Hospice Clinical Appropriateness: Oncology/Cancer
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While a patient's goal is long-term control of the malignancy, there may come a time when the cancer can no longer be controlled or when the response to treatment is less than hoped for.
Hospice care for a cancer patient is designed for the treatment of a wide range of issues, including pain, weight loss and progression of other symptoms, such as dyspnea. Additionally, VITAS provides the emotional and spiritual support so many oncology patients and their loved ones seek—all tailored to the patients' needs.
Knowing when an oncology patient is ready for hospice care
Below are a variety of systems used to assess prognosis in patients with oncological diseases. Because specific patient prognosis varies from individual to individual, we suggest using these factors as general guidance.
Using the ECOG (Eastern Cooperative Oncology Group) scale, a median survival of three months roughly correlates with an ECOG score of >3.
1 Symptomatic but completely ambulatory
2 Symptomatic, <50% in bed during the day
3 Symptomatic, >50% in bed but not bedbound
Ask the Patient
The simplest method to assess functional ability is to ask patients: How do you spend your time? How much time do you spend in a chair or lying down?
If the response is that >50% of their time is spent sitting or lying down and that time is increasing, you can roughly estimate the prognosis at three months or less. Survival time tends to decrease further with increasing numbers of physical symptoms—especially dyspnea if secondary to the cancer.
Using the Karnofsky Performance Status scale1, a median survival of three months roughly correlates with a Karnofsky score <40.
100 Normal; no complaints; no evidence of disease
90 Able to carry on normal activity; minor signs or symptoms of disease
80 Normal activity with effort; some signs or symptoms of disease
70 Cares for self; unable to carry on normal activity or do active work
60 Requires occasional assistance, but is able to care for most personal needs
50 Requires considerable assistance and frequent medical care
40 Disabled; requires special care and assistance
30 Severely disabled; hospital admission is indicated although death is not imminent
20 Very sick; hospital admission necessary; active supportive treatment necessary
10 Moribund; fatal processes progressing rapidly
Number Staging Systems
Number staging systems usually use the TNM (tumor, nodes, metastasis) system to divide solid tumor cancers into stages. Most types of cancer have 4 stages, numbered from 1 to 4. Often doctors write the stage down in Roman numerals, so you may see stage 4 written as stage IV.
Here is a brief summary of what the stages mean for most types of cancer:
- Usually means a cancer is relatively small and contained within the organ it started in.
- Usually means a cancer has not started to spread into surrounding tissue but the tumor is larger than in stage 1. Sometimes stage 2 means that cancer cells have spread into lymph nodes close to the tumor. This depends on the particular type of cancer.
- Usually means the cancer is larger. It may have started to spread into surrounding tissues.
- Means the cancer has spread from where it started to another body organ. This is also called secondary or metastatic cancer.
Several common cancer syndromes have well-documented short median survival times2:
- Malignant hypercalcemia: 8 weeks, except newly diagnosed breast cancer or myeloma
- Malignant pericardial effusion: 8 weeks
- Carcinomatous meningitis: 8–12 weeks
- Multiple brain metastases: 1–2 months without radiation; 3–6 months with radiation
- Malignant ascites, malignant plural effusion or malignant bowel obstruction: <6 months
Categories of Treatment
Categories of treatment can be considered as well. Categories listed here are evaluations of tumor progressions and likely treatment or non-treatment options.
Oncologists traditionally rely on charts that rank malignancies on scales of treatablility/probability of cure/prognosis, from curable to untreatable. The most common malignancies are categorized from the point of view of hospice appropriateness. Treatments and medications change quickly; this chart is a guideline as specific diseases may move from one category to another.
Treatable; high or moderate expectation of cure.
- Testicular carcinoma
- Choriocarcinoma and trophoblastic malignancy
- Childhood acute lymphoblastic leukemia
- Other pediatric malignancies
- Acute promyelocytic leukemia
- Hodgkin's disease
Treatable; high probability of complete remission, low probability of cure.
- Ovarian carcinoma
- Adult acute myeloblastic leukemia and acute lymphoblastic leukemia
- Intermediate and high-grade non-Hodgkin's lymphoma
- Small-cell (oat cell) bronchogenic carcinoma
Treatable; incurable when metastatic; favorable prognosis.
- Prostate carcinoma
- Breast carcinoma
- Chronic lymphocytic leukemia
- Low-grade non-Hodgkin's lymphoma
- Multiple myeloma and the immunoproliferative disorders
- Myelodysplastic syndrome
- Thyroid carcinoma (except anaplastic)
Treatable in a minority of patients with metastatic disease; less favorable prognosis
- Bladder carcinoma
- Primary brain tumors
- Grade III astrocytoma
- Gynecological malignancies other than ovary
- Colorectal carcinoma
- Non-small-cell bronchogenic carcinoma
- Squamous-cell carcinoma
- Large-cell carcinoma
- Bronchoalveolar carcinoma
- Head and neck carcinomas
- Esophageal carcinoma
- Gastric carcinoma
- Pancreatic carcinoma
- Soft-tissue sarcomas
- Renal cell carcinoma
Generally unresponsive to standard therapy
- Renal cell carcinoma
- Malignant melanoma
- Hepatobiliary and gall bladder carcinoma
- Adrenal carcinoma
- AIDS-associated high-grade lymphoma
VITAS provides these guidelines as a convenient tool. They do not take the place of a physician's professional judgment.
1 Oxford Textbook of Palliative Medicine, Oxford University Press. 1993; 109
2 Author: David E Weissman, MD