Expert Interview With Dr. Jennifer Temel

Chemotherapy + Early Palliative Care = A New Equation

Nancy Terry


September 24, 2010

In This Article

The Interview

Medscape: What prompted you to undertake the study?

Dr. Temel: The impetus for me choosing a career in lung cancer both as a clinician and researcher was to try to develop strategies for improving the experience for patients and families facing this challenging disease. These patients have an incredibly high symptom burden -- not just physical symptoms but also psychological symptoms -- which also affects their family members. I've always been focused on trying to alter clinical care to improve the experience for patients facing advanced lung cancer.

Medscape: Tell us a little bit about the study and what you learned from it.

Dr. Temel: In this study, all of the patients received standard cancer care. They were all cared for by thoracic oncologists here at Mass General. Their cancer treatment was not dictated by the study; patients received the cancer care their oncologist deemed appropriate, including participating in treatment clinical trials. The study design was quite simple: Patients were randomly assigned to standard oncology care alone or standard oncology care along with early palliative care. Patients assigned to early palliative care began meeting with the palliative-care clinician soon after diagnosis and throughout the course of their disease.

After a patient who was assigned to early palliative care finished their visit with medical oncology, they would also have a clinical visit with the palliative-care physician or nurse practitioner. The nature of the palliative-care visits was not prescribed because what the palliative-care teams really do depends on what's going on with the patient. For example, if a patient was in pain, then the nature of the visit was mostly going to be talking about pain control. If the patient asked about their prognosis -- which happened all the time -- obviously the nature of the conversation was on goals of care and decision-making. We really left the palliative-care intervention open so that the providers could meet the individual needs of the patients and their families.

Medscape: Your study showed that the addition of palliative care to standard chemotherapy extended survival of patients with metastatic lung cancer by 2.7 months. Were you and your colleagues surprised by this finding?

Dr. Temel: One of the things I think is very funny is that all of the palliative-care doctors say that they were not surprised at all, and all of the oncologists say that they were very surprised.

<Level 2> Can the Temel Findings Be Replicated?

Medscape: Editorialists from The New England Journal of Medicine commented that it might be hard to replicate your study's findings because the interventions were not specified.[2] Do you agree with their assessment?

Dr. Temel: Keeping the nature of the palliative-care visits unscripted and flexible was the best thing to do for the patients because it provided them with individualized and appropriate care. However, the editorial is correct in that it will be difficult to repeat our study in other care settings. In order to successfully implement a multisite trial, we would need to develop a more structured intervention. That's one of the things that's been challenging about supportive care and palliative-care research to date. I think we really were able to overcome that barrier with this study, but moving forward we will have to develop a standardized intervention for palliative care.

Medscape: You want to be responsive to the patient's situation but at the same time get data that support the value of integrated palliative care. How do you propose to do that?

Dr. Temel: One thing that we've proposed in our next study is to audiotape the visits. I just submitted a large grant to the National Cancer Institute describing how we would audiotape the visits to get a better sense of what happens in the interventions.

Our palliative-care clinicians told us that the oncologist would see the patient and come out and say, "Mr. Jones is doing fine. He's ready for cycle 2, with no issues." Two minutes later, the palliative-care clinician would visit with the patient, and Mr. Jones would say, "I know I'm going to die of this. I'm not sure that I want to keep doing chemo." What patients would portray to the oncologist and what they would feel comfortable saying to the palliative-care clinician were often 2 very different things.

The important thing about this next study is to figure out what transpired between the palliative-care clinicians and the patients that led to or mediated the important outcomes. How did the palliative-care visits lead to improved quality of life? How did the palliative-care visits lead to significantly lower rates of depression? Was the survival benefit due to the improved quality of life and the lower rates of depression? That's the goal of this next study.

Palliative Care and Chemotherapy Not Mutually Exclusive

Medscape: A lot of literature supports the use of palliative care, and yet consistently physicians have some resistance to using it. Why would you say that is?

