(ChemotherapyAdvisor) – The main barriers to timely referral of patients with metastatic disease to specialized palliative care is lack of availability of that care for those on chemotherapy and referral late in the disease course for patients with uncontrolled symptoms, a study published in the Journal of Clinical Oncology online October 29 has found.

The World Health Organization has recognized that “palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy,” noted Camilla Zimmermann, MD, PhD, Princess Margaret Hospital, Toronto, Ontario, Canada, and colleagues. “However, despite these standards and recommendations, referral to specialized palliative care tends to occur late in the course of illness. Most patients are referred to palliative care services within 30 to 60 days of death, and many are referred in the last days of life,” she added.

The study surveyed Canadian oncologists to determine how and when patients were referred to specialized palliative care. Of the 72% of those who responded (603 of 839); 37% were medical oncologists/hematologists, 50% were radiation oncologists, and 12% were surgical oncologists. The majority (94%) reported specialized palliative care was available; however, “only 37% reported that these services accepted patients on chemotherapy.”

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Terminally ill patients were usually or always referred, 84% reported, “but generally for uncontrolled symptoms or discharge planning late in the disease course,” they found. One-third noted they would refer to specialized palliative care earlier “if it was renamed supportive care.”

Oncologists referred patients more frequently if comprehensive specialized palliative care services were available (P=0.004); they were satisfied with that availability (P<0.001); services accepted patients receiving chemotherapy (P<0.001); and they had “ease with referring patients to a palliative care service before they were close to death (P<0.001).”

“Our results demonstrate that oncologists prioritized uncontrolled physical symptoms when considering referral to specialized palliative care,” Dr. Zimmermann noted. “Indeed, oncologists were more likely to refer patients with a prognosis greater than 1 year and uncontrolled symptoms than symptom-free patients with a shorter prognosis. Potential difficulties with this referral pattern are that symptoms may remain unaddressed for longer, particularly if they are not actively screened for, and advance care planning and psychosocial needs may be neglected.”

They concluded that “…better availability of comprehensive, multidisciplinary palliative care services, with less restriction surrounding concurrent provision of treatments such as chemotherapy, would allow for better integration of specialized palliative care into routine oncology care.”