Symptom Management and Supportive Care

Attitudes and Beliefs Toward Supportive and Palliative Care Referral Among Hematologic and Solid Tumor Oncology Specialists DAVID HUI,a MINJEONG PARK,b DIANE LIU,b AKHILA REDDY,a SHALINI DALAL,a EDUARDO BRUERAa Departments of aPalliative Care and Rehabilitation Medicine and bBiostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA Disclosures of potential conflicts of interest may be found at the end of this article.

Key Words. Access x Hematology x Neoplasms x Palliative care x Referral x Supportive care

ABSTRACT Background. Palliative care (PC) referrals are often delayed for patients with hematologic malignancies. We examined the differences in attitudes and beliefs toward PC referral between hematologic and solid tumor specialists and how their perception changed with use of the service name “supportive care” (SC). Materials and Methods. We randomly surveyed 120 hematologic and 120 solid tumor oncology specialists at our tertiary care cancer center to examine their attitudes and beliefs toward PC and SC referral. Results. Of the 240 specialists, 182 (76%) responded. Compared with solid tumor specialists, hematologic specialists were less likely to report that they would refer symptomatic patients with newly diagnosed cancer to PC (solid tumor, 43% vs. hematology, 21%; p 5 .002). A significantly greater proportion of specialists expressed that they would refer a patient with newly diagnosed cancer

to SC than PC (solid tumor specialists: SC, 81% vs. PC, 43%; p , .001; hematology specialists: SC, 66% vs. PC, 21%; p , .001). The specialists perceived that PC was more likely than SC to be a barrier for referral (PC, 36% vs. SC, 3%; p , .001), to be synonymous with hospice (PC, 53% vs. SC, 6%; p , .001), to decrease hope (PC, 58% vs. SC, 8%; p , .001), and to be less appropriate for treatment of chemotherapy side effects (PC, 64% vs. SC, 19%; p , .001). On multivariate analysis, female clinicians (odds ratio [OR], 4.5; 95% confidence interval [CI], 1.3-15.2; p 5 .02) and the perception that PC is a barrier for referral (OR, 3.0; 95% CI, 1.2-7.6; p 5 .02) were associated with PC referral if the service name “SC” was used. Conclusion. Hematologic specialists were less likely to refer patients early in the disease trajectory and were conducive to referral with the service name SC instead of PC.The Oncologist 2015;20:1326–1332

Implications for Practice: The present survey of oncology specialists found that hematologic specialists were less likely than solid tumor specialists to report that they would refer symptomatic patients with newly diagnosed cancer to palliative care. However, both groups were significantly more willing to refer patients early in the disease trajectory if the service name “supportive care” were used instead of “palliative care.” These findings suggest that rebranding might help to overcome the stigma associated with palliative care and improve patient access to palliative care services.

INTRODUCTION Palliative care is a discipline that aims to improve the quality of life of patients and families by addressing their physical, emotional, existential, and informational needs [1]. A growing body of evidence supports the early introduction of palliative care from the time of cancer diagnosis for improved outcomes [2–6]. The American Society of Clinical Oncology has published multiple statements to support early palliative care [7, 8]. Several randomized controlled trials also support the routine involvement of specialist palliative care within 8 weeks of diagnosis of advanced cancer to improve patient outcomes [3, 4].

Currently, referral to palliative care remains delayed because of multiple patient-related, clinician-related, and system barriers [9, 10]. One of the key clinician-related barriers is the stigma associated with the service name “palliative care” [11, 12]. We previously conducted a survey of oncology specialists at our cancer center to examine clinicians’ beliefs toward the service names “palliative care” and “supportive care.” When asked whether the “service name can decrease hope in patient and families,” 61% of oncology specialists agreed with this statement for palliative care in contrast to 15%