Dr. Temel: Doctors, in general, are fairly data driven, and especially oncologists, who take care of really sick patients. It's hard to not be skeptical. We give these patients intensive, toxic chemotherapy that only helps them live a couple of months longer. So why would an oncologist think that palliative care could help patients live longer? On the flipside, it's somewhat intuitive. You have a team of doctors and nurses whose only goal is to help maximize quality of life. Their only focus is to help the patients feel better, physically and mentally. The care the palliative teams offer lets patients be more active, which means they stay healthier. They're less depressed so they're more likely to be out and about and keeping physically fit. Of course, they live longer.

Medscape: What about the patient response to being told that they were going to be getting early palliative care? Was there any resistance? Was there acceptance from the patients and their families?

Dr. Temel: We accrued an incredibly high percentage of eligible patients into the trial, so this did not appear to be a barrier. I suspect that some of the people who didn't participate did have fears about it, but we were able to accrue 151 patients in one cancer center in 3 years, which is about 50% of all eligible patients. I think the reason we were so successful is that our oncologists have a lot of experience doing this type of work. We've worked closely with the palliative-care doctors on this type of research for a decade. Our comfort level with discussing palliative and supportive care is quite high.

I'm hoping that that's one of the really important messages to come out of the study -- that it's clear to clinicians that palliative care and oncology care aren't mutually exclusive. They can be done at the same time.

Palliative Care May Be Appropriate for Anyone With a Challenging Illness

Medscape: At Massachusetts General, palliative care is standard practice, but for physicians and oncologists in other environments, it may be hard to switch gears from an emphasis on cure to one that acknowledges that it may be time to withhold aggressive treatment.

Dr. Temel: That was one of the great things about this study. These patients all got what we would consider to be standard, state-of-the art chemotherapy, meaning their cancer treatment wasn't dictated by their participating in the study. We didn't hold back any of the cancer care, and it wasn't altered in any way by this study. Patients were able to get all of their state-of-the art, expert cancer care and still focus on quality of life by the involving palliative-care team. Patients weren't asked to choose. They were able to do both.

Traditionally, palliative-care clinicians are asked to see patients very late in their disease course. The paradigm-changing component of this study is that we asked the palliative-care team to meet patients at the time of diagnosis [of their stage 4 metastatic disease] and follow them throughout the course of their disease.

Medscape: Commentators have remarked that this is a practice-changing study.

Dr. Temel: I don't necessarily think that the point of this study is that every single cancer patient needs to get palliative care from the time of diagnosis. We do need more data before we come out with a statement like that.

The message is that you can do both at the same time. Even if someone isn't newly diagnosed, even if somebody doesn't fit the criteria, if an oncologist thinks a patient could benefit from additional symptom management or if the patient and family are having a lot of distress, there is an added service that's available to them.

Hopefully with more research we'll get information about who should be getting early palliative care. Is it everybody, or is it just certain subsets? For now, I think the real take-home message is that palliative care is not just for people at the end of life; it's for anybody struggling with a challenging illness.

I'm starting to embark on a similar research program in breast cancer to determine whether palliative care still has benefit in a population that lives for years. I think that's a really important question.

Medscape: The study did not report on the cost-effectiveness of the treatment arms. However, it seems logical that reducing high-cost, aggressive forms of care would lower overall costs. Have you found evidence that palliative care integrated into treatment is cost-effective?

Dr. Temel: We really haven't had a chance to look at it all, but we will in the future. That's a goal that we hope to apply to this current dataset and to our future research. We'll make sure that we look at that data very carefully.

Medscape: Should palliative care take on greater emphasis in cancer research?

Dr. Temel: We all want to find a cure for lung cancer -- and for all cancers for that matter -- but while we're striving to find the cure, we can't ignore all the people who are dying of their disease. I think it's important that people understand that funding supportive care research, or even funding end-of-life care research, isn't saying that we're giving up trying to find cures for these horrible diseases. However, we can no longer ignore the important goal of making sure that patients who are dying receive the optimal care.