Palliative Cancer Care Guidelines
The World Health Organization (WHO) describes palliative care as services designed to prevent and relieve suffering for patients and families facing life-threatening illness, through early management of pain and other physical, psychosocial, and spiritual problems.  Growing recognition of palliative care as an integral aspect of cancer treatment, with the ability to improve quality of life and prevent unnecessary hospital admissions and the use of health services, especially when instituted early in the course of disease, has prompted the development of a range of guidelines concerning palliative cancer care. [1, 2]
The American Society for Clinical Oncology (ASCO) recommends considering the combination of palliative care with standard oncology care early in the course of treatment for patients with metastatic cancer and/or a high symptom burden.  Specific recommendations are as follows:
According to ASCO, essential components of palliative care may include the following  :
ASCO recommendations on delivery of palliative care are as follows 
The National Comprehensive Cancer Network (NCCN) concurs and includes the following additional recommendations  :
The NCCN recommends assessment by the oncology team for patients whose screening confirms the presence of one or more of the following  :
Additional indicators may include the following:
National Comprehensive Cancer Network (NCCN) guidelines identify general principles of pain management and provide specific recommendations for assessment, management, and reassessment of cancer pain in adults. Major recommendations include the following  :
Assessment recommendations are as follows:
Cancer pain management guidelines from the European Society for Medical Oncology (ESMO) follow the WHO strategy of a sequential three-step analgesic ladder from non-opioids to weak opioids to strong opioids, gauged to pain intensity.  ESMO recommendations for choice of analgesics according to pain severity are as follows:
ESMO guidelines note that although oral administration is advocated, patients presenting with severe pain that needs urgent relief should be treated and titrated with parenteral opioids, usually subcutaneous or intravenous. 
ESMO recommendations regarding alternative strong opioids include the following:
For pain related to an oncologic emergency, such as bone fracture, infection, or obstruction, the NCCN recommends treating the pain directly in addition to providing specific treatment for the underlying condition (eg, surgery, steroids, radiation therapy, antibiotics). For pain not related to an oncologic emergency, NCCN recommendations vary according to whether the patient is opioid naïve or opioid tolerant. The U.S. Food and Drug Administration (FDA) defines opioid tolerance as receiving, for 1 week or longer, one of the following  :
For opioid-naïve patients, the NCCN recommends the following non–oncologic emergency pain management  :
For opioid-tolerant patients who have breakthrough pain of intensity ≥4 (on a scale of 0-10) or whose goals of pain control and function are not met, management is as follows  :
Subsequent management is based on the continued pain rating score and includes the following:
For ongoing care, if an acceptable level of comfort and function has been achieved and the patient’s 24-hour opioid requirement is stable, convert to an extended-release oral medication (if feasible) or other extended-release formulation (e, transdermal fentanyl).
In 2012 the European Association for Palliative Care (EAPC) updated its guidelines for the use of opioid analgesics to treat cancer pain and provided the following recommendations  :
The NCCN guidelines for treatment of dyspnea in cancer patients are based on estimates of the patient’s life expectancy.  For patients with a life expectancy of years to months to weeks, the NCCN recommends assessment of symptom intensity followed by treatment of underlying causes or comorbid conditions with measures such as the following:
For symptomatic relief, the following interventions may be used, as appropriate:
For patients with a life expectancy of weeks to days, the following measures may be used, in addition to the interventions listed above:
If fluid overload is a contributing factor, interventions include the following:
The only treatment for dyspnea recommended in the Oncology Nursing Society (ONS) guidelines is parenteral or oral immediate-release opioids. For patients with a life expectancy of years to months to weeks, the ONS deemed the following interventions “likely to be effective“  :
For patients with a life expectancy of weeks to days, the ONS recommendations are as follows:
Guidelines for the management of anorexia/cachexia in patients with advanced cancer have been issued by the NCCN and the European Palliative Care Research Collaborative (EPCRC).
The NCCN guidelines are based on estimates of the patient’s life expectancy.  For patients with a life expectancy of years to months, the recommendations are as follows:
For patients with a life expectancy of months to weeks to days, the NCCN recommends first determining the importance of the symptoms to patient and family; if considered important, the anorexia/cachexia can be treated with megestrol acetate. Further recommendations are as follows:
Finally, inform the patient and family of the natural history of advanced cancer, including the following:
The EPCRC guidelines focus on refractory cachexia in patients with advanced cancer, which it defines as “a stage where reversal of weight loss is no longer possible due to very advanced or rapidly progressive cancer unresponsive to anti-cancer therapy.” The recommendations in the guidelines are aimed at alleviating the consequences and complications of cachexia and eating-related distress of patients and families and include the following  :
The NCCN guidelines for distress management include recommendations for ongoing screening, monitoring, documentation, and treatment of distress throughout all stages of cancer treatment.  Screening for distress using the Distress Thermometer and Problem Checklist should be conducted at the initial visit and at other appropriate intervals, especially with changes in disease status (ie, remission, recurrence, or disease progression).
Treatment is determined on the basis of the level and source(s) of distress identified. Clear roles are delineated for members of the primary oncology team as well as for psychosocial oncology professionals who deliver mental health services, social work and counseling services, and chaplaincy services. 
In 2014, ASCO released evidence-based guidelines for managing depression and anxiety in patients with cancer.  These guidelines were adapted from the 2010 Pan-Canadian Practice Guideline: Screening, Assessment and Care of Psychosocial Distress (Depression, Anxiety) in Adults with Cancer, which was developed as a synthesis of five practice guidelines, including the NCCN guidelines for stress management. 
