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Posts Tagged ‘treatment decisions’


Palliative Care

Writer and Curator: Larry H. Bernstein, MD., FCAP

http://www.caregiverslibrary.org/caregivers-resources/grp-end-of-life-issues/hsgrp-hospice/hospice-vs-palliative-care-article.aspx

The differences between hospice and palliative care.

Hospice care and palliative care are very similar when it comes to the most important issue for dying people: care. Most people have heard of hospice care and have a general idea of what services hospice provides. What they don’t know or what may become confusing is that hospice provides “palliative care,” and that palliative care is both a method of administering “comfort” care and increasingly, an administered system of palliative care offered most prevalently by hospitals. As an adjunct or supplement to some of the more “traditional” care options, both hospice and palliative care protocols call for patients to receive a combined approach where medications, day-to-day care, equipment, bereavement counseling, and symptom treatment are administered through a single program. Where palliative care programs and hospice care programs differ greatly is in the care location, timing, payment, and eligibility for services.
Hospice

Hospice programs far outnumber palliative care programs. Generally, once enrolled through a referral from the primary care physician, a patient’s hospice care program, which is overseen by a team of hospice professionals, is administered in the home. Hospice often relies upon the family caregiver, as well as a visiting hospice nurse. While hospice can provide round-the-clock care in a nursing home, a specially equipped hospice facility, or, on occasion, in a hospital, this is not the norm.

Palliative Care

Palliative care teams are made up of doctors, nurses, and other professional medical caregivers, often at the facility where a patient will first receive treatment. These individuals will administer or oversee most of the ongoing comfort-care patients receive. While palliative care can be administered in the home, it is most common to receive palliative care in an institution such as a hospital, extended care facility, or nursing home that is associated with a palliative care team.

Hospice

You must generally be considered to be terminal or within six months of death to be eligible for most hospice programs or to receive hospice benefits from your insurance.

Palliative Care

There are no time restrictions. Palliative care can be received by patients at any time, at any stage of illness whether it be terminal or not.

Hospice

Before considering hospice, it is important to check on policy limits for payment. While hospice can be considered an all-inclusive treatment in terms of payment (hospice programs cover almost all expenses) insurance coverage for hospice can vary. Some hospice programs offer subsidized care for the economically disadvantaged, or for patients not covered under their own insurance. Many hospice programs are covered under Medicare.

Palliative Care

Since this service will generally be administered through your hospital or regular medical provider, it is likely that it is covered by your regular medical insurance. It is important to note, however, that each item will be billed separately, just as they are with regular hospital and doctor visits. If you receive outpatient palliative care, prescriptions will be billed separately and are only covered as provided by your regular insurance. In-patient care however, often does cover prescription charges. For more details, check with your insurance company, doctor, or hospital administration.

Hospice

Most programs concentrate on comfort rather than aggressive disease abatement. By electing to forego extensive life-prolonging treatment, hospice patients can concentrate on getting the most out of the time they have left, without some of the negative side-effects that life prolonging treatments can have. Most hospice patients can achieve a level of comfort that allows them to concentrate on the emotional and practical issues of dying.

Palliative Care

Since there are no time limits on when you can receive palliative care, it acts to fill the gap for patients who want and need comfort at any stage of any disease, whether terminal or chronic. In a palliative care program, there is no expectation that life-prolonging therapies will be avoided.

It is important to note, however, that there will be exceptions to the general precepts outlined. There are some hospice programs that will provide life-prolonging treatments, and there are some palliative care programs that concentrate mostly on end-of-life care. Consult your physician or care-administrator for the best service for you.

Reprinted from “Hospice vs. Palliative Care,” by Ann Villet-Lagomarsino. Educational Broadcasting Corporation/Public Affairs Television, Inc. Reprinted with permission.

http://www.webmd.com/palliative-care/palliative-care-mr

For the last thirty years, palliative care has been provided by hospice programs for dying Americans. Currently these programs serve more than 1 million patients and their families each year.