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Correspondence: David Hui, M.D., Department of Palliative Care and Rehabilitation Medicine, Unit 1414,The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA. Telephone: 713-792-6085; E-Mail: [email protected] Received June 15, 2015; accepted for publication July 31, 2015; published Online First on September 28, 2015. ©AlphaMed Press 1083-7159/2015/ $20.00/0 http://dx.doi.org/10.1634/theoncologist.2015-0240

The Oncologist 2015;20:1326–1332 www.TheOncologist.com

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MATERIALS AND METHODS Participants The present report describes the planned secondary analysis of a study that examined the end-of-life care preferences among hematologic and solid tumor oncology specialists [20]. In brief, oncologists and midlevel providers (i.e., physician assistants or advanced nurse practitioners) in either hematologic oncology or solid tumor oncology at the University of Texas MD Anderson Cancer Center (MDACC) were invited to participate. We excluded oncology specialists from the phase I and general oncology programs, because they routinely treat both hematologic malignancies and solid tumors. The MDACC institutional review board approved the present study and waived the requirement for review and informed consent. Because the degree of provision of palliative care varies widely across the United States [21], we designed this as a single-institution study to control for the level of access to specialist palliative care programs.

Survey Development The survey covered 3 key aspects of end-of-life care: (a) palliative systemic therapy, (b) attitudes and beliefs toward end-of-life care, and (c) specialist palliative care referral. The first two domains have been previously reported in detail [20]. The present study focused on the third domain regarding specialist palliative care referral. We used questions from a previously published survey that compared health care professionals’ preferences for the service names “supportive care” and “palliative care” [13] . We asked the respondents whether they would use the palliative care service for a patient with symptoms and who is (a) newly diagnosed with cancer, (b) undergoing active primary treatment for cancer (curative intent), (c) without evidence of active cancer, (d) receiving active

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treatment for advanced cancer (palliative intent), and (e) no longer receiving cancer treatment. They were also asked whether the service name (a) is a barrier for referral, (b) is synonymous with hospice and end-of-life care, (c) decreases hope in patients and families, and (d) is associated with treatment of chemotherapy side effects.These nine questions were repeated for the service name “supportive care.” The choices were “strongly agree,” “agree,” “neither agree nor disagree,” “disagree,” and “strongly disagree.” We combined the answers “strongly agree” and “agree” for reporting purposes. At the end of the survey, the respondents were asked to provide their characteristics, such as age group, sex, oncology specialty, years of clinical experience, and palliative care training. We also asked them to estimate the percentage of advanced cancer patients they referred to palliative care.

Survey Process As reported previously [20], we identified all eligible oncologists and midlevel providers in the Division of Cancer Medicine at the MDACC and randomly sampled 60 of 67 hematologic oncologists, 60 of 97 solid tumor oncologists, 60 of 103 hematologic oncology midlevel providers, and 60 of 99 solid tumor midlevel providers. All individuals surveyed received an initial invitation electronically and on paper, followed by reminders accompanied by the survey at 2, 4, 8, and 12 weeks. An incentive of $10 was provided to all participants. Data collection occurred between May and August 2014.

Statistical Analysis As reported previously, the present study was powered to compare the treatment preferences between hematologic and solid tumor oncology specialists. With 120 participants surveyed in each group and an anticipated response rate of 60%, we had 93% power to detect an effect size as small as 0.59 using a two-sided two-sample t test with a 5% significance level [20]. We summarized the data using standard descriptive statistics, including medians, interquartile ranges, proportions, and frequencies. We compared the responses between the solid tumor oncology teams and hematologic malignancy teams using the chi-square test or Fisher’s exact test for categorical variables and the Wilcoxon rank sum test for nonparametric continuous variables. Because each clinician answered the questions regarding their attitudes and belief toward palliative care referral and then repeated the same questions for the alternative service name “supportive care,” we used the McNemar test to compare the intraindividual differences between the two service names. We then determined the factors associated with each clinician’s attitudes toward referral of a symptomatic patient with newly diagnosed cancer. We focused on this specific population, because it represents the earliest possible time point for palliative care involvement and because a vision statement from the American Society of Clinical Oncology stated that “palliative cancer care is consistently delivered to prevent and relieve the suffering of patients and families from the day of diagnosis” [7]. Among the clinicians who stated that ©AlphaMed Press 2015

