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Palliation should be comparable for patients with hematologic malignancies, solid tumors
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Patients with hematologic malignancies treated in community practices have end-of-life symptoms and patterns of physical decline comparable to those of patients with solid tumors, according to study results.
Thus, the use of palliative care services should not be limited among patients with hematologic malignancies, according to the researchers.
“It is often stated by health professionals that the symptom burden for people with hematologic malignancies is totally different to those with solid tumors and other life-limiting illnesses,” David C. Currow, BMed, PhD, MPH, FRACP, professor of palliative and support services at Flinders University in Adelaide, Australia, told HemOnc Today. “This is used as a justification for the very poor referral rates to hospice and palliative care for people with advancing hematologic malignancies. This study was really done in order to understand better whether this assertion is accurate.”
The analysis included 4,638 patients (hematologic malignancy, n = 224; solid tumor, n = 4,414) who were admitted to Silver Chain Hospice Care Service in Perth, Australia and who died between Jan. 1, 2011 and Dec. 31, 2013. Researchers assessed physical function and symptoms in patients at 90, 60, 30 and 7 days before death.
Patients with hematologic malignancies had a median time between referral and death of 34 days, whereas patients with solid tumors were referred a median 56 days before death (P < .0001).
The most troublesome symptoms reported among patients with hematologic malignancies included fatigue (mean score, 5.2; standard deviation [SD], 2.7) and loss of appetite (mean score, 2.3; SD, 2.9). Fatigue (P = .0035) and loss of appetite (P = .016) worsened as patients approached death.
Patients with hematologic malignancies experienced a significantly cumulative increase in their overall symptom burden over time (P = .0084).
The most prevalent symptoms among patients with solid tumors — which occurred in similar proportions of patients with hematologic malignancies — included fatigue, pain and appetite changes.
Overall, there were no significant differences in symptom scores changes over time — individually or cumulatively — or the pattern of functional decline between the two cohorts.
“Importantly, the symptom burden looks almost identical,” Currow said. “Given poor rates of access to hospice and palliative care, this suggests that systematically patients and their family caregivers are missing out on real opportunities to improve physical symptom control and also access the necessary emotional, social and existential support that is so important for people at the end of life.”
Using the Australia-modified Karnofsky performance scale, researchers observed no significant differences in declines in physical function between the two cohorts at any time point. Both cohorts of patients had moderate declines between 60 days and 30 days, and drastic declines from 30 days to 7 days (P ˂ .0001).
“Although it is true that when an acute hematologic malignancy is diagnosed there may be some ‘make-or-break’ decisions to treat very aggressively without knowing whether the outcome will be successful, for people living with chronic hematologic malignancies, there are signs that will alert health professionals to the need for referral to hospice and palliative care,” Currow said. “If we are serious about patient-centered care, it is time that we replaced some of our beliefs with firm data and, as clinicians, ensure that people can access the best possible support as they face life-limiting illnesses.”
Simon Noble
These findings justify the increased use of palliative care services for patients with hematologic malignancies in order to improve patient outcomes, Simon Noble, MBBS, MRCP, FRCP, clinical reader in palliative medicine at Marie Curie Palliative Care Research Group of Cardiff University in the U.K., wrote in an accompanying editorial.
“[This study] challenges the opinion that end-stage hematological cancers confer a different burden of symptoms and care needs to solid cancers,” Noble wrote. “An understanding of trajectories of patient decline has directly influenced the development of community palliative and end-of-life services. This [study] provides an opportunity to improve advanced care planning and to enable patients to be put in their preferred place of care at the end of life.
“The benefits of early and concurrent involvement of palliative care with solid cancer services are clear,” Noble added. “Should we not then attempt to replicate this model in the hematological setting? After all, the patients and their needs are not so different.” – by Anthony SanFilippo
For more information:
David C. Currow, BMed, PhD, MPH, FRACP, can be reached at Discipline of Palliative and Supportive Services, Flinders University, Sturt Road, Bedford Park SA 5042, Australia.
Disclosure: The researchers and Noble report no relevant financial disclosures.
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