Now this very same approach to care is being used by other health care providers, including teams in hospitals, nursing facilities and home health agencies in combination with other medical treatments to help people who are seriously ill.

To palliate means to make comfortable by treating a person’s symptoms from an illness. Hospice and palliative care both focus on helping a person be comfortable by addressing issues causing physical or emotional pain, or suffering. Hospice and other palliative care providers have teams of people working together to provide care. The goals of palliative care are to improve the quality of a seriously ill person’s life and to support that person and their family during and after treatment.

Hospice focuses on relieving symptoms and supporting patients with a life expectancy of months not years, and their families. However, palliative care may be given at any time during a patient’s illness, from diagnosis on. Most hospices have a set of defined services, team members and rules and regulations. Some hospices provide palliative care as a separate program or service, which can be very confusing to patients and families. The list of questions below provides answers to common questions about the difference between hospice and palliative care.

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000536.htm

The goal of palliative care is to help patients with serious illnesses feel better. It prevents or treats symptoms and side effects of disease and treatment. Palliative care also treats emotional, social, practical, and spiritual problems that illnesses can bring up. When patients feel better in these areas, they have an improved quality of life.

Palliative care can be given at the same time as treatments meant to cure or treat the disease. You may get palliative care when the illness is diagnosed, throughout treatment, during follow-up, and at the end of life.

Who gives palliative care?

Any health care provider can give palliative care. But some providers specialize in it. Palliative care may be given by:

  • A team of doctors
  • Nurses
  • Registered dietitians
  • Social workers
  • Psychologists
  • Massage therapists
  • Chaplains

Palliative care may be offered by hospitals, home care agencies, cancer centers, and long term care facilities. Your doctor or hospital can give you the names of palliative care specialists near you.

A serious illness affects more than just the body. It touches all areas of a person’s life, as well as that person’s family members’ lives. Palliative care can address these effects of a person’s illness.

Physical problems. Symptoms or side effects include:

Treatments may include:

  • Medicine
  • Nutritional guidance
  • Physical therapy
  • Occupational therapy
  • Integrative therapies

Emotional, social, and coping problems. Patients and their families face stress during illness that can lead to fear, anxiety, hopelessness, or depression. Family members may take on care giving, even if they also have jobs and other duties.

Treatments may include:

  • Counseling
  • Support groups
  • Family meetings
  • Referrals to mental health providers

Practical problems. Some of the problems brought on by illness are practical, such as money- or job-related problems, insurance questions, and legal issues. A palliative care team may:

  • Explain complex medical forms or help families understand treatment choices
  • Provide or refer families to financial counseling
  • Help connect you to resources for transportation or housing

Spiritual issues. When people are challenged by illness, they may look for meaning or question their faith. A palliative care team may help patients and families explore their beliefs and values so they can move toward acceptance and peace.

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Use of Subtyping for Presurgical Breast Cancer Treatment Use

Reporter, Reblog: Larry H Bernstein, MD, FCAP

 

 

More Accurate Identification of Molecular Subgroups May Better Guide Neo-adjuvant Treatment of Breast Cancer

By Susan Reckling
Posted: 8/19/2014 12:43:52 PM
Last Updated: 8/19/2014 12:43:52 PM

Key Points:
  • Although accurate classification of breast tumors by molecular subtype may guide the appropriate selection of therapy, conventional assessment methods lack standardization.
  • In the Neoadjuvant Breast Registry Symphony Trial of more than 400 women with breast cancer, standard assessment methods were compared with a novel 80-gene classifier known as BluePrint in combination with MammaPrint.
  • BluePrint molecular subtyping reclassified nearly one-fourth of tumors, with more responsive patients reassigned to the HER2 and basal categories and less responsive patients reassigned to the luminal category.

BluePrint in combination with MammaPrint molecular subtyping reclassified more than 20% of breast cancer patients into a different subgroup compared with conventional assessment, according to the results of the prospective Neoadjuvant Breast Registry Symphony Trial (NBRST). In Annals of Surgical Oncology, Whitworth et al reported that this reclassification of patients led to an improved distribution of response rates and a more accurate picture of which patients were likely to respond (or not respond) to neoadjuvant chemotherapy for breast cancer.