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for supportive care. When asked whether the “service name is a barrier for me to refer patients,” 44% agreed for the term “palliative care” compared with 11% for the term “supportive care” [13]. This led us to change our program name from palliative care to supportive care in 2007, without changing the nature of our service. We found more referrals and earlier referrals among outpatients after the name change, supporting our hypothesis that the term “supportive care” facilitates palliative care access [14]. Another important clinician-related barrier is oncology specialty—patients with hematologic malignancies were much less likely to be referred to palliative care than patients with solid tumors despite a similar symptom burden [15–17]. The attitudes and beliefs toward palliative care referral have not been well examined among hematologic oncologists [18, 19]. A better understanding of how these oncology professionals perceive palliative care and the factors associated with referral could allow us to better overcome the barriers to early palliative care referral. In the present study, we examined the attitudes and beliefs toward palliative care referral between hematologic and solid tumor specialists and how their perception changed with use of the service name “supportive care.”

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Table 1. Palliative care and supportive care referral by oncology specialty Hematologic oncology, n (%) Survey statement I use the “palliative care” service for a patient with symptoms and who is . . . Newly diagnosed with cancer Undergoing active primary treatment for cancer (curative intent) Without evidence of active cancer Receiving active treatment for advanced cancer (palliative intent) No longer receiving cancer treatment I use the “supportive care” service for a patient with symptoms and who is . . . Newly diagnosed with cancer Undergoing active primary treatment for cancer (curative intent) Without evidence of active cancer Receiving active treatment for advanced cancer (palliative intent) No longer receiving cancer treatment

Solid tumor oncology, n (%)

MLP

Both

Faculty

MLP

Both

p valuea

7 (16) 9 (21)

11 (26) 11 (26)

18 (21) 20 (24)

20 (45) 15 (34)

21 (40) 23 (44)

41 (43) 38 (40)

.002 .02

7 (16) 30 (70)

11 (26) 40 (95)

18 (21) 70 (82)

10 (23) 37 (84)

10 (19) 48 (92)

20 (21) 85 (89)

.95 .24

35 (81)

31 (74)

66 (78)

32 (73)

39 (75)

71 (74)

.56

25 (58) 29 (67)

31 (74) 36 (86)

56 (66) 65 (76)

33 (75) 29 (66)

46 (87) 45 (85)

79 (81) 74 (76)

.02 .98

21 (49) 33 (77)

26 (63) 37 (88)

47 (56) 70 (82)

24 (55) 38 (86)

35 (66) 52 (98)

59 (61) 90 (93)

.51 .03

37 (86)

37 (90)

74 (88)

33 (75)

47 (89)

80 (82)

.29

Faculty

Data are presented as number (%) of respondents who agreed or strongly agreed. a Chi-square or Fisher’s exact test used, as appropriate. Abbreviation: MLP, midlevel providers (including physician assistants and advanced nurse practitioners).

they would not refer a symptomatic patient with newly diagnosed cancer to palliative care, we determined the clinician demographics, attitudes, and beliefs that were associated with a change in this decision with the name “supportive care.” We conducted univariate analysis using the chi-square test or Fisher’s exact test for categorical variables and the Wilcoxon rank sum test for nonparametric continuous variables. p values , .10 were considered in a multivariate logistic regression model. The Statistical Analysis Software, version 9.3 (SAS Institute, Inc., Cary, NC, http://www.sas.com), software program was used for statistical analysis. We considered p , .05 to indicate statistical significance.

