Dr Thomas LeBlanc: Patients With Blood Cancer and Palliative Care

Thomas LeBlanc, MD, of the Duke Cancer Institute, discusses the trends of hospice care services used among patients with blood cancer compared with patients with solid tumors.

Transcript

What has caused the differences in hospice use between patients with blood cancers and patients with solid tumors?

Patients who have advanced solid organ tumors, we often know by definition don’t have curable disease. Although that’s an awful and difficult situation, it does make some of the discussions and decision making a little easier and more clear, because you can focus on the risks and benefits of treatment around improving symptoms, quality of life, and longevity, but the possibility of cure isn’t something that’s usually on the table in that situation. In patients with blood cancers, even when they’re advanced or treatment refractory or have a poor prognosis in the long run, there are still often patients in any risk group with various diseases like acute leukemias, for example, who end up being cured, and sometimes that requires really aggressive intensive therapy like a stem cell transplant. So, that could be a treatment that leads to a person’s death and yet the hope and expectation was that that might cure them, and that very much could be goal concordant care. The right person that’s consistent with their goals, values and preferences.

So, the challenge there is we often don’t really know what to expect, and we are often doing difficult and more intensive things to these patients in the hope we will get a good outcome not knowing what the outcome is actually going to be. Another issue that probably reduces the frequency of blood cancer patients using hospice care services is that the clinicians who seeing and treating these patients, mostly hematologists, tend to have different perceptions about what we mean when we say palliative care. They tend to think of palliative care as being just what you do when you don’t have treatment options left and when a person is dying, and in the blood cancer space, we often don’t know that until the last hours or days, which again is very different than those with advanced solid organ tumors.

So, in 2017, when palliative care is really a specialty medical service that you can engage just like another consultant, say, an infectious disease specialist, and add it to specialized cancer care to improve patient symptom management, quality of life, distress, and things like that, many hematologists actaually don’t realize that’s what we’re talking about and think we’re talking about death and dying and hospice, specifically, which is a very particular thing related to insurance benefit and end of life care. But it’s different farther upstream specialty palliative care. So, that really plays into the issue as well.