Early palliative care improves quality of life, frequency of end-of-life discussions

Earlier initiation of palliative care improved quality of life and coping abilities of patients with advanced lung and gastrointestinal cancers, according to study results presented at the Palliative Care in Oncology Symposium.

Perspective from Arif H. Kamal, MD

Further, patients who received earlier palliative care were more likely to have discussed their end-of-life preferences with their clinicians.

Andrew S. Epstein

“Our research looked at a new measure of a patient’s ability to cope effectively with their diagnosis. What we found was the patients who received early palliative care were more likely to use adaptive coping strategies — meaning they were more likely to take some action to make their lives better as well as to accept their diagnosis,” Joseph Andrew Greer, PhD, clinical director of psychology and research scientist at the Center for Psychiatric Oncology & Behavioral Sciences at Massachusetts General Hospital, said in a press release. “Palliative care is a key ingredient to improving a quality of life, which is important to both patients and their families.”

Early palliative care has been shown to improve the outcomes of patients with newly diagnosed metastatic non–small cell lung cancer and in patients with a poor prognosis.

Greer and colleagues evaluated the impact early, integrated palliative care had on 350 patients newly diagnosed with incurable lung cancer (n = 191) — including NSCLC, small cell lung cancer and mesothelioma — or gastrointestinal cancer (n = 159), including pancreatic, hepatobiliary, gastric and esophageal.

Researchers randomly assigned patients 1:1 to receive palliative care integrated with oncology care, which included monthly palliative care visits, or usual care.

Patients completed the Functional Assessment of Cancer Therapy-General (FACT-6) to assess quality of life and the Patient Health Questionnaire-9 (PHQ-9) to assess mood at baseline, 12 weeks and 24 weeks. Researchers also used the Brief COPE to evaluate patients’ coping styles by measuring their acceptance of their diagnosis, positive reframing and use of emotional support.

To evaluate the intervention’s effects on patient-reported outcomes, researchers calculated the B unstandardized coefficient using linear regression.

Overall, patients who received early palliative care had better quality of life (B = 5.36; 95% CI, 2.04-8.69) and less depression on the PHQ-9 (B = –1.17; 95% CI, –2.33 to –0.01) at 24 weeks. However, these measures were comparable between the groups at 12 weeks.

Those who received early palliative care also were more likely to use active and engaging coping styles at 24 weeks (B = 1.09; 95% CI, 0.23-1.96).

Although a comparable portion of patients assigned early palliative care and usual care reported that their cancer was unlikely to be cured (33.6% vs. 37.4%), more patients in the palliative care group had discussed their end-of-life preferences (30.2% vs. 14.5%; P = .004).

The researchers noted that the early palliative care model can be expanded to benefit patients with other types of advanced cancer.

“Findings such as these continue to expand and build on the benefits of integrating palliative care into the cancer care continuum,” Andrew S. Epstein, MD, ASCO expert who was not involved with the study and medical oncologist at Memorial Sloan Kettering Cancer Center, said in the press release. “A diagnosis of cancer is never easy for patients, so it is promising that we now have a strategy of early palliative care that can help patients cope while improving their quality of life.” – by Alexandra Todak

Reference:

Greer JA, et al. Abstract 104. Scheduled for presentation at: Palliative Care in Oncology Symposium; Sept. 9-10, 2016; San Francisco.

Disclosure: One researcher reports travel accommodations and expenses from, as well as research funding from, Helsinn Therapeutics.

Perspective

Arif H. Kamal, MD

A short 6 years ago, the medical world was shaken by the news that early palliative care integrated within usual oncology care does not only improve quality of life, but also improves symptoms, end-of-life care utilization and possibly survival. In truth, the work of Temel and colleagues added additional chapters to an evolving book regarding the patient- and caregiver-centered support with an “additional layer of support” from specialty palliative care. Better understanding of how palliative care can aid health systems and payers in reaching the “Triple Aim” — better experience, better outcomes and lower costs — have launched palliative care from the deep corners of care delivery novelty to a widely considered standard of care. Further development of the evidence base for palliative care continues to transform it from what was once a short story into an elegant and robust novel.
Greer and colleagues report the findings of a novel study to regularly incorporate specialty palliative care into the routine care of patients with advanced thoracic and gastrointestinal malignancies. Building upon the findings of previous studies — from their group, Project ENABLE, Zimmermann and colleagues and others — the research reported improvements in quality of life and depression among the intervention arm.
The researchers report two behaviors improved by the palliative care intervention. First, patients receiving palliative care reported more active and engaging coping styles as opposed to negative coping styles, like acting out or withdrawing. Second, those patients participated in more discussions regarding end-of-life preferences, reflecting a level of engagement around care preferences unlike that of usual care.
As studies like these add to the collective evidence base of the benefits of palliative care, it’s important to remember that palliative care is not just “something done to others,” but also a vehicle for behavioral modification and skills attainment. Palliative care’s mission is to build rapport and aid in coping. It is the field’s ethos, known by practitioners for decades, and now being borne out in clinical studies.
As palliative care’s book expands through further development of the evidence base, we will start to find no doubt that this book was about empowering our patients and caregivers, more than it was about doing things to them.

Reference:

Temel JS, et al. N Engl J Med. 2010;doi:10.1056/NEJMoa1000678.
Zimmermann C, et al. Lancet. 2014;doi:10.1016/S0140-6736(62416-2.

Arif H. Kamal, MD

Duke Cancer Institute

Disclosures: Kamal reports no relevant financial disclosures.