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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Dr. Ruchika Talwar, and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. Today, I'm really excited to be joined by Dr. Michael Rabow, who is the Director of Palliative Care for the Cancer Center at UCSF, the University of California, San Francisco. He’s going to be sharing some insights on early interventions with palliative care in our prostate cancer population. Thank you so much, Dr. Rabow, for taking the time to chat with us today.

Michael Rabow: Thank you very much for inviting me. I'm really happy to present just a few slides today, and then open it up for a little bit more discussion about the benefits of early palliative care in prostate cancer. It's very much my pleasure to present just a few core concepts about the benefits of early palliative care for advanced prostate cancer. This is evidence that's accumulated over the last 10 to 15 years. I think it's important for all urologic oncologists to be aware of because it really does impact patients in very, very significant ways.

And I think that the benefits of early integrated palliative care for people with prostate cancer fall along four different lines. One is improved satisfaction. The other is improved symptom burden. The third is improved efficiency of care and the resultant improvement in costs. And finally, an improvement in prolonged life, which I think we all need to take super seriously when we're considering what the benefits are of the additional treatments that palliative care brings.

So first and foremost, we have good evidence that early integrated palliative care improves patient satisfaction, improves caregiver satisfaction, family caregivers, and also, notably, it improves the satisfaction of providers themselves. Providing palliative care, primary or specialty palliative care, is often what many clinicians went into health care for—to help people feel better, to improve the quality of people's lives.

It's very, very clear that palliative care can improve symptom burdens. A lot of this data comes from patients in cancer centers, but it's been proven across multiple different diseases, including chronic non-malignant diseases as well. So we have improvement in pain and shortness of breath and nausea and fatigue. Essentially, every symptom that we've looked at, including emotional symptoms like depression and anxiety, can be improved with palliative care's attention.

The third clear benefit that's been shown in multiple different diseases, especially though in cancer care, has been improved efficiency with associated reduced costs. And that is because, at the end of life, with very, very advanced disease, most patients prefer less aggressive, less hospital-based, less interventional care, and that is associated with decreased cost. So because patients don't want to be in the hospital at the end of life and because palliative care's influence often is to get people to the place of dying that they prefer, care costs less with integrated palliative care.

The estimate is that for patients who are getting palliative care earlier than the last three months of their life, we may have savings across the system of $3,500 to $5,000 per patient. So over and over again, we've seen that when patients are getting the kind of care that they want at the very end of life, that care ends up being more efficient, less interventional, and costs less. So palliative care saves lives. Most important, I think for us and for our patients and their loved ones, is that there is some evidence that integrated palliative care prolongs life.

We have plenty of evidence to prove that palliative care doesn't shorten life, that palliative care provides benefits. And one of those benefits for many people might be prolongation of life. This comes from a really practice-changing study from 2010 from Jennifer Temel looking at patients with non-small cell lung cancer at Mass General Hospital in Boston. And they had a randomized trial comparing immediate versus delayed palliative care along with the usual oncologic care.

And the patients who got palliative care right from diagnosis of metastatic disease, the patients who got early integrated palliative care had improved quality of life, less depression. They got less chemotherapy in the last two weeks of life, had fewer hospitalizations at the end of life. And this was the real shocker: patients who got early integrated palliative care lived nearly three months longer than those who got delayed palliative care or palliative care reserved for the very end of life.

So since the Temel study, we've had to accept the reality and being able to enjoy the reality that early integrated palliative care is essential for most patients, resulting in a better life and potentially even a longer life. This prolongation of life has been shown in non-small cell lung cancer. It's never been tested in prostate cancer. It's been shown in some other areas and not been proven in other areas of cancer care. But the reality exists that it's quite possible that palliative care, while doing no harm or shortening people's lives, palliative care does an amazing job of both improving quality of life as well as potentially helping patients live longer.

This evidence is so strong that the American Society of Clinical Oncology, since 2017, has been recommending early integrated palliative care to all clinicians who care for people with cancer. And this recommendation from 2017 was updated just very recently this year, with the conclusion that oncology clinicians should refer patients with advanced solid and hematologic malignancies to specialized interdisciplinary palliative care teams that provide outpatient and inpatient care beginning early in the course of a disease alongside treatment of their cancer.

So ultimately, the conclusion is that we should be referring essentially all of our patients with advanced disease, with metastatic disease, for palliative care integrated with their oncologic care. That is, the best kind of care for almost all of us—for our loved ones, for our patients, for us if we ended up needing it—is a combination of really great oncologic and surgical care as well as palliative care mixed in and coordinated with that care.

Ruchika Talwar: Thank you so much. So many important pearls of wisdom there. And I really want to underscore how grateful we are to have you here sharing your expertise, but also as a call of action to our urologic oncology community to remind us that for a lot of GU cancers, prostate cancer being one of them, it really is critical that we engage and interface with our palliative care counterparts.

Now, I think a lot of the historical hesitation has been because folks feel that palliative care is synonymous with hospice. And so clinicians tend to hesitate to get that early intervention going. What is your advice to our urologic community on how to overcome that historical barrier, and what should we be keeping in mind moving forward as we tend to think more about early palliative care intervention?

Michael Rabow: Yeah. I think that the reality is that most of America doesn't know what palliative care is, which is a downside for sure, but a potential opportunity, which is to say that means that you as the clinician get to define it for them. And our research or market research shows that more than 92% of people, once they hear what palliative care is, support it and want it for themselves and for their loved ones. So I think that urologic oncologists can be confident that if they explain palliative care to their patients as part of the service that they provide, as part of the service that they recommend, that patients will become comfortable with it.

And it's perfectly OK for oncologists or urologists to talk about how palliative care is care focused on quality of life, helping people live as well and as long as they possibly can, as opposed to other kinds of care that we have for people who are at the end of life. And that palliative care is for living as well as possible. It is not focused on the end of life. In particular, that's what hospice care does and is available to us for. But palliative care is something different, so making that distinction can be very important.

Ruchika Talwar: Yeah.

Michael Rabow: I also would consider not using the phrase "palliative care," if you feel or find that phrase is really problematic with your colleagues, with your patients, with your leadership, to really understand that what people benefit from is really an attention on good communication and good symptom control. And if you want to talk about referring people to experts in communication or experts in symptom control, that's perfectly fine. As a matter of fact, at my institution at UCSF, we started our palliative care program in 2005—so a long time ago.

I didn't mention the phrase "palliative care" for the first 10 years because I was worried that people were going to misunderstand what it was we were offering. But as soon as people understand who's providing it, understand what its focus is around symptom management and especially around communication, people are very comfortable with it. As a matter of fact, most patients, when you ask them if they wished they had been referred to palliative care earlier, almost all patients will say yes. It's really just the stigma of dying, which is, as I say, not related to palliative care that is the distracting barrier for most people.

Ruchika Talwar: Yeah. Absolutely. Like I said before, so many important points. And we're so grateful that you took the time here to chat with us today. Thank you so much for sharing your insights. And I really hope that this is a call to action for all of my colleagues. I know it certainly was a really important reminder. And I'm already going through my head thinking of patients who I think could benefit from a palliative care expert.

Michael Rabow: Wonderful. And for sure, I think palliative care is one of those things that patients would consider if they knew it was an option. But they expect their physicians, their clinicians, to bring it up.

Ruchika Talwar: Yeah.

Michael Rabow: It is our job.

Ruchika Talwar: Absolutely. Absolutely. And so to our audience, I hope that you'll join me in being a little more mindful about including these sorts of services into the care that we provide for urologic cancers. Thank you so much for joining us. And we'll see you next time.

Michael Rabow: My pleasure.