Palliative (Non‑Curative) Oncology Care

1. Scope & Definition

Palliative oncology encompasses interventions for patients with advanced or biologically incurable malignancy where the therapeutic intent is symptom relief, functional preservation, prolongation of meaningful survival, and alignment with patient values—rather than eradication of all malignant cells. It integrates disease‑modifying therapies (when benefit outweighs burden) with comprehensive supportive and psychosocial care.

2. Goals of Care Domains

| Domain | Illustrative Objectives | Metrics of Success |
|——–|————————|——————–|
| Symptom Control | Pain, dyspnea, nausea, obstruction, bleeding | Validated symptom scales (e.g., ESAS) |
| Functional Preservation | Maintain ADLs, performance status | ECOG/Karnofsky trends |
| Life Prolongation (Proportionate) | Extend survival without compromising quality | Quality‑adjusted survival, hospitalization-free days |
| Psychosocial & Existential | Anxiety reduction, coping, caregiver support | Distress thermometer, caregiver burden indices |
| Advance Planning | Clarify preferences, document directives | Completed ACP documentation |

3. Distinguishing Palliative vs Curative Intent

| Feature | Curative Intent | Palliative Intent |
|———|—————–|——————-|
| Therapeutic endpoint | Eradicate disease | Optimize quality & function; prolong life selectively |
| Dose intensity | Maximal tolerated (often) | Proportionate; may de‑escalate |
| Tolerance threshold | Accept higher acute toxicity | Lower threshold; toxicity tradeoff central |
| Treatment duration | Finite (protocol-defined) | Adaptive; reassessed at milestones |
| Stopping rules | Progression after standard lines, intolerable toxicity | Net burden exceeds benefit, patient preference |

4. Patient Selection for Disease-Modifying Therapy

| Consideration | Favor Continuing/Initiating | Favor Transition to Supportive Care Alone |
|—————|—————————-|——————————————|
| Performance Status | ECOG 0–2 | ECOG ≥3 (unless reversible) |
| Symptom Etiology | Tumor-related & reversible with therapy | Non-tumor or multifactorial refractory burden |
| Line of Therapy | Early lines with expected benefit | Multiple refractory failures |
| Biomarkers/Targets | Actionable mutation with high response probability | No remaining targetable alterations |
| Patient Goals | Explicit desire for life prolongation with acceptable risk | Prioritizes comfort, minimal clinic time |

5. Shared Decision-Making Workflow

1. Clarify illness understanding & expectations.
2. Elicit patient values (function, cognition, longevity, symptom priorities).
3. Present evidence-based options with absolute benefit framing (e.g., median OS gain, NNT/NNH where available).
4. Explore tradeoffs (clinic visits, side effects, financial toxicity).
5. Reach consensus; document and revisit periodically or at inflection points (progression, new symptoms, hospitalization).

6. Symptom Cluster Management

| Cluster | Core Interventions | Notes |
|———|——————–|——-|
| Pain | WHO analgesic ladder, adjuvant neuropathic agents, interventional blocks | Regular reassessment; opioid stewardship |
| Dyspnea | Opioids (low-dose), fan/airflow, treat effusions/obstruction, non-invasive ventilation (select) | Evaluate reversible contributors (anemia, PE) |
| Nausea/Vomiting | Mechanism-specific antiemetics (5‑HT3, D2, NK1), bowel regimen | Identify obstruction vs metabolic causes |
| Fatigue | Activity pacing, treat anemia, optimize sleep, psychostimulants (select) | Multifactorial assessment |
| Anorexia/Cachexia | Nutritional counseling, exercise, select pharmacologic (e.g., short-course corticosteroids) | Avoid forcing intake; focus on enjoyment |
| Depression/Anxiety | SSRIs/SNRIs, counseling, mindfulness, psychiatric referral | Routine screening (PHQ‑9, GAD‑7) |

