The Intersection of Palliative Care and Survivorship

People who are diagnosed with cancer become our patients, but, by some definitions, they also qualify as cancer survivors and people who may need palliative care. This may be confusing for patients with cancer and for those who define care by oncology setting or specialty. It may be helpful to test these concepts using case studies.

Case Study 1

Maria is a 54-year-old woman with newly diagnosed stage II estrogen receptor-positive, progesterone receptor-positive HER2neu-negative cancer in the right breast. After she recovers from her lumpectomy and axillary node sampling, she will start chemotherapy and then radiation therapy, followed by five years of tamoxifen (Nolvadex®).

•  Survivorship: Maria sees herself becoming a survivor when she finishes treatment. She knows a survivorship care plan and a treatment summary will be shared with her and her primary care provider.

•  Palliative care: Maria currently has no physical symptoms, but she is very worried about cancer recurrence and the upcoming birth of a grandchild. When asked if she would like to see the palliative care provider to discuss her concerns, she states that she “is not dying.”

Case Study 2

Al is a 70-year-old man with recurrent prostate cancer (radical prostatectomy 10 years prior) with new bone metastases. He has a rising prostate-specific antigen and will be starting leuprolide acetate and radiation therapy to the painful bone metastasis at L2 as well as starting a bisphosphonate.

•  Survivorship: Al has viewed himself as a cancer survivor for the past 10 years. He knows that his treatment is not curative, but his doctor says that the disease could “go on a long time.”

•  Palliative care: Al’s back pain is poorly managed with oxycodone and acetaminophen and he is looking forward to some relief from radiation treatments. The nurse suggests the palliative care nurse practitioner (NP) may provide some ideas to relieve the pain and improve his quality of life. Al agrees to an appointment with the NP to discuss pain management strategies.

Case Study 3

Burt is a 66-year-old man with a new diagnosis of metastatic left non-small cell lung cancer with a solitary brain metastasis. He presented with cough, weight loss, and cognitive changes, and will be starting chemotherapy and radiation therapy to his brain.

•  Survivorship: Burt does not see himself as a survivor because he knows this disease will shorten his life. He wants palliative chemotherapy and radiation therapy to improve his quality of life and maybe “get him to the next Christmas.”

•  Palliative care: Burt is worried that he will not be able to care for his disabled son. He needs to make plans for his son’s future and needs his brother to be a backup for medical decisions for himself and his son. The nurse recommends a visit with the social worker from the palliative care team to discuss his advance care planning.

People with a cancer diagnosis vary in terms of treatments, expectations, and needs. In these three cases, each patient differs in terms of prognosis, symptoms, and concerns. There also is contrast in their views of themselves as cancer survivors and/or people in need of palliative care. For example, inadequately treated pain, as in Al’s case, may require experts in symptom management from the palliative care team. On the other hand, people with a new cancer diagnosis, such as Maria, may have the perception that palliative care is hospice or end-of-life care. They may not understand the scope of palliative care or the services the team can offer, such as conversations about fears and concerns.

It may be confusing for newly diagnosed patients to discuss cancer treatment, cancer survivorship, and palliative care at the same time. Although all of these services should be available to patients as part of comprehensive cancer care, it is essential that we think about each patient and talk about their needs, assess their understanding, and offer resources to improve their quality of life. The intersection of treatment, survivorship, and palliative care is best navigated within established relationships with patients. When nurses understand their patients’ needs and patients trust their nurses, productive conversations can lead to timely and appropriate interventions to address the needs of the individual patient.

About the Author(s)

Lisa Kennedy Sheldon, PhD, APRN, AOCNP®, FAAN, is the chief clinical officer at the Oncology Nursing Society in Pittsburgh, PA, and an oncology nurse practitioner in the Cancer Center at St. Joseph Hospital in Nashua, NH. Kennedy Sheldon can be reached at CJONEditor@ons.org. The author takes full responsibility for the content of the article. No financial relationships relevant to the content of this article have been disclosed by the editorial staff. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Oncology Nursing Society.