Supportive Care in Cancer

, Volume 23, Issue 4, pp 1073–1080 | Cite as

The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer

  • Breffni Hannon
  • Nadia Swami
  • Ashley Pope
  • Gary Rodin
  • Elizabeth Dougherty
  • Ernie Mak
  • Subrata Banerjee
  • John Bryson
  • Julia Ridley
  • Camilla ZimmermannEmail author
Original Article


Several recently published randomized controlled trials have demonstrated the benefits of early palliative care involvement for patients with advanced cancer. In the oncology outpatient setting, palliative care clinics are an ideal site for the provision of early, collaborative support, which can be maintained throughout the cancer trajectory. Despite this, access to ambulatory palliative care clinics is limited, even at tertiary cancer centres. Existing programs for outpatient palliative care are variable in scope and are not well described in the literature. We describe the development and expansion of an outpatient palliative care clinic at the Princess Margaret Cancer Centre, Toronto, Canada, demonstrating how the clinic functions at a local and regional level. This clinic served as the intervention for a recent large cluster-randomized trial of early palliative care. The model for this service can be adapted by other palliative care programs that aim to provide early, integrated oncology care.


Palliative care Advanced cancer Early intervention Outpatient clinic 



We extend our thanks to all the interdisciplinary palliative care team members who made the functioning of this clinic possible. Special thanks to Catherine Purcell, Christine Cameron, Malka Berman and Pat Cotman for their commitment to clinical and academic excellence in developing our outpatient palliative care service. This research was funded by the Canadian Cancer Society (grant #700862; CZ), and the Ontario Ministry of Health and Long Term Care. Dr. Zimmermann is supported by the Rose Family Chair in Supportive Care, Faculty of Medicine, University of Toronto.

Conflict of interest

There are no financial disclosures from any of the authors.