7. Management of Structural Complications

| Complication | Palliative Interventions | Goal |
|————-|————————–|——|
| Malignant obstruction (Airway, GI) | Stenting, laser debulking, palliative RT, systemic therapy if responsive | Relieve obstruction, improve intake/breathing |
| Spinal cord compression | High-dose steroids, urgent MRI, decompression + RT | Preserve neurologic function |
| Pathologic fracture risk (bone mets) | Orthopedic stabilization, RT, bone-modifying agents | Maintain mobility, reduce pain |
| Brain metastases (selected) | SRS, short-course RT, steroids for edema | Control focal symptoms, cognition preservation |
| Malignant effusions (pleural, peritoneal) | Drainage, indwelling catheter, pleurodesis | Relieve dyspnea/pressure |

8. Rational Use of Systemic Therapies in Palliative Setting

| Therapy Class | When Considered | Caution |
|————–|—————–|——–|
| Cytotoxic chemotherapy | Chemo-sensitive histology with expected symptom/OS gain | Avoid in ECOG ≥3 unless clear reversible driver |
| Targeted therapy | Actionable mutation, high response probability, lower toxicity | Monitor for chronic low-grade adverse events |
| Immunotherapy | Biomarker-selected (e.g., PD-L1 high, MSI-H) durable potential | Risk of irAEs; delayed responses |
| Endocrine therapy | Hormone receptor-driven tumors | Slow onset; pair with symptom palliation |
| Radiopharmaceuticals | Symptomatic bone-predominant disease | Marrow reserve assessment |

9. Outcome Reassessment Triggers

| Trigger | Action |
|——–|——-|
| Radiologic progression with symptom escalation | Re-evaluate goals; consider line switch vs de‑escalation |
| Decline in performance status by ≥1 ECOG point | Assess reversible causes before stopping disease therapy |
| Unplanned hospitalization | Review feasibility and benefit of ongoing regimen |
| New severe toxicity (Grade 3–4) | Dose adjust, supportive care, or discontinue |

10. Ethical & Communication Principles

| Principle | Application |
|———-|————|
| Proportionality | Balance expected clinical benefit against cumulative burden |
| Transparency | Provide absolute rather than relative risk reductions |
| Autonomy | Support informed decisions without coercive optimism |
| Non-Abandonment | Continue supportive care even when stopping disease-directed therapy |
| Cultural Sensitivity | Adapt framing, decision style to cultural/individual preferences |

11. Early Specialized Palliative Care Integration

Randomized data (e.g., metastatic lung cancer studies) show early palliative care improves quality of life, mood, and may extend survival by avoiding futile late-line toxic therapy and optimizing symptom control.

12. Documentation Checklist

• Performance status baseline and every visit.
• Active symptoms with severity scores.
• Advance directives / code status updated.
• Current goals-of-care statement (date stamped).
• Medication reconciliation (including adjuvant supplements for interactions).

13. Metrics for Quality Programs

| Metric | Description |
|——–|————-|
| Unplanned acute care utilization | ED visits or admissions per patient-month |
| Time on hospice | Median days (aim to avoid very late enrollment) |
| Chemotherapy in last 14 days of life | Lower rates correlate with guideline-concordant care |
| PRO improvement | Change in ESAS or similar scores over time |

14. Transition to Hospice / Best Supportive Care

Indicators: No further effective systemic options, declining ECOG >2, refractory symptom burden, patient prioritizes comfort. Transition planning includes deprescribing, home services coordination, and psychosocial/spiritual support referral.

15. Key Takeaways

• Palliative oncology centers on aligning proportionate disease-directed therapy with patient-defined quality and functional goals.
• Early integration of palliative expertise enhances outcomes and may modestly prolong survival.
• Objective performance status, symptom trajectory, and biomarker-driven response probability are pivotal in treatment continuation decisions.
• High-quality documentation and iterative shared decision-making prevent overtreatment and support patient autonomy.

Disclaimer: Educational summary; adapt to institutional guidelines and individual patient context.