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 Title

Integration of palliative care in the medical treatment of advanced malignancies for the benefit of patients and for increasing quality of medical care in various sanitary institutions -
Romanian-Swiss study

Principal investigators:

Oncology Instirute Prof. Dr. Ion Chiricuţă, Cluj Napoca
Cantonal Hospital St Gallen, Switzerland
Partners: participants individuals from Alba/Braşov/Bucureşti/Iaşi


According to the WHO definition of Palliative Care , PC interventions should start early in the course of illness, in conjunction with other therapies that are intended to prolong life. Therefore, in the care of advanced incurable cancer patients, there should not be a transition from oncology to palliative care but a continuous adaptation or change of goals (EAPC White Paper, ESMO DC Cerny N Ann Oncol 2005; ASCO Ferris JCO 2010?). Medical oncologist and other cancer-related health care professionals play a sentinel role in not only providing tumour directed treatment, but also in identifying and treating palliative care needs (ESMO/ASCO Curriculum Oncology) at basic and often advanced levels. For patients with complex multidimensional and acute needs, refractory to current management, additional specialist palliative care teams are clearly required, both for management and help to identify such patients and their caregivers. This integration of palliative care and oncology is closely linked with community care, including GP’s, home care nurses and others (EAPC community Pall Care @ www.eapcnet.org). In busy oncological clinics and more pronounced in resource restricted settings, this integration of palliative care procedures in daily practise however is challenging (Smith T JCO 2012). There are different models of professionals delivering Palliative Care interventions (Hui J Clin Oncol 2012; Teunissen S 2012). ASCO and ESMO included substantially Palliative Care in the curriculum for medical oncologists, but at the same time specialist palliative care is needed (Temel NEJM 2010, Smith J Clin Oncol 2012, Quill & Abernethy NEJM 2013). Models of integrated oncology and Palliative Care are developing, one important is the ESMO designated centers incentive program providing 13 criteria’s (Cerny Ann Oncol 2005). However this is linked to substantial institutional commitments, which might not be feasible in more resource restricted settings. Field data from eastern Europe countries is sentinel to move the field forward.
Integration of Oncology and Palliative Care in the Romanian context
In Romania, many aspects of oncological care are under rapid development, but there is a high variability on access to high level quality palliative care and substantial regional (rural/urban) disparities. Recent successes focus on access to pain medication (Mosiou Lancet 2006) and the perceived need of HCP for improvements in education and access is growing (Dumitrescu Croat Med J 2006).

The main challenges are the following:

● Systematic information about incurable cancer patients’ current symptom burden (Dumitrescu JPSM 2007) and other palliative care needs in Romania is scarce, but necessary to improve patient care and oncology specific and economic outcomes.

● Validated, and internationally “bench-markable” outcome instruments for palliative care interventions are rare in Romania, but necessary for good, sound research

● Models of integrated oncology and palliative care may need to be adapted for eastern Europe countries.
In the care of advanced incurable cancer patients medical oncologists and other cancer-related healthcare professionals play a sentinel role in not only providing tumour directed treatment, but also in identifying and treating palliative care needs. This work is closely linked with community care, including GP’s, home care nurses and others. In busy oncological clinics and more pronounced in resource restricted settings, the integration of palliative care procedures in daily practise however is challenging. Models of integrating oncology and palliative care are developing, but require local and national adaption of processes. The Swiss- Romanian partnership grant offers an opportunity to investigate this approach further.
In Romania, many aspects of oncological care are under rapid development, but the high variability on access to high quality palliative care and substantial regional (rural/urban) disparities demand a structured approach to improve patient care. In such settings of variable roles and competences in providing Palliative Care, the approach to investigate and subsequently improve integration of oncology and Palliative Care can’t rely on structures only and therefore mainly on definable processes.
The implementation of appropriate, patient needs based, so called Key Interventions of Palliative Cancer Care (KI-PCC: 1. Illness understanding and patient education, 2. Symptom screening/ management, 3. Decision making (i.e. about anticancer treatments), 4. Coping with a life- threatening illness/ end of life preparation, 5. Support network of patients and family members / care plan) could contribute substantially to quality of care and finally QoL of both patients and their family members. Consequently, outcome quality indicators may assist to indicate quality of care. In a further step tailored clinical practise tools and educate may integrate specific palliative care procedures into daily practise.

Aim: Our group aims to collect original data (“reality map”) about the implementation of defined KI-PCC and specific outcome quality indicators. The hypothesis is that both predefined cofactors and appropriately delivered KI-PCC will predict quality of individual patient’s care, measured as composite endpoint.

Objective: To prospectively measure, based on original data from advanced, incurable cancer patients from defined, various care settings, the patient perceived need for the 5 KI-PCC, their current appropriate implementation in routine care, and defined associated quality Indicators in those patients and family members.

Methods: A prospective, longitudinal, multicentre data collection in 5 institutions in Romania and 1 institution in Switzerland for 6 months or until death (depending what comes first) with validated tools for Palliative Care needs (such as symptoms [IPOS] and health related quality of life [EQ5D], patients (and/or family members) perceived KI-PCC, and defined outcome quality indicators, collected by a research assistant on randomly selected patients in at each institution predefined populations having advanced incurable cancer and defined minimal symptom burden.

Expected impact: The results will provide the basis for further research on implementation of tailored interventions of palliative care procedures provided by oncologists and other health care professionals.

Future steps: In the next phase of this joint research program, the research group amended by international experts will propose, on the basis of this data, tailored practice tools or other interventions for each institution and the expected effect of their implementation on outcomes such as patient reported outcomes, tumor control including anticancer treatment toxicities, and health service costs.