The ASCO guidelines identify separate processes for screening, assessment, and treatment of depression and anxiety in adults with cancer. Timing of evaluation, types of assessment tools, and specific treatment pathways are recommended depending on the levels of symptoms reported. Recommendations for follow-up and ongoing re-assessment are also provided. 
In 2009, the European Association of Palliative Care (EAPC) published guidelines to address the key clinical issues surrounding palliative sedation. The recommendations in the guidelines are intended to be modified to reflect local culture; legal considerations; and specific needs of the home, hospital, or hospice-based setting. The recommendations include the following  :
The presence of refractory psychological symptoms does not necessarily indicate a far advanced state of physiological deterioration; sedation should be reserved for patients in advanced stages of terminal disease under the following circumstances:
The 2014 European Society of Medical Oncology (ESMO) guidelines for use of palliative sedation in advanced-stage cancer are derived from the EAPC guidelines and contain no major variances in the recommendations. 
NCCN guidelines for palliative sedation are also in general agreement with EAPC. Additional specific recommendations include the following  :
Palliative Care Fact sheet N°402. World Health Organization. Available at http://www.who.int/mediacentre/factsheets/fs402/en/. 19 February 2018; Accessed: July 9, 2018.
Greer JA, Jackson VA, Meier DE, Temel JS. Early integration of palliative care services with standard oncology care for patients with advanced cancer. CA Cancer J Clin. 2013 Sep. 63 (5):349-63. [Medline].
[Guideline] Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2017 Jan. 35 (1):96-112. [Medline]. [Full Text].
[Guideline] NCCN Clinical Practice Guidelines in Oncology. Palliative Care. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf. Version 1.2018 — December 19, 2017; Accessed: July 9, 2018.
[Guideline] NCCN Clinical Practice Guidelines in Oncology. Adult Cancer Pain. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/pain.pdf. Version 1.2018; Accessed: July 9, 2018.
[Guideline] Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F, ESMO Guidelines Working Group. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol. 2012 Oct. 23 Suppl 7:vii139-54. [Medline]. [Full Text].
Extended-Release (ER) and Long-Acting (LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy (REM). U.S. Food and Drug Administration. Available at http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf. June 2015; Accessed: July 10, 2018.
[Guideline] Caraceni A, Hanks G, Kaasa S, Bennett MI, Brunelli C, et al. Use of opioid analgesics in the treatment of cancer pain: evidence-based recommendations from the EAPC. Lancet Oncol. 2012 Feb. 13 (2):e58-68. [Medline]. [Full Text].
[Guideline] DiSalvo WM, Joyce MM, Tyson LB, Culkin AE, Mackay K. Putting evidence into practice: evidence-based interventions for cancer-related dyspnea. Clin J Oncol Nurs. 2008 Apr. 12 (2):341-52. [Medline].
[Guideline] Clinical practice guidelines on cancer cachexia in advanced cancer patients. European Palliative Care Research Collaborative. Available at http://www.cancercachexia.com/literature-watch/43_clinical-practice-guidelines-on-cancer-cachexia-in-advanced-cancer. 2010; Accessed: July 10, 2018.
[Guideline] NCCN Clinical Practice Guidelines in Oncology. Distress Management. National Comprehensive Cancer Network. Available at http://www.nccn.org/professionals/physician_gls/pdf/distress.pdf. Version 2.2018 — February 23, 2018; Accessed: July 10, 2018.
[Guideline] Andersen BL, DeRubeis RJ, Berman BS, Gruman J, Champion VL, Massie MJ, et al. Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation. J Clin Oncol. 2014 May 20. 32 (15):1605-19. [Medline]. [Full Text].
[Guideline] Howell D, et al. A Pan-Canadian Practice Guideline: Screening, Assessment and Care of Psychosocial Distress (Depression, Anxiety). Canadian Association of Psychosocial Oncology. Available at http://www.capo.ca/ENGLISH_Depression_Anxiety_Guidelines_for_Posting.pdf. August 2010; Accessed: July 10, 2018.
[Guideline] Cherny NI, Radbruch L, Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009 Oct. 23 (7):581-93. [Medline]. [Full Text].
[Guideline] Cherny NI, ESMO Guidelines Working Group. ESMO Clinical Practice Guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol. 2014 Sep. 25 Suppl 3:iii143-52. [Medline]. [Full Text].
Winston W Tan, MD, FACP Associate Professor of Medicine, Mayo Medical School; Consultant and Person-in-Charge of Genitourinary Oncology-Medical Oncology, Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic Jacksonville; Vice Chairman of Education, Division of Hematology/Oncology, Mayo Clinic Florida
Winston W Tan, MD, FACP is a member of the following medical societies: American College of Physicians, American Society of Clinical Oncology, American Society of Hematology, Philippine Medical Association, Texas Medical Association
Disclosure: Nothing to disclose.
Jessica M McMillan, DNP, ARNP, FNP-BC Advance Registered Nurse Practitioner, Mayo Clinic Hospital; Advance Registered Nurse Practitioner, Brooks Rehabilitation Hospital
Jessica M McMillan, DNP, ARNP, FNP-BC is a member of the following medical societies: American Association of Nurse Practitioners, American Nurses Association, Florida Nurses Association, Florida Society of Clinical Oncology, Hospice and Palliative Nurses Association, Northeast Florida Advance Registered Nurse Practitioners, Oncology Nursing Society, Sigma Theta Tau International Honor Society of Nursing
Disclosure: Nothing to disclose.
Palliative Cancer Care Guidelines
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