Best Supportive Care in cancer: working models require both resource and accountability for delivery if patients are to benefit.


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Joanna Bowden1,Mhairi Gilmour2,Steinunn Boyce2,Jane Wilson2
1NHS Fife, Kirkcaldy, UK, University of Edinburgh, Edinburgh, UK, University of St Andrews, St Andrews, UK,2NHS Fife

Abstract

Background

Best Supportive Care (BSC) is the recorded plan for patients who are unable (or who choose not to) receive cancer treatment. In practice, there is a lack of consensus about what BSC is and who is responsible for its delivery. A working model of BSC in lung cancer, funded by Macmillan, was developed by Fife Specialist Palliative Care in 2015, resulting in major improvements in quality of care and a reduction in acute hospitalisation. In 2018, Macmillan provided funding to extend BSC to people with hepatobiliary (HPB) cancers and cancers of unknown primary (CUP).

Method

BSC delivery was to be shared between Oncology, Primary Care and Specialist Palliative Care teams. Retrospective and prospective data collection and descriptive statistical analysis enabled patients’ diagnostic pathways and outcomes to be described before and after new models of care.

Results

Median survival from diagnosis was 64 days for HPB BSC patients and 51 days for CUP patients. Two thirds of patients with HPB cancer and over half of patients with CUP were hospital inpatients at diagnosis. Over half of HPB and CUP patients had a biopsy, often in their last weeks of life. Major challenges in implementing shared care models of BSC were encountered, reflecting chaotic clinical pathways and a lack of resource and confusion about accountability. As a result, no improvements in the quality and reliability of BSC were seen.

Conclusion

Important lessons have been learned and these are generalisable to wider cancer populations. People with HPB cancers and CUP who are for BSC are typically near the end of life at diagnosis. Without working models of BSC they are at risk of overmedicalisation, missing out on honest conversations, timely symptom control and realistic goal-setting. BSC requires resource and accountability for delivery. Without these, it risks being an empty label that simply means ‘no cancer treatment’.