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Introduction

Scientific advances have led to ever-increasing cancer treatment options and longer lives for patients with incurable malignancies. Many of these patients have complex symptoms due to the cumulative effects of long-term cancer treatment, disease progression and pre-existing morbidities. There is a need for efficacious supportive care interventions aimed at relieving the debilitating physical and psychological symptoms which have a negative impact on quality of life (QOL).1 The advances in cancer treatment have outpaced progress in terms of supportive care provision for cancer patients, and only in the last decade has palliative care become recognized as an essential component of oncology care and integrated models of care have been proposed and evaluated. The World Health Organization defines palliative care as an approach that improves the QOL of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.2 There is a growing body of evidence to demonstrate the value of integrating palliative care into routine oncology care.1,3-8 This chapter presents an overview of the research evidence, the patient and service level barriers to implementation, and recommendations for practice.

Recent developments

Traditionally patients with cancer were referred to palliative care as a last resort when treatment options had been exhausted and death was imminent. Over the last decade there has been a growing body of research to support earlier integration of palliative care into oncology care. The research evidence consists of a number of randomized controlled trials, largely from North America, which have demonstrated an association of early palliative care with improved symptoms and QOL and reduced acute hospital admissions and aggressive cancer treatments at the end of life.1,3,5,7,8 The interventions in these trials varied and some of the benefits have been inconsistent across trials (e.g. QOL, symptom improvement). In general, however, common characteristics were assessment and several follow-up consultations by specialist palliative care teams over a period of 2-3 months, which occurred about 6-14 months before patients died. Systematic reviews and pooled analyses of routinely collected data have also demonstrated an association between early palliative care intervention and an increased proportion of home deaths as well as a reduction in emergency admissions for patient with cancer.9,10 This evidence has begun to influence policy in the USA: the American Society of Clinical Oncology recommends that the integration of palliative care into oncology management should be considered early in the course of illness for any patient with metastatic cancer or a high symptom burden.11

Implementing this evidence in routine clinical practice in the UK presents challenges. Only two-thirds of cancer patients are referred to palliative care services before they die, and those who do receive palliative care are typically referred late ...

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