  1. 1.
    Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363(8):733–742. doi: 10.1056/NEJMoa1000678 CrossRefPubMedGoogle Scholar
  2. 2.
    Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, Hull JG, Li Z, Tosteson TD, Byock IR, Ahles TA (2009) Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA 302(7):741–749. doi: 10.1001/jama.2009.1198 CrossRefPubMedCentralPubMedGoogle Scholar
  3. 3.
    Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, Moore M, Rydall A, Rodin G, Tannock I, Donner A (2014) Lo C (2014) Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 383(9930):1721–30. doi: 10.1016/S0140-6736(13)62416-2 CrossRefPubMedGoogle Scholar
  4. 4.
    Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL, Earle CC, Weeks JC (2012) Associations between end-of-life discussion characteristics and care received near death: a prospective cohort trial. J Clin Oncol 30(35):4387–95. doi: 10.1200/JCO.2012.43.6055 CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    World Health Organisation (2010) WHO definition of palliative care. Accessed 17 December 2013
  6. 6.
    Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, Ferrell BR, Loscalzo M, Meier DE, Paice JA, Peppercorn JM, Somerfield M, Stovall E, Von Roenn JH (2012) American Society of Clinical Oncology Provisional Clinical Opinion: the integration of palliative care into standard oncology care. J Clin Oncol 30(8):880–887. doi: 10.1200/JCO.2011.38.5161 CrossRefPubMedGoogle Scholar
  7. 7.
    Foley K, Gelband H (eds) (2001) Improving palliative care for cancer: summary and recommendations. National Academies Press, Washington DCGoogle Scholar
  8. 8.
    Weissman DE, Meier DE (2008) Operational features for hospital palliative care programs: consensus recommendations. J Palliat Med 11(9):1189–1194. doi: 10.1089/jpm.2008.0149 CrossRefPubMedGoogle Scholar
  9. 9.
    Meier DE, Beresford L (2008) Outpatient clinics are a new frontier for palliative care. J Palliat Med 11(6):823–828. doi: 10.1089/jpm.2008.9886 CrossRefPubMedGoogle Scholar
  10. 10.
    Follwell M, Burman D, Le LW, Wakimoto K, Seccareccia D, Bryson J, Rodin G, Zimmermann C (2009) Phase II study of an outpatient palliative care intervention in patients with metastatic cancer. J Clin Oncol 27(2):206–213. doi: 10.1200/JCO.2008.17.7568 CrossRefPubMedGoogle Scholar
  11. 11.
    Rabow M, Kvale E, Barbour L, Cassel JB, Cohen S, Jackson V, Luhrs C, Nguyen V, Rinaldi S, Stevens D, Spragens L, Weissman D (2013) Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med 16(12):1540–9. doi: 10.1089/jpm.2013.0153 CrossRefPubMedGoogle Scholar
  12. 12.
    Hui D, Elsayem A, De la Cruz M, Berger A, Zhukovsky DS, Palla S, Evans A, Fadul N, Palmer JL, Bruera E (2010) Availability and integration of palliative care at US cancer centres. JAMA 303:1054–61. doi: 10.1001/jama.2010.258 CrossRefPubMedCentralPubMedGoogle Scholar
  13. 13.
    Strasser F, Sweeney C, Willey J, Benisch-Tolley S, Palmer JL, Bruera E (2010) Impact of a half-day multidisciplinary symptom control and palliative care outpatient clinic in a comprehensive cancer centre on recommendations, symptom intensity, and patient satisfaction: a retrospective descriptive study. J Pain Symptom Manag 27(6):481–91CrossRefGoogle Scholar
  14. 14.
    Smith AK, Thai JN, Bakitas MA, Meier DE, Spragens LH, Temel JS, Weissman DE, Rabow MW (2013) The diverse landscape of palliative care clinics. J Palliat Med 16(6):661–8. doi: 10.1089/jpm.2012.0469 CrossRefPubMedCentralPubMedGoogle Scholar
  15. 15.
    Anderson F, Downing GM (1996) Palliative Performance Scale (PPS): a new tool. J Palliat Care 12(1):5–11PubMedGoogle Scholar
  16. 16.
    Ho F, Lau F, Downing MG, Lesperance M (2008) A reliability and validity study of the Palliative Performance Scale. BMC Palliat Care 7:10. doi: 10.1186/1472-684X-7-10 CrossRefPubMedCentralPubMedGoogle Scholar
  17. 17.
    Cancer Care Ontario (2013) Palliative Care Collaborative Care Plans (CCPs) End-of-Life Stage. Cancer Care Ontario. Accessed 17 December 2013
  18. 18.
    Bryson J, Coe G, Swami N, Murphy-Kane P, Seccareccia D, Le LW, Rodin G, Zimmermann C (2010) Administrative outcomes five years after opening an acute palliative care unit at a comprehensive cancer centre. J Palliat Med 13(5):559–65. doi: 10.1089/jpm.2009.0373 CrossRefPubMedGoogle Scholar
  19. 19.
    Zimmermann C, Seccareccia D, Clarke A, Warr D, Rodin G (2006) Bringing palliative care to a Canadian cancer centre: the palliative care program at Princess Margaret Hospital. Support Care Cancer 14(10):982–987CrossRefPubMedGoogle Scholar
  20. 20.
    Bruera E (1991) The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 7:6–9PubMedGoogle Scholar
  21. 21.
    Chang VT, Hwang SS, Feuerman M (2000) Validation of the Edmonton Symptom Assessment Scale. Cancer 88(9):2164–2171CrossRefPubMedGoogle Scholar
  22. 22.
    Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET, Carbone PP (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649–55CrossRefPubMedGoogle Scholar
  23. 23.
    Canadian Cancer Society (2010) Living with Advanced Cancer. Accessed 09 March 2014
  24. 24.
    Towns K, Dougherty E, Kevork N, Wiljer D, Seccareccia D, Rodin G, Le LW, Zimmermann C (2012) Availability of services in Ontario hospices and hospitals providing inpatient palliative care. J Palliat Med 15(5):527–34. doi: 10.1089/jpm.2011.0453 CrossRefPubMedGoogle Scholar
  25. 25.
    Selby D, Cascella A, Gardiner K, Do R, Morovan V, Myers J, Chow E (2010) A single set of numerical cutpoints to define moderate and severe symptoms for the Edmonton Symptom Assessment System. J Pain Symptom Manag 39(2):241–9. doi: 10.1016/j.jpainsymman.2009.06.010 CrossRefGoogle Scholar
