot, they have to define shared continuity of care programs to assure rehabilitation and palliative care to all patients affected by cancer.
According to AIOM, cancer patient care should include optimal palliative and continuous care up to advanced-terminal disease stage by medical oncology units or through predefined agreements. If palliative care is supplied by a different unit, i.e., a palliative care unit, hospice, home care unit, integrated home care service, or non-profit organization, oncology units should establish close relationships with them, sharing guidelines and assuring continuous care and medical advice or admission to hospital, if necessary.

Organization
AIOM identifies ESMO’s integration model as the best one for the needs of cancer patients, in particular in anticipating them13,15. Simultaneous care optimizes quality of life throughout the course of an illness and guarantees flexible patient/disease management and appropriate objectives in each clinical situation13.
The experience of Italian centers certified by ESMO has shown that to realize simultaneous care is feasible in different Italian regions and hospital agencies. In order to realize this model, each oncology unit should have admission beds available for critical decisional-making in the management of cancer patient. Moreover, it would be useful if each oncology unit would specify a physician for clinical management, training and research on palliative care.
Furthermore, AIOM outlines the importance of ad hoc instruments (pain intensity, distress, multiparametric tests of quality of life) for early control of pain and other symptoms during anticancer treatment and of prognosis indicators (PaP score) in an advanced stage.
Timing and organization of oncology units need to be reevaluated to guarantee adequate time for each patient.
AIOM believes that an oncology department could be the most consistent model to realize simultaneous care and to assure continuity of care in advanced disease. Otherwise, oncology units have to create the necessary relationships at an interdepartmental level with other hospitals and/or with territorial structures (regional oncologic network).
Palliative care management in advanced-terminal disease could be realized through close collaboration between the oncology unit and the palliative care unit of an oncology department (if it does not provide its own resources). According to ESMO, a simultaneous care of all persons affected by cancer assures complete care through a “flexible primary care coordination”, defined on the basis of disease stage and organization of each hospital.
Nevertheless, the duty of the medical oncologist is to guarantee continuity and end-of-life care of all persons affected by cancer in qualified structures whenever needed.

References
 1. ASCO Special article. Cancer care during the last phase of life. J Clin Oncol, 16: 1986-1996, 1998.
 2. Ferris FD, Bruera E, Cherny N, Cummings C, Currow D, Dudgeon D, Janjan N, Strasser F, von Gunten CF, Von Roenn JH: Palliative cancer care a decade later: accomplishments, the need, next steps – from the American Society of Clinical Oncology. J Clin Oncol, Ahead of Print on May 18, 2009 as 10.1200/JCO.2008.20.1558.
 3. ESMO/ASCO Task Force: Recommendations for global core curriculum in medical oncology. Ann Oncol, 15: 1603-1612, 2004.
 4. Cherny NI, Catane R, Kosmidis P, and Members of the ESMO Taskforce on Supportive and Palliative Care: ESMO takes a stand on supportive and palliative care. Editorial. Ann Oncol, 14: 1335-1337, 2003.
 5. Baselga J, Mellsted H, Kerr D on behalf of ESMO: ESMO’s new strategic plan: our society’s road to the future of oncology. Ann Oncol, 20: 3-4, 2009.
 6. AIOM: Il ruolo dell’oncologo medico nelle cure palliative. In: il ruolo dell’oncologia medica in Italia. Workshop AIOM. Castel Gandolfo 9-10 luglio 2005.
 7. World Health Organization. Avocilabile at: http.www.who.org (accessed March 2009).
 8. Ahmedzai SH, Costa A, Blengini C, Bosch A, Sanz-Ortiz J, Ventafridda V, Verhagen SC; international working group convened by the European School of Oncology: A new international framework for palliative care. Eur J Cancer, 40: 2192-2200, 2004.
 9. Maltoni M, Amadori D: Palliative medicine and medical oncology. Ann Oncol, 12: 443-450, 2001.
10. Martoni AA, Tanneberger S, Mutri V: Cancer chemotherapy near the end of life: the time has come to set guidelines for its appropriate use. Tumori, 93: 417-422, 2007.
11. Back AL, Arnold RM, Tulsky JA: Discussing prognosis. 44th Annual Meeting, Chicago, 2008. ASCO Educational Book, pp 135-138, 2008.
12. Catania C, Zagonel V, on behalf of Italian Society of Medical Oncology (AIOM) Working group: “Humanization and organization”, “care and self care”, “good as a mirror of the self”. J Cancer Education, 24: 80-82, 2009.
13. Maltoni M: Opioids, pain and fear. Editorial. Ann Oncol, 19: 5-7, 2008.
14. Catania C, Zagonel V, Fosser V, La Verde N, Bertetto O, Iacono C, Venturini M, Radice D, Adamoli L, Boccardo F: Opinions concerning euthanasia, life-sustaining treatment and acceleration of death: results of an Italian Association of Medical Oncology (AIOM) survey. Ann Oncol, 19: 1947-1954, 2008.
15. 2008 Erice group. The 2008 Erice Statement toward a more Humanistic Oncology. J Ambulatory Care Manage. 32: 252-258, 2009.



 
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