Integrating oncology
and palliative care

Gaetano Lanzetta

Head of Medical Oncology, Casa di Cura INI Grottaferrata Division, Italy

“Several randomised trials have indicated that adding specialty palliative care to standard oncology treatment for patients with advanced cancer is associated with significant improvements in quality of life, symptom burden and end-of-life care and may also have a survival benefit. In addition, there is evidence to suggest that palliative care involvement at or near the time of cancer diagnosis in the outpatient setting is most beneficial,” explains Gaetano Lanzetta, who is Head of Medical Oncology at the Casa di Cura INI Grottaferrata Division, an ESMO Designated Centre of Integrated Oncology and Palliative Care since 2010 and reconfirmed in 2013 and 2016. At this private multidisciplinary institute of health, which is accredited by the Italian National Health Service, a highly qualified team of medical and paramedical staff provide oncology and palliative medicine services using a ‘fully embedded model’—weekly meetings between oncologists and the palliative care team are conducted to deliver accurate and careful professional support for patients and family members. Lanzetta continues, “From my experience at INI, systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of healthcare resources.” Patient-centred care should also be an integrated part of oncology care, independent of patient prognosis and treatment intention. “In our Institution, the integration of acute oncology and palliative care is an increasingly important aspect of our daily work.”

In recent times, integration of oncology and palliative care have progressed further. “It seems to me that oncologists are acquiring the skills and management strategies of palliative care physicians and palliative care physicians are, in turn, incorporating the perspective of the oncologist into their daily work,” Lanzetta continues, “These changes reflect the ESMO recommendation to include early palliative care during anticancer treatment.”

Integrated care allows palliative care physicians to actively participate with the oncologist in patient management and, when the patient is near the end of life, to take the lead in this management. “The oncologist continues to see the patient during the palliative phase to ensure that patients do not feel abandoned at this stage”, he explains. “Patient demand for improved integration is real and data suggest that patients with advanced cancer have palliative care needs that go unmet in around two-thirds of cases.”

“Lack of established priorities for achieving effective integration of oncology and palliative care still represent the biggest challenge.”

According to Lanzetta, other current barriers to integration include the common misconception, even among oncologists, that palliative care is end-of-life care only, stigmatisation of death and insufficient infrastructure and funding. “In Italy, both patients and clinicians lack sufficient training to emotionally manage the term ‘hospice’, and oncologists still find it difficult to talk about palliative care with patients who are not at the end of their lives,” he comments. “In my opinion, this barrier could be overcome with improved education, tools and better guidelines.”

Lanzetta is cautiously optimistic about the future of integrated care, but many aspects such as having optimal models to establish when and how palliative care should be delivered still need to be addressed. “It seems to me that we are improving management strategies to achieve good patient-centred care. However, there is still much to be done and successful integration must focus on a combined approach that places the patient's perspective at the centre. Changes in professional cultures and priorities in healthcare along with adequate resource allocation are thus required, and new care models, education and research programmes need to be developed and then adapted to meet specific local needs.”

The ESMO Designated Centre of Integrated Oncology and Palliative Care programme is helping to achieve these goals. “This programme is leading oncologists towards the use of standardised care pathways and multidisciplinary teams in order to promote the integration of oncology and palliative care. It calls for changes at the system level to coordinate the activities of professionals, and for the development of new and improved education programmes.”

Lanzetta has big plans for his centre. “Over the next few years, we are planning to improve our palliative care outpatient clinic, with the aim of delivering a more organised service of simultaneous care to our patients. Our main objective is to more effectively provide joint anticancer treatment and palliative care by developing education and research programmes that involve not only our Oncology and Palliative Care Unit but also our entire institution.”