  26. 26.
    Cheung WY, Le LW, Zimmermann C (2009) Symptom clusters in patients with advanced cancers. Support Care Cancer 17(9):1223–30. doi: 10.1007/s00520-009-0577-7 CrossRefPubMedGoogle Scholar
  27. 27.
    Lo C, Burman D, Rodin G, Zimmermann C (2009) Measuring patient satisfaction in oncology palliative care: psychometric properties of the FAMCARE-Patient scale. Qual Life Res 16(6):747–52. doi: 10.1007/s11136-009-9494-y CrossRefGoogle Scholar
  28. 28.
    Zimmermann C, Burman D, Bandukwala S, Seecareccia D, Kaya E, Bryson J, Rodin G, Lo C (2010) Nurse and physician inter-rater agreement of three performance status measures in palliative care outpatients. Support Care Cancer 18(5):609–16. doi: 10.1007/s00520-009-0700-9 CrossRefPubMedGoogle Scholar
  29. 29.
    Riechelmann R, Burman D, Rodin G, Tannock I, Zimmermann C (2010) Phase II trial of mirtazapine for cancer-related cachexia. Am J Hosp Palliat Med 27(2):106–10. doi: 10.1177/1049909109345685 CrossRefGoogle Scholar
  30. 30.
    Zimmermann C, Burman D, Follwell M, Wakimoto K, Seccareccia D, Bryson J, Le L, Rodin G (2010) Predictors of symptom severity and response in patients with metastatic cancer. Am J Hosp Palliat Med 27(3):175–81. doi: 10.1177/1049909109346307 CrossRefGoogle Scholar
  31. 31.
    Ma C, Bandukwala S, Burman D, Bryson J, Seccareccia D, Banerjee S, Myers J, Rodin G, Dudgeon D, Zimmermann C (2010) Interconversion of three measures of performance status: an empirical analysis. Eur J Cancer 46(18):3175–3183CrossRefPubMedGoogle Scholar
  32. 32.
    Jang RW, Burman D, Swami N, Kotler J, Banerjee S, Ridley J, Mak E, Bryson J, Rodin G, Le LW, Zimmermann C (2013) Impact of an oncology palliative care clinic on access to home care services. Am J Hosp Palliat Med 30(5):425–31. doi: 10.1177/1049909112452469 CrossRefGoogle Scholar
  33. 33.
    Jang RW, Caraiscos V, Swami N, Banerjee S, Mak E, Kaya E, Rodin G, Bryson J, Ridley J, Le LW, Zimmermann C A simple prognostic model for patients with advanced cancer based on performance status. J Oncol Pract (in press)Google Scholar
  34. 34.
    Wentlandt K, Krzyzanowska M, Swami N, Rodin G, Le L, Zimmermann C (2012) Referral practices of oncologists to specialized palliative care. J Clin Oncol 30(35):4380–6. doi: 10.1200/JCO.2012.44.0248 CrossRefPubMedGoogle Scholar
  35. 35.
    Schenker Y, Crowley-Matoka M, Dohan D, Rabow MW, Smith CB, White DB, Chu E, Tiver GA, Einhorn S, Arnold RM (2013) Oncologist factors that influence referrals to subspecialty palliative care clinics. J Oncol Practice [epub ahead of print]Google Scholar
  36. 36.
    Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ (2008) Aggressiveness of cancer care near the end of life: is it a quality of care issue? J Clin Oncol 26(23):3860–3866. doi: 10.1200/JCO.2007.15.8253 CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Ho TH, Barbera L, Saskin R, Lu H, Neville BA, Earle CC (2011) Trends in the aggressiveness of end-of-life cancer care in the universal health care system of Ontario, Canada. J Clin Oncol 29(12):1587–91. doi: 10.1200/JCO.2010.31.9897 CrossRefPubMedCentralPubMedGoogle Scholar
  38. 38.
    Maciasz RM, Arnold RM, Chu E, Park SY, White DB, Vater LB, Schenker Y (2013) Does it matter what you call it? A randomized trial of language used to describe palliative care services. Support Care Cancer 21:3411–3419. doi: 10.1007/s00520-013-1919-z CrossRefPubMedGoogle Scholar
  39. 39.
    Dalal S, Palla S, Hui D, Nguyen L, Chacko R, Li Z, Fadul N, Scott C, Thornton V, Coldman B, Amin Y, Bruera E (2011) Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer centre. Oncologist 16(1):105–11. doi: 10.1634/theoncologist.2010-0161 CrossRefPubMedCentralPubMedGoogle Scholar
  40. 40.
    Rhondali W, Burt S, Wittenberg-Lyles E, Bruera E, Dalal S (2013) Medical oncologists’ perception of palliative care programs and the impact of name change to supportive care on communication with patients during the referral process. A qualitative study. Palliat Support Care 11(5):397–404. doi: 10.1017/S1478951512000685 CrossRefPubMedGoogle Scholar
  41. 41.
    Milne D, Jefford M, Schofield P, Aranda S (2013) Appropriate, timely referral to palliative care services: a name change will not help. J Clin Oncol 31(16):2055. doi: 10.1200/JCO.2012.48.4493 CrossRefPubMedGoogle Scholar
  42. 42.
    Bruera E, Sweeney C (2001) The development of palliative care at the University of Texas M.D. Anderson Cancer Centre. Support Care Cancer 9(5):330–4CrossRefPubMedGoogle Scholar
  43. 43.
    Muir JC, Daly F, Davis MS, Weinberg R, Heintz JS, Paivanas TA, Beveridge R (2010) Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manag 40(1):126–35. doi: 10.1016/j.jpainsymman.2009.12.017 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Breffni Hannon
    • 1
    • 4
  • Nadia Swami
    • 4
  • Ashley Pope
    • 4
  • Gary Rodin
    • 3
    • 4
    • 5
  • Elizabeth Dougherty
    • 4
  • Ernie Mak
    • 2
    • 4
  • Subrata Banerjee
    • 2
    • 4
  • John Bryson
    • 1
    • 4
  • Julia Ridley
    • 2
    • 4
  • Camilla Zimmermann
    • 1
    • 3
    • 4
    • 5
    Email author
  1. 1.Division of Medical Oncology & Hematology, Department of MedicineUniversity of TorontoTorontoCanada
  2. 2.Division of Palliative Care, Department of Family and Community MedicineUniversity of TorontoTorontoCanada
  3. 3.Department of PsychiatryUniversity of TorontoTorontoCanada
  4. 4.Department of Psychosocial Oncology and Palliative Care, Princess Margaret Cancer CentreUniversity Health NetworkTorontoCanada
  5. 5.Campbell Family Cancer Research Institute, Princess Margaret Cancer CentreUniversity Health NetworkTorontoCanada

Personalised recommendations