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Early palliative care may improve quality of life in patients with lung, gastrointestinal cancers
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Early integration of palliative care for patients with newly diagnosed incurable gastrointestinal and lung cancers improved quality of life, reduced depression symptoms, and enhanced coping with prognosis and communication about end-of-life preferences, according to a randomized clinical trial published in Journal of Clinical Oncology.
“These are incredibly important outcomes for patients with cancer, and we now have several palliative care studies that have shown these benefits,” Jennifer S. Temel, MD, clinical director of thoracic oncology at Dana-Farber Cancer Institute, told HemOnc Today. “We showed that patients receiving early integrated palliative care were more than twice as likely to have discussed their preferences for care at the end of their lives.”
The researchers enrolled 350 adult patients (54% male; 92.3% white; mean age, 64.8 years) within 8 weeks of being diagnosed with incurable lung — non–small cell lung cancer, small-cell or mesothelioma — or noncolorectal gastrointestinal cancers, including pancreatic, esophageal, gastric or hepatobiliary cancers. The researchers randomly assigned patients to receive early integrated palliative care and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015.
Patients assigned to the intervention met with a palliative care clinician at least once per month until death. Patients in the control arm received usual care and consulted with a palliative care clinician only upon request.
Temel and colleagues used the 27-item Functional Assessment of Cancer Therapy–General (FACT-G) scale — which assesses physical, functional, emotional and social well-being — to measure quality of life. Patients completed the Patient Health Questionnaire-9 and the Hospital Anxiety and Depression Scale to assess mood and anxiety.
Change in quality of life from baseline to week 12 served as the primary outcome. Secondary endpoints included change in quality of life from baseline to week 24, change in depression, and differences in end-of-life communication.
The mean number of palliative care visits was 6.54 per 24 weeks in the intervention group and 0.89 visits per 24 weeks in the usual care group.
Temel and colleagues found that intervention patients had significantly greater improvement in quality of life from baseline to week 24 than usual care patients (FACT-G from baseline, 1.59 vs. –3.4; P = .01), but the difference was not significant not from baseline to week 12 (0.39 vs. –1.13).
Intervention patients also reported lower depression at week 24 (adjusted mean difference –1.17; 95% CI, –2.33 to 0.01; P = .048).
Patients with lung cancer who received at least monthly palliative care consultations reported improvements in quality of life and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration.
Patients with gastrointestinal cancers in both study groups reported improvements in quality of life and mood by week 12.
Twice as many intervention patients compared with control patients of both cancer types discussed their wishes with their oncologists (30.2% vs. 14.5%; P = .004).
“While palliative care clinicians are certainly experts in symptom management, our data shows that they also focus on helping patients with advanced cancer cope more effectively with their cancer,” Temel said. “We show that patients receiving early integrated palliative care were more likely to report that knowing about their prognosis helped them cope with their illness and make decisions about their care. Palliative care also helps patients engage in conversations about their goals and values, both as they navigate their cancer diagnosis and near the end of life.”
The content of palliative care discussions changes according to the trajectory of a patient’s disease and the needs of the patient and his or her family, Temel added.
“We show that during the first 6 months after diagnosis, palliative care focuses predominantly on assessing and managing symptoms and on addressing and offering strategies for coping with their illness,” Temel said. “During this time [palliative care clinicians] also focus on establishing relationships with patients and their families and helping them understand their diagnosis and its likely trajectory.”
Temel and colleagues note that limitations of their study include the fact that patients and clinicians were not blinded to group assignment and that the differences in quality of life between cancers were unexpected. Also, more than one-third of patients in the usual care group met with palliative care clinicians in the first 24 weeks of the study.
Although studies demonstrate the benefits of earlier involvement of palliative care for patients with advanced cancer, many cancer care settings do not have adequate numbers of palliative care clinicians to provide early palliative care as standard of care, Temel said.
“This study provides further and novel evidence for early integrated palliative and oncology care for patients with advanced cancer and supports the recent ASCO 2016 Clinical Practice Guideline Update on integration of palliative care,” she said.
In an accompanying editorial, Eric J. Roeland, MD, assistant clinical professor at University of California, San Diego, Health Sciences, applauded Temel and colleagues for adding to the “growing body of data supporting early integration” of palliative care in cancer.
However, Roeland noted that the participants in this study were primarily white and English-speaking and thus it is not clear if a palliative care intervention would have the same impact on non–English-speaking, culturally diverse patient populations. He also noted that the study occurred at a single academic center that provided palliative care to one-third of the usual care group, potentially diluting the results.
“Yet, the unexpected findings regarding differential efficacy in this study show exactly why we need to continue doing these studies,” Roeland wrote.
Roeland added that the availability of palliative care specialists who effectively engage in oncology is highly variable, especially in the outpatient setting. Because patient visits may not be feasible in rural settings, one possible solution is telemedicine-based strategies.
“As we look to the future, we will require new strategies and methods to effectively integrate palliative care within the evolving oncology landscape,” Roeland wrote. “Research opportunities exist in developing adaptive integrative models to meet the unique needs while technology expands our ability to collect information, broaden our reach, educate and support patients and caregivers throughout the spectrum of cancer care. As we increasingly tailor cancer interventions to the unique biology of individual tumors, so too, must we tailor palliative care to meet the dynamic needs of the patient as a person.”– by Chuck Gormley
Disclosure: NIH and National Institute of Nursing Research funded the study. Temel reports research funding from Helsinn Therapeutics and Pfizer. Roeland reports no relevant financial disclosures.
Perspective
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This valuable study compared early palliative care intervention (combined with oncology care) with usual care in incurable lung and noncolorectal gastrointestinal cancers. Researchers used a thoughtful design and sophisticated statistical analytic techniques. The population was representative of the cancer population by age, and the two groups appeared well balanced on most demographic and clinical characteristics.
The study population — restricted to those with a good ECOG (0-2) performance status — nearly all had an ECOG score of 0 or 1. The researchers noted that the population was mostly male and predominantly white — due no doubt to an “ivory tower effect” — but the near absence of other ethnic groups is a concern for the generalizability of the results. It also appears that the population had a relatively low symptom burden, which is not surprising given the ECOG status. Nevertheless, the researchers have convincingly demonstrated an additive effect of early palliative care on quality of life, depression and communication outcomes.
It is extraordinary that it is possible to improve quality of life in people with incurable solid tumors followed for months longitudinally with apparently simple palliative care interventions. Set against that, it can be argued that some of the gains are modest and the palliative care interventions relatively ill-defined. There is a lack of information about concurrent antitumor treatments or outcomes, which would have been of interest — perhaps that is for another paper.
The apparent delay in effect on quality of life to 24 weeks is intriguing and unexplained. It raises the issue of not only early but sustained palliative care intervention as important, as well as the consequent costs involved. I was surprised that earlier effects were not noted; perhaps this would have been the case if the study population comprised patients with worse performance status and greater symptom burden.
The researchers appeared somewhat surprised at the variation in outcomes between lung and other cancers, but the trajectory and natural history of these diseases are very different and I did not find this remarkable.
The low rate of referral to palliative care and the inadequate exploration of end-of-life care preferences — which improved in the intervention group — in the usual care group is noteworthy. This raises concerns about the training of oncologists in appropriate use of supportive care services — which admittedly the study was intended, in part, to address. This study is another important piece of evidence in the expanding literature to support integrated palliative care as an integral and important part of modern cancer care.
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