RESULTS Clinician Demographic Data

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The response rate by oncology specialty was 85 of 120 (71%) for hematologic oncology and 97 of 120 (81%) for solid tumor oncology. The response rate by profession was 87 of 120 (73%) for physicians and 95 of 120 (79%) for midlevel providers. The overall response rate was 182 of 240 (76%). The characteristics of the clinicians who completed the survey have been previously reported [20]. In brief, 120 of 182 (66%) were older than 40 years, 123 of 182 (68%) were women, and the median postgraduate clinical experience was 10 years (interquartile range, 6–17). Regarding palliative care training, 2 of 182 (1%) reported that they had completed a formal fellowship, 36 (20%) reported at least a 1-month clinical rotation, and 84 (46%) reported attendance at palliative care courses or continuing medical education.

Differences in Specialist “Palliative Care” and “Supportive Care” Referral Between Hematologic and Solid Tumor Specialists Hematologic specialists were less likely to report that they would refer to “palliative care” patients with newly diagnosed cancer (21% vs. 43%, p 5 .002) and undergoing active primary treatment (24% vs. 40%, p 5 .02) than were solid tumor specialists (Table 1). Only 21% in both groups reported that they would refer patients without evidence of active cancer. A vast majority of oncology specialists would use the palliative care service for patients receiving palliative cancer therapies and no longer receiving cancer treatment (Table 1). Hematologic specialists were also less likely to refer patients with newly diagnosed cancer (66% vs. 81%, p 5 .02) and those receiving active treatment for advanced cancer (82% vs. 93%, p 5 .03) to “supportive care.” No significant difference was found between how hematologic and solid tumor specialists perceived the terms “palliative care” and “supportive care” (Table 2).

Differences in Attitudes and Beliefs Toward the Service Names “Palliative Care” and “Supportive Care” When making a referral, oncology specialists significantly preferred the service name “supportive care” over “palliative care” (Table 3). Specifically, clinicians reported that they would be more likely to refer those patients with newly diagnosed cancer (74% vs. 32%, p , .001), undergoing active treatment (76% vs. 32%, p , .001), without evidence of cancer (58% vs. 21%, p , .001), and no longer receiving cancer treatments (85% vs. 75%, p 5 .003) to “supportive care.” “Supportive care” was also perceived as less likely to be a barrier for referral (3% vs. 36%, p , .001), less likely to be synonymous with hospice (6% vs. 53%, p , .001), less likely to

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Table 2. Perception of the terms “palliative care” and “supportive care” by oncology specialty

Perception Regarding “palliative care” Service name is a barrier for me to refer patients Service name is synonymous with hospice and end-of-life care Service name can decrease hope in patients and families Service name is associated with treatment of chemotherapy side effects Regarding “supportive care” Service name is a barrier for me to refer patients Service name is synonymous with hospice and end-of-life care Service name can decrease hope in patients and families Service name is associated with treatment of chemotherapy side effects

Hematologic oncology, n (%)

Solid tumor oncology, n (%)

Faculty

MLP

Both

Faculty

MLP

Both

18 (42) 26 (60)

18 (43) 22 (52)

36 (42) 48 (56)

14 (32) 20 (45)

16 (30) 29 (55)

30 (31) 49 (51)

.11 .42

26 (60)

27 (64)

53 (62)

25 (57)

28 (53)

53 (55)

.29

5 (12)

9 (21)

14 (16)

6 (14)

15 (28)

21 (22)

.38

1 (2) 2 (5)

2 (5) 3 (7)

3 (4) 5 (6)

1 (2) 3 (7)

2 (4) 3 (6)

3 (3) 6 (6)

2 (5) 21 (49)

5 (12) 31 (74)

7 (8) 52 (61)

3 (7) 25 (57)

4 (8) 39 (74)

7 (7) 64 (66)

p valuea

. .99 . .99 .80 .50

Data are presented as number (%) of respondents who agreed or strongly agreed. a Chi-square or Fisher’s exact test used, as appropriate. Abbreviation: MLP, midlevel providers (including physician assistants and advanced nurse practitioners).

