RESIDENTS & FELLOWS COMMITTEE: Utilization of Palliative Care: An Imperative for the Modern Urologist
By: Woodson Smelser, MD | Posted on: 01 Oct 2022
Most of us are familiar with the epidemiologic statistics regarding genitourinary cancers. Regardless of your urologic practice, you likely encounter patients with a diagnosis of or sequelae related to treatment for cancer. In 2022, it is expected that there will be more than 81,000 new bladder cancer diagnoses and over 17,000 deaths in the United States. Kidney cancer parallels these figures with 79,000 cases and more than 13,000 deaths. Meanwhile, prostate cancer remains the most prevalent cancer in most men, with 268,490 new cases and >34,000 deaths expected, the second leading cause of cancer death behind lung cancer.1 Despite great advances in therapies across all stages, many patients with these diagnoses are at risk of ultimately succumbing to their cancer. Yet, utilization of palliative care in bladder cancer patients was recently estimated at <4% among patients with muscle-invasive disease, and only 4.1% among patients with either node-positive or metastatic disease.2
Palliative care is defined as “specialized healthcare focused on improving quality of life for patients with serious illnesses.”3 Importantly, palliative care is not just end-of-life care but can be integrated throughout the natural history of most serious illnesses in which cure may be impossible.4 It is important to distinguish this from hospice care, which is aimed at minimizing burden and treatment impacts in patients in whom the life expectancy related to a serious illness is <6 months. Though hospice may be an important component of palliative care, they are not synonymous or mutually binding. Patients receiving palliative care may still receive life-prolonging treatment. An example is a patient receiving androgen deprivation therapy for metastatic prostate cancer and radiation to painful bone metastases. These treatments are not necessarily curative, but they improve the patient’s day-to-day life regardless of their life expectancy. Urologists as a whole place a strong emphasis on measures to predict, monitor, and improve impacts on quality of life for our patients. Yet, there are clearly barriers to the utilization of palliative care in urologic cancers given the low rates of use reported in even our most lethal malignancies.2–4 Thus, I implore the modern urologist to consider ways in which discussions regarding palliative care can become commonplace.
Unfortunately, discussion of palliative care measures is often reserved for near the end of life, and this has contributed to the stigma that palliative care constitutes the treating physician “giving up on the patient” by the patient, family, other healthcare workers, and even ourselves. I admit that I feel a sense of immense personal failure when I learn that one of my patients has developed a metastatic recurrence or transitioned into an incurable stage. However, integration of palliative care early improves the patient experience, particularly in diseases with a high burden of pain such as advanced bladder cancer or metastatic prostate cancer.2–4
One strategy to counter the stigma surrounding palliative care is to routinely discuss the topic much earlier in the treatment journey. To build this into your workflow, consider adding discussion of future utilization of palliative care into your counseling scripts beginning at the diagnosis of cancer. Broaching the subject at diagnosis listed among a majority of options aimed at curative intent may blunt the future impact and shock of discussion when palliative care is perhaps the best option. To this end, I regularly discuss palliative care as a future option at the initial diagnostic consultation for all patients in whom I estimate the 5-year overall survival for treated patients is 70% or less. Admittedly, mentioning this option early—often at the first encounter with a patient—can seem awkward. I have found that discussing all curative options first, and then describing the possibility of eventual use of palliative care to safeguard quality of life is a transition that many patients understand. My usual script is:
“Though you and I are both here meeting with the goal and intent of complete cure, I want you to know that at some point in your treatment journey—perhaps years from now—you may want to focus on options that prioritize quality of life over length of life. There are a number of treatments that prioritize decreasing suffering related to your cancer diagnosis, but may not be curative, and YOU are the one to determine when that has become your goal.”
I have lost count of how many times I have made this statement. In my experience, this approach reinforces that curative intent is the goal, and empowers the patient early on that they are the person in charge of their care decisions. It also subtly acknowledges that not all patients are cured despite our earnest efforts. I have even had a few patients later broach the topic of palliative care to me by reminding me that I once told them they were the one in control and that they did not want to proceed with a suggested treatment. To me, these are small victories in an otherwise difficult situation. Likewise, I discuss palliative care with patients at major post-treatment milestones such as at the time of biochemical recurrence of prostate cancer or at the development of the first metastatic recurrence following cystectomy. Examine your own practice and search for opportunities in which to empower your patient with options that both of you may be wanting to discuss.
My journey into urologic oncology was heavily influenced by prior experiences as a hospice volunteer in college and medical school. Even before medical training, it was apparent to me the impact that thoughtful integration of palliative care early in treatment could ultimately have on the end of life. Those insights have shaped the way I approach shared decision-making for patients with urologic cancer. Nevertheless, contemporary data described above implicates that we as urologists continue to be low utilizers of these resources in even our most at-risk patients. I am no different and am working to identify new opportunities to help patients with palliative care.
In conclusion, I will share a few additional pragmatic recommendations that have helped me overcome barriers to effective use of palliative care. First, meet other providers in your organization that provide palliative care services. They often meet our patients in the last weeks of life, with fewer options available due to late intervention. Speak honestly with them about your fears regarding integration of palliative care and let them also suggest opportunities for earlier referral. Second, if your institution or practice participates in a multidisciplinary tumor board, consider integrating a palliative care specialist into those discussions to help identify patients in whom these services will be beneficial. Finally, read the articles cited below and compare the findings with your own practice patterns. Patients will thank you for the extra consideration. They may even make a future difficult conversation easier by suggesting use of palliative care themselves.
I thank Dr. Lee Hugar for tremendous contributions in researching and publishing on the topic of palliative care in urological cancer.
- Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72(1):7-33.
- Hugar LA, Lopa SH, Yabes JG, et al. Palliative care use amongst patients with bladder cancer. BJU Int. 2019;123(6):968-975.
- Hugar LA, Wulff-Burchfield EM, Winzelberg GS, Jacobs BL, Davies BJ. Incorporating palliative care principles to improve patient care and quality of life in urologic oncology. Nat Rev Urol. 2021;18(10):623-635.
- Wu JN, Meyers FJ, Evans CP. Palliative care in urology. Surg Clin North Am. 2011;91(2):429-444.