Care Across the Cancer Continuum

Case Report

A42-year-old Caucasian woman with a diagnosis of stage IV breast cancer and a chief complaint of weight loss presented to her primary care provider (PCP). She had lost 7 kg since her last visit 2 months ago; she now weighs 56 kg with a body mass index of 19.3 kg/m². She is consuming 2000 kcal per day and supplementing meals with nutritional shakes after seeing a nutritionist. She reports significant stress at meal times when her husband repeatedly tells her to eat more when she is not hungry. She denies nausea, vomiting, constipation, diarrhea, fevers, or chills.

She follows closely with a local oncologist and has had disease progression on her last imaging 2 weeks ago despite multiple lines of chemotherapy. She is to begin whole brain radiation for central nervous system metastases and remains on enoxaparin for her lower extremity deep venous thrombosis that occurred 3 months ago.

She reports significant stress related to her daughter's school behavior and disrupted sleep pattern. She states, “Why would God take me before my daughter enters first grade? What am I supposed to do, tell her that I'm dying?”

She endorses cancer-associated pain in her right upper quadrant associated with known extensive metastatic liver disease. She continues to use long acting morphine 30 mg twice daily, but she has been requiring ∼5 breakthrough doses of immediate release morphine 15 mg per day for the past 2 weeks. She states that her oncologist told her at her last visit that she did not feel comfortable prescribing higher doses of opioids. She states that her husband “knows what she wants” should she no longer be able to make medical decisions for herself; she has not completed an advance directive, nor designated a medical power of attorney.

The next best step in her care would be to confer with her oncologist and:

A. begin megestrol acetate,

Discussion

Breast cancer is the most common cancer among American women (excluding skin cancers) and is the second leading cause of cancer death in women, surpassed only by lung cancer. Approximately 12% of women in the United States will develop invasive breast cancer during their lifetime. It is estimated that in 2015 more than 40,000 women died from the disease. ¹ PCP engagement in the care of women with breast cancer care is high for most women. However, many women report less primary care engagement than before their diagnosis despite reporting high-quality primary care. ² It is recommended that concurrent standard oncological care and PC should be considered early for patients with metastatic disease or high-symptom burden ³ as PC has been shown to improve quality of life and increases satisfaction with care in a variety of advanced malignancies. ⁴

PC is a growing multidisciplinary field focusing on the supportive care needs of patients with advanced, life-limiting illnesses. Beyond patients with advanced cancer, PC is now being engaged early in the care of patients with advanced heart, pulmonary, liver, and neurological diseases. PC physicians are board-certified subspecialists with expertise in advanced care planning, complex symptom management, communication, psychosocial, and spiritual support. PC teams are interdisciplinary, typically including physicians, social workers, and chaplains. These teams seek to address the physical, psychological, existential, and spiritual needs of a patient and their loved ones. PC teams aim to provide care that honors a patient's goals, preferences, and values. This care can be provided concurrently with any disease directed or curative treatments and does not replace any other care that a patient may be receiving.

PC can be provided in a variety of settings, including hospitals, outpatient clinics, and patients' homes; however, the availability of this full range of services can vary widely by location and healthcare system. PC must be distinguished from end-of-life or hospice care, which is a distinct subset of PC for patients who are terminally ill. This represents a paradigm shift from how the discipline was previously viewed. Indeed, it can be provided at any stage of a life-limiting illness and is increasingly incorporated at the time of identification of a disease process that cannot be cured.

PC consultations can decrease costs, improve quality of care and patient satisfaction, and are associated with increased survival in some cases. ^5,6 Although all providers require skills in symptom management and alignment of treatment plans with patient goals, PC consultations can benefit patients with refractory symptoms, existential distress, or complex medical decision making, highlighting the importance of primary versus specialty PC. ⁷ Innovative PC training is recommended for primary care clinicians caring for patients who will eventually die from specific diseases. In contrast, specialty PC would focus on education, research, and care of patients with complex or refractory suffering. ⁸ PCPs report a high level of comfort with advanced care planning discussions; however, low rates of completion have been shown. ⁹ PC consultations have been shown to facilitate advance care planning and, furthermore, in special populations, to hone an advance directive into a specialized preparedness plan. ¹⁰ In addition, early PC involvement has been shown to decrease depression and subjective burden of care in informal caregivers of patients with advanced cancer. ¹¹

Quality-of-life issues related to complex symptom management needs, psychosocial or existential distress, or the need for reassessment of medical treatment should precipitate referral to a PC specialist. Prognostic uncertainty should not serve as a barrier to referral, nor to maximal supportive care and aggressive symptom management. PCPs should familiarize themselves with PC services available in their area and consider incorporating such care for patients with advanced illness and multifaceted quality-of-life needs.

Our patient reported poor pain control, cancer-associated anorexia and cachexia, caregiver and existential distress, and concerns about communicating prognosis with her child. She also lacked documented advance care planning. At this time, specialty PC consultation will help address the complex, multifaceted care needs in the setting of incurable malignancy while the patient is pursuing disease-directed therapy.

Answer: B

Evidence supports early referral to PC for patients with advanced illness to assist with complex symptom management, advance care planning, and evaluation of psychosocial and existential distress.