Table 3. Differences between “palliative care” and “supportive care” perceived by oncology specialists Palliative care, n (%) Statement I use this service for a patient with symptoms and who is . . . Newly diagnosed with cancer Undergoing active primary treatment for cancer (curative intent) Without evidence of active cancer Receiving active treatment for advanced cancer (palliative intent) No longer receiving cancer treatment Regarding the service name Service name is a barrier for me to refer patients Service name is synonymous with hospice and end-of-life care Service name can decrease hope in patients and families Service name is associated with treatment of chemotherapy side effects

Hematologic

Solid tumor

18 (21) 20 (24)

41 (43) 38 (40)

18 (21) 70 (82)

Supportive care, n (%) Hematologic

Solid tumor

Both

p valuea

59 (32) 58 (32)

56 (66) 65 (76)

79 (81) 74 (76)

135 (74) 139 (76)

, .001 , .001

20 (21) 85 (89)

38 (21) 155 (85)

47 (56) 70 (82)

59 (61) 90 (93)

106 (58) 160 (88)

, .001 .52

66 (78)

71 (74)

137 (75)

74 (88)

80 (82)

154 (85)

.003

36 (42)

30 (31)

66 (36)

3 (4)

3 (3)

6 (3)

, .001

48 (56)

49 (51)

97 (53)

5 (6)

6 (6)

11 (6)

, .001

53 (62)

53 (55)

106 (58)

7 (8)

7 (7)

14 (8)

, .001

14 (16)

21 (22)

35 (19)

52 (61)

64 (66)

116 (64)

, .001

Both

decrease hope in patients and families (8% vs. 58%, p , .001), and more likely to be associated with treatment of chemotherapy side effects (64% vs. 19%, p , .001).

Factors Associated With a Referral to “Supportive Care” but Not “Palliative Care” Among the clinicians who stated that they would not refer a symptomatic patient with newly diagnosed cancer to “palliative care,” we found that female sex, faculty membership,

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reporting that palliative care is a barrier for referral, and reporting that supportive care is associated with treatment of chemotherapy side effects were associated with a decision to refer the same patient to “supportive care” (Table 4). On multivariate analysis, female clinicians (odds ratio, 4.5; 95% confidence interval, 1.3-15.2; p 5 .02) and the perception that palliative care is a barrier for referral (odds ratio, 3.0; 95% confidence interval, 1.2-7.6; p 5 .02) were associated with a referral to ”supportive care” but not to “palliative care.” ©AlphaMed Press 2015

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Data are presented as number (%) of respondents who agreed or strongly agreed. a McNemar test.

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Table 4. Factors associated with a referral if name changed from “palliative care” to “supportive care”

Characteristic Age group (yr) 20–29 30–39 40–49 50–59 60–69 $70 Female cliniciansb Hematologic specialty Faculty (vs. MLP)b Postgraduate experience (yr)b Median Interquartile range The service name “palliative care” . . . Is a barrier for referralb Is synonymous with hospice and end-of-life care Decreases hope in patients and families Is associated with treatment of chemotherapy side effects The service name “supportive care” . . . Is a barrier for referral Is synonymous with hospice and end-of-life care Decreases hope in patients and families Is associated with treatment of chemotherapy side effectsb

Would not refer to either “palliative care” or “supportive care” (n 5 46), n (%)

Would not refer to “palliative care” but would refer to “supportive care” (n 5 76), n (%)

p valuea .30

1 (2) 15 (33) 13 (28) 10 (22) 5 (11) 2 (4) 22 (48) 28 (61) 28 (61)

6 (8) 20 (26) 22 (29) 22 (29) 6 (8) 0 (0) 55 (72) 39 (51) 32 (42)

14 (9–19)

10 (5–16)

12 (26) 25 (54) 25 (54) 8 (17)

35 (46) 48 (63) 45 (59) 14 (18)

.03 .34 .60 .89

0 (0) 4 (9) 4 (9) 25 (54)

4 (5) 3 (4) 4 (5) 55 (72)

.11 .27 .46 .04

.006 .30 .045 .06c

Data are presented as number (%) of respondents agreed or strongly agreed, unless otherwise specified. a Chi-square or Fisher’s exact test where appropriate, unless otherwise specified. b These variables had p , .10 and were entered into a multivariate logistic regression model. c Mann-Whitney U test. Abbreviation: MLP, midlevel providers (including physician assistants and advanced nurse practitioners).