Selection of the appropriate therapy for a woman with breast cancer can be guided by accurate classification of the tumor by molecular subtype. Currently, however, conventional assessment methods such as immunohistochemistry and fluorescence in situ hybridization (FISH) lack standardization and the interpretation of test results differs among laboratories.

Thus, investigators have turned to other potentially more effective approaches to molecular subtyping. BluePrint, a novel molecular profile, is a multigene classifier, determining the mRNA levels of 80 genes. In combination with MammaPrint (risk stratification by multigene assays), BluePrint can classify patients with breast cancer into three subtypes based on functional molecular pathways: luminal (A or B), HER2, and basal.

Study Details

In the NBRST study, the investigators attempted to predict chemosensitivity in women with histologically proven breast cancer with the 80-gene BluePrint functional subtype profile vs conventional subtyping. Chemosensitivity was defined as pathologic complete response or the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resected specimen.

More than 400 women with breast cancer who had started or were scheduled to start neoadjuvant chemotherapy or hormone therapy took part in the multicenter NBRST study. All of them had definitive surgical resection. The age of study participants ranged from 22 to 80 years, with a median age of 52 years. Most of the patients (85%) had T2 or T3 tumors.

Patients who had undergone an excisional biopsy or axillary dissection or who had confirmed distant metastases were excluded from the study. Also, those who had received prior chemotherapy, radiotherapy, or endocrine therapy for breast cancer were ineligible for study participation.

Microarray analysis for the 80-gene BluePrint subtype and the 70-gene MammaPrint profiles was conducted at Agendia Laboratory, which was blinded to both clinical and pathologic data. BluePrint and MammaPrint analysis categorized the study patients as follows: 59 (14%) were luminal A, 153 (36%) were luminal B, 74 (17%) were HER2, and 140 (33%) were basal.

Reclassification to Different Molecular Subgroup

In total, 22% (94 of 426 patients) were reclassified in a different BluePrint/MammaPrint molecular subgroup compared with conventional subtyping. For instance, 37 of 211 patients (18%) of conventionally determined hormone receptor–positive/HER2-negative patients were reassigned by BluePrint as basal (35) or HER2-positive (2). In addition, 53 of 123 conventionally determined HER2-positive patients (43%) were reclassified as luminal (36) or basal (17).

As for response rates to neoadjuvant chemotherapy, the investigators reported an overall pathologic complete response rate of 25% (99 of 403 patients). Six percent of patients with luminal breast tumors had a pathologic complete response rate (2% for luminal A, 7% for luminal B).

More than half of the 74 patients with BluePrint-determined HER2-positive tumors had a pathologic complete response, which the investigators noted was significantly superior (P = .047) to the 38% of conventionally assigned HER2-positive patients.

Clinical Implications

Use of the multigene classifier BluePrint may assist oncologists in accurately identifying which patients with breast cancer may benefit from neoadjuvant chemotherapy and which ones are less likely to do so. According to the investigators, there are potential clinical implications for two particular groups of reassigned patients via BluePrint molecular subtyping: (1) those who were conventionally assigned as HER2-positive but not classified as such by BluePrint, and (2) those who were considered to have hormone receptor–positive/HER2-negative disease via conventional assessment but were reclassified to basal disease by BluePrint.

“This reclassification of patients leads to an improved distribution of response rates in the different subgroups of patients: a lower pathologic complete response rate for BluePrint luminal patients compared with [immumohistochemistry]/FISH-defined conventional luminal patients, with more responsive patients reassigned to the HER2 and basal categories,” concluded the investigators.

Pat Whitworth, MD, of the Department of Surgery, Nashville Breast Center, Nashville, Tennessee, is the corresponding author of the article in Annals of Surgical Oncology.

Lisette Stork-Sloots, MSc, and Femke A. de Snoo, MD, PhD, are employees of Agendia NV, Amsterdam, The Netherlands. The other authors disclosed no potential conflicts of interest.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.

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