A Multidisciplinary Approach to Palliative Care Improves Quality of Life in Cervical Cancer

Alexandra S. Bercow, MD

Alexandra S. Bercow, MD

While patients with early-stage cervical cancer may be able to experience cure of their disease and live long lives with no recurrence, patients with advanced-stage disease only have a 17% 5-year survival rate. However, the integration of palliative care into the multidisciplinary team for patients with advanced cervical cancer may help improve the quality of life, as well as symptom control.

The current treatment for advanced cervical cancer remains as chemoradiation. However, this therapy is associated with high morbidity, and patients often experience a high symptom profile. Because gynecologic oncologists have limited time with these patients due to the aggressive nature of the disease, they do not have enough time to manage every symptom in a patient. However, patients can be referred to a palliative care team to help alleviate some of the burden, as well as improve their symptoms.

Many studies have evaluated the role of palliative care in patients with ovarian cancer or endometrial cancer, but patients with cervical cancer are often unrepresented in these studies. These patients tend to have a much different profile than those with ovarian cancer, such as lower healthcare literacy and poorer access to healthcare in general. These patients tend to be younger and of a minority background, as well as lower socioeconomic status. Palliative care may play a bigger role in this patient population, especially during the end of life.

In an interview withTargeted Oncology, Alexandra S. Bercow, MD, Brigham and Women’s Hospital, Massachusetts General Hospital, discussed the results from a retrospective study, which evaluated the role of palliative care in women who died from cervical cancer between 2000 and 2017 at 2 institutions. She also highlighted the benefit of palliative care and why this patient population could benefit more than those with ovarian or endometrial cancers.

TARGETED ONCOLOGY: How does prognosis compare in patients with cervical cancer across different stages of the disease?

Bercow: Theprognosis for patients with cervical cancer varies widely across cervical cancer stages. Stage I patients have very good prognoses, and oftentimes, they experience cure of their disease with no recurrence. However, patients diagnosed with advanced disease, such as stage III or IV disease, carry a 5-year survival rate of only 17%.

TARGETED ONCOLOGY: What are options for patients with advanced disease now, and in what ways can we improve on this?

Bercow:The mainstay of treatment for advanced cervical cancer is chemoradiation. Unfortunately, chemoradiation carries high morbidity. It often leads to a high symptom profile and a low quality of life. There have been a lot of studies and a lot of people have talked about it at this conference, but there are different immunotherapies that may be improving the recurrence rate and remission rate for patients with advanced-stage cervical cancer. There are also a bunch of new drugs as well that people are looking at, such as the immune checkpoint inhibitors.

TARGETED ONCOLOGY: What was the rationale for evaluating palliative care in this patient population?

Bercow:There have been a lot of studies on palliative care within gynecologic malignancies, but there haven’t been robust studies looking at palliative care specifically for patients with cervical cancer. Often, it is either just looked at in ovarian cancer or endometrial cancer or gynecologic malignancies in general with a very low proportion of patients with cervical cancer. In addition to that, cervical cancer patients carry a vastly different profile than both ovarian and endometrial cancers. These patients are younger, often of a minority background, lower socioeconomic status, lower healthcare literacy, and therefore, have poorer access to healthcare. We hypothesized was that their uptake in palliative care may be different than their ovarian and endometrial counterparts given their vastly different needs at the end of life.

TARGETED ONCOLOGY: What were the methods of design?

Bercow:We did a retrospective study looking at patients who died from cervical cancer at our 2 institutions between 2000 and 2017. We looked through their charts to figure out whether they had been referred to palliative care or not, and then what type of palliative care consultation they had, in-patient versus out-patient.

TARGETED ONCOLOGY: What were the findings from this study?

Bercow:We found several things. The first is that in our 2 groups, patients who did get a palliative care consult and those who did not were slightly different in age. The women who were referred to palliative care were significantly younger with a median age of 49 compared to 57.5. There was a 47% palliative care referral rate, which is pretty low when you think about the fact that all of these women were women who had died of the disease and likely would have needed palliative care the most.

We also found there were more in-patient consultations than out-patient consultations. We found palliative care was significantly associated with a hospice referral and death in hospice. In addition, we found that the patients that did have a palliative care consult spent more time in hospice than those who did not have a palliative care consult. They spent 21 days in hospice compared to 12 days in hospice.

Lastly, we looked at measures of aggressive care that are recommended by the National Quality Forum. We found that palliative care consults were associated with fewer ICU admissions, fewer emergency department visits, shorter and less frequent hospitalizations, and a decreased rate of death in the acute care setting, so a decrease in the rate of death on the in-patient floor, the ICU, or the emergency department, as well as increased rate of code discussion with the primary providers within the last 30 days of life.

We also found that the 2 groups received the same amount of treatment at the end of life, the same amount of chemotherapy and radiation for the last 30 days of life, and the same amount of invasive procedures at the last 3 months of life. Importantly, that did not lead to increased time spent in the hospital. They still spent less time in the hospital, which we think is valuable to quality of life and overall end of life care.

TARGETED ONCOLOGY: What is the take home message?

Bercow: