Cure simultanee in oncologia

Transcript

1 Cure simultanee in oncologia Vittorina Zagonel Dipartimento Oncologia Istituto Oncologico Veneto, IRCCS, Padova Regione del Veneto

2 The goal of care in oncology has changed Jordan K et al, Ann Oncol 2018;29:36-43.

3 Early integration of palliative care - EIPC - Several randomized controlled trials provided level I evidence that supports EIPC for patients with advanced stage/incurable cancer EIPC is associated with improved QoL, symptoms control, patient and cargiver satisfaction, best quality of end of life care, reduced depression, use more appropriate care settings, and in some case, improved survival*. WHO, ESMO, ASCO, EAPC, NCCN guidelines integrated EIPC as an essential goal to guarantee a comprehensive cancer care. *Ferrell BR et al.jco 2017, 35:

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5 Traditional versus early palliative care Kaasa S. et al. Lancet Oncology online 18 oct 2018

6 Conceptual model of palliative care delivery based on provider expertise Kaasa S. et al. Lancet Oncology online 18 oct 2018

7 Proposed model of optimal oncology palliative care provision Kaasa S. et al. Lancet Oncology online 18 oct 2018

8 The challenge: the silos must be connected Oncologist Palliative care team Primary Care Physician share the patient's care path

9 Tertiary palliative care on the basis of referral to palliative care clinic Kaasa S. et al. Lancet Oncology online 18 oct 2018

10 Open questions 1. How to define the timing of PC access? 2. How oncology & palliative-care teams can better integrate? What is recommended integration level? 3. How integration should be tailored to the characteristics of the health care systems, hospital setting, and local resource availability?

11 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.

12 Il modello ESMO di integrazione dal : 4 centers 2018: 40 centers Italy, the nation with the largest number of ESMO Designated Centers

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14 EARLY PALLIATIVE CARE: temporaneità (rispetto ai bisogni del paziente) della attivazione delle cure palliative, concomitanti alle terapie oncologiche attive. STUMENTI PER RILEVARE I BISOGNI SIMULTANEOUS CARE: modalità di erogazione delle cure palliative precoci (ambulatorio condiviso tra oncologo e team di cure palliativemodello integrato-). ORGANIZZAZIONE

15 Screening for EIPC for oncology outpatients 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 needs performed by oncologists at every consultation When unmet needs emerged, oncologist fill out the list to send the patient to the simultaneous care clinic

16 2 ambulatori/sett. per pazienti ambulatoriali; 2 breefing /sett. per pazienti ricoverati Performance Status Sintomi Prognosi Terapie con impatto sulla sopravvivenza Tossicità attesa dai trattamenti Problemi psico- socioassistenziali SCORE >10 visita entro 10 gg Tra 5-9 entro 1 mese Tra 0-4 entro 2 mesi

17 Ambulatorio Cure Simultanee Visita: oncologo e team di cure palliative 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

18 Electronic Medical Record First visit Diagnosis Therapeutic plan Prep. & admin of Rx Exams Actors and Services Oncologist Nurse Pharmacist Palliative care specialist Nutritionist Psychologist Setting Outpatient clinic Day Hospital / In-patient ward Outpatient clinic Communication to Primary Care Physician 18

19 Open questions 1. How to define the timing of access to PC? 2. How oncology & palliative-care teams can better integrate? What is recommended integration level? 3. How integration should be tailored to the characteristics of the health care systems, hospital setting, and local resource availability?

20 Integrazione: un lungo e complesso processo Processes (13) Clinical Structures (4) Research (4) AREAS OF INTEGRATION Education (8) Administration (9) Hui D & Bruera E, Nat Rev Clin Oncol 2016;13:

21 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

22 Three levels of integration Kaasa S. et al. Lancet Oncology online 18 oct 2018

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24 Regione del Veneto

25 Cure palliative precoci e simultanee Regione del Veneto DGR 553/2018

26 Regione del Veneto DGR 553/2018

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28 Percorsi Diagnostici Terapeutici ed Assistenziali Vescica Testa-Collo Rene Tumori Neuroendocrini Melanoma Sarcomi Esofago Mammella Tumori ereditari Stomaco Polmone SNC Prostata Colon-retto Ovaio Testicolo Metastasi scheletriche Fegato Tumori endocrini Pancreas

29 I nodi strategici Ambulatori condivisi di cure simultanee Procedura condivisa per l accesso agli ambulatori integrati Condividere test validati per il rilievi sistematico dei sintomi/prognosi Condividere 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

30 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).

31 STRUCTURE (3) PROCESS (3) OUTCOME (3) EDUCATION (4) 1. Presence of Palliative Care (PC) inpatient consultation team 2. Presence of PC outpatient clinic 3. Presence of interdisciplinary PC team 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 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 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

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33 OUTCOME PROCESS STRUCTURE Indicators of Integration at ESMO-DCs:results EDUCATION

34 Palliative Care Oncology Integration Index (PCOI) Median PCOI-13 index:7.8 A higher PCOI-13 index was significantly associated with presence of dually trained palliative oncologists (median 8.4 vs 7.0;p=0.01)

35 OUTCOME PROCESS STRUCTURE Livelli di integrazione: ESMO vs ITALIA EDUCATION G. Lanzetta, G. Farina, V. Franciosi, V. Zagonel. Poster AIOM 2017, SLBA2620