DISCUSSION

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The hematologic specialty remained a barrier to early palliative care access, after controlling for other clinician characteristics, such as age, sex, palliative care training, and attitudes and beliefs toward palliative care. We also found that “supportive care” as a service name was associated with a significant increase in early referral among both solid tumor and hematologic specialists. Our findings provide further evidence to support the use of the program name “supportive care” to facilitate palliative care access for patients with solid tumors and patients with hematologic malignancies. Early referral to palliative care has been associated with improved quality of end-of-life care for cancer patients [6]. A growing body of evidence supports the role of palliative care in the provision of symptom management [3, 5, 22]. Although the optimal timing of referral remains to be defined, multiple organizations such as the American Society of Clinical Oncology and National Cancer Institute have supported that the timing can be as early as around the time of diagnosis [7, 23]. This might be particularly true if the patient has significant symptom needs. Because palliative care and hospice referrals are often initiated by oncology specialists, their perception of these services can be a key determinant in

whether patients are referred. In the present study, we found that hematologic specialists were significantly less likely than were solid tumor specialists to report that they would refer patients early in the disease trajectory to palliative care. Our findings are consistent with a recent qualitative study from the United Kingdom and multiple studies examining palliative care referral patterns [9, 16, 18]. Some of the reasons for delayed referral might include a perceived lack of palliative care needs among these patients, the possibility of cure in the advanced disease setting, heightened expectations regarding treatment outcomes, uncertainty in the disease trajectory, confidence in the provision of supportive care, a strong sense of responsibility to provide care, the stigma associated with palliative care, and the lack of randomized controlled trials to support early palliative care for patients with hematologic malignancies [11, 18, 19, 24, 25]. Practice guidelines, decision aids, care pathways, and other methods to integrate hematology and palliative care, such as increased education regarding the role of palliative care, might improve the referral process [26]. Because of the persistent stigma that palliative care is associated with death and dying, the name “supportive care” has been adopted by various palliative care programs around the world to facilitate referral [12, 13]. We previously

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conducted a systematic review of the definitions for “supportive care,” “palliative care,” and “hospice care” in published studies and developed a conceptual framework that put these terms in context of each other. [27] Supportive care was defined as “the provision of the necessary services for those living with or affected by cancer to meet their informational, emotional, spiritual, social, or physical needs during their diagnostic, treatment, or follow-up phases encompassing issues of health promotion and prevention, survivorship, palliation, and bereavement” [28]. Under this conceptual framework, palliative care is, by definition, supportive care for patients with advanced diseases [29]. Consistent with our hypothesis, both solid tumor specialists and hematologic specialists perceived the service name “supportive care” to be more conducive for referral. In contrast to a similar survey in 2009, we found greater differences favoring the term “supportive care” [13]. Importantly, we found that hematologic specialists were receptive to the term “supportive care” and reported that they would increase the referral of newly diagnosed cancer patients from 21% to 66%. Interestingly, solid tumor specialists also reported a similar magnitude of increase from 43% to 81%. Thus, the present study, for the first time, has demonstrated how an intervention to overcome the stigma could potentially result in greater rates of palliative care access among hematologic specialists. Further studies are needed to examine whether the actual referral patterns mirror the survey findings. Other interventions to further destigmatize “palliative care,” such as rotations through palliative care and routine involvement of palliative care physicians in hematology patient care rounds, might also be useful and need to be tested [30]. Among the clinicians who stated that they would not refer a symptomatic patient with newly diagnosed cancer to palliative care, most (76 of 122, 62%) stated that they would refer the patient when the service name was changed to “supportive care.” We found that clinicians who perceived that the term “palliative care” was a barrier for referral were more likely to make this switch. Our findings further support that the name “supportive care” helps to overcome the stigma associated with the phrase “palliative care.” Female sex was also a predictive factor, independent of other clinician demographics such as health profession. Further research is necessary to understand why female clinicians were more receptive to this term. The present study had several limitations. First, it was a single-institution study at a tertiary care cancer center in the

