Presentations

Abstract

Introduction:

Advanced head and neck cancer (HNC) is associated with high levels of physical, mental, emotional, and financial hardship on patients and caregivers. Advanced HNC is also associated with high healthcare utilization. These factors indicate poor quality of life and inadequate end-of-life care for patients. Palliative care (PC) is interdisciplinary care aiming to improve quality of life for patients with serious illness, and their families. Early palliative care is encouraged by international agencies such as the WHO, stating explicitly that "palliative care is applicable early in the source of illness, in conjunction with other therapies that are intended to prolong life." Involvement of palliative care offers many benefits to HNC patients by decreasing levels of patient and family distress, improving perceptions of care, and lowering rates of ICU readmissions. At EVMS, there are no current set guidelines for palliative care consultation in the HNC patient population. While patients are admitted, PC is often engaged for complex symptom management, discussion of goals of care, pain management, and for family/patient support. In an ambulatory setting, patients are noted to likely benefit from PC care, but do not always receive PC evaluation. There is additionally no set timeline for PC referrals (i.e. at initial diagnosis, after HNTB discussion, or in ICU with an end-stage diagnosis).

Our aim is to characterize the utilization of palliative care services in our practice with the intent of developing "triggers" to automate PC consultation in advanced HNC patients.

Methods:

After IRB approval, a retrospective chart review was conducted on patients presented to the EVMS multidisciplinary Head and Neck tumor board between 2021 to 2023 who received recommendations for palliative treatment. Adults ages 18-99 years old were included. Data regarding patient demographics, oncologic staging, surgical interventions, pathology findings, ED evaluations, ICU admissions, and reasons for palliative care consultation was obtained.

Results:

115 patient charts were reviewed. The average age of HNC patients was 69.4 years. The average length of time between initial tumor board evaluation and PC consult was 62.5 days. Despite tumor board recommendation for palliative care consultation, only 60.9% of patients received a palliative care consult and approximately 39.1% of patients did not. Palliative care was more often engaged in an inpatient setting (77.1%) than an ambulatory setting (28.6%). Palliative care consults were placed for goals of care discussion (52.7%), clarify goals (40.5%), symptom management (27.0%), patient/family support (35.1%), and pain management (16.2%). Of the patients who received PC consults, a majority had advanced stage III and IV disease with primary tumor T4 stage (64.3%, p = 0.04, OR = 2.38). Patients with T3 stage disease showed comparable rates of PC consults (18.6%) and no PC consults (22.2%). However, when accounting for comorbidities, patients with T3 stage and at least one comorbidity (diabetes mellitus, coronary artery disease, or previous history of malignancy) had a higher rate of receiving PC consults than not receiving a PC consult (OR = 1.67). Additionally, patients receiving PC consults had low Palliative Performance Scale (PPS) scores of 10-30% (27.9%), 40-70% (60.7%), and 80-100% (11.5%).

Conclusion:

Appropriate and timely palliative care services in advanced HNC cancer has the potential to improve patient quality of life and reduce healthcare costs. This quality improvement project characterizes our institution's current utilization of PC to identify triggers that can be implemented for standardized PC consults. These triggers will be implemented in discussion of HNC patients at the EVMS multidisciplinary Head and Neck tumor board to standardize and automate PC consultation. A prospective cohort study will be pursued after implementation of triggers and with the addition of quality of life indicators including documentation of advanced care planning, proxy decision maker, location of death, and receipt of chemotherapy in the last two weeks of life. It is our goal to provide a PC referral if deemed appropriate within 8 weeks of diagnosis in agreement with American Society of Clinical Oncology guidelines.