United States, which might limit the generalizability ofour study. It should be noted, however, that a survey of Canadian oncologists and a randomized controlled trial of patients’ perception both demonstrated that the service name “supportive care” was preferred over “palliative care,” consistent with our findings [31, 32]. Second, our center had already adopted the service name “supportive care,” which might have potentially biased our findings. Finally, we did not include oncologists who provide care to both patients with hematologic malignancies and patients with solid tumors. More research is needed to understanding their referral practices.

CONCLUSION Our study findings have revealed that inherent differences exist in the attitudes and beliefs toward palliative care between hematologic and solid tumor specialists. Encouragingly, the stigma associated with palliative care can partly be overcome by a simple change in the service name to “supportive care,” which was well received by many clinicians. Other approaches to further destigmatize palliative care and integrate these programs into cancer care are needed to optimize care for cancer patients.

ACKNOWLEDGMENTS We thank all the clinicians who responded to our study. David Hui is supported in part by a National Institutes of Health grant (R21CA186000-01A1), an American Cancer Society Mentored Research Scholar Grant in Applied and Clinical Research (MRSG-14-1418-01-CCE), and an institutional startup grant (18075582). The funding organizations had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

AUTHOR CONTRIBUTIONS Conception/Design: David Hui, Minjeong Park, Diane Liu, Eduardo Bruera Provision of study material or patients: David Hui Collection and/or assembly of data: David Hui, Akhila Reddy Data analysis and interpretation: David Hui, Minjeong Park, Diane Liu, Shalini Dalal, Eduardo Bruera Manuscript writing: David Hui, Eduardo Bruera Final approval of manuscript: David Hui, Minjeong Park, Diane Liu, Akhila Reddy, Shalini Dalal, Eduardo Bruera

DISCLOSURES The authors indicated no financial relationships.

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need, next steps—From the American Society of Clinical Oncology. J Clin Oncol 2009;27:3052–3058. 8. Smith TJ, Temin S, Alesi ER et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012;30: 880–887. 9. Hui D, Kim SH, Kwon JH et al. Access to palliative care among patients treated at a comprehensive cancer center. The Oncologist 2012;17:1574–1580. 10. Morita T, Akechi T, Ikenaga M et al. Late referrals to specialized palliative care service in Japan. J Clin Oncol 2005;23:2637–2644.

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This article is available for continuing medical education credit at CME.TheOncologist.com.

For Further Reading: David Hui, Yu Jung Kim, Ji Chan Park et al. Integration of Oncology and Palliative Care: A Systematic Review. The Oncologist 2015;20:77-83. Implications for Practice: This systematic review identified 38 indicators of integration of oncology and palliative care (PC). On further validation, these indicators may facilitate benchmarking, prioritization, quality improvement, and accountability. Specifically, these indicators may facilitate (a) referring physicians, patients, and caregivers to identify the centers that offer a high level of access to PC services; (b) policy makers and administrators to benchmark their level of integration nationally and internationally, standardize their services, and allocate appropriate resources toward quality improvement; (c) organizations to provide special designations based on the level of integration; and (d) researchers to examine how the extent of integration is associated with various health care outcomes.

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Attitudes and Beliefs Toward Supportive and Palliative Care Referral Among Hematologic and Solid Tumor Oncology Specialists.

Palliative care (PC) referrals are often delayed for patients with hematologic malignancies. We examined the differences in attitudes and beliefs towa...
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