Early Palliative Care Beneficial in Metastatic NSCLC

Roxanne Nelson

December 29, 2011

December 29, 2011 — Combining early palliative care with standard care can help optimize the timing of final chemotherapy administration and transition to hospice services. Overall, this resulted in higher-quality end-of-life care, according to an article by Joseph A. Greer, PhD, from the Center for Psychiatric Oncology and Behavioral Sciences, Massachusetts General Hospital Cancer Center, Boston, and colleagues, published online December 27 in the Journal of Clinical Oncology.

Among patients with metastatic non–small cell lung cancer (NSCLC), those who received early palliative care combined with a standard oncology regimen had less than half the odds of receiving chemotherapy within 60 days of their death (odds ratio, 0.47; 95% confidence interval, 0.23 - 0.99; P = .05) compared with those who received standard care alone. They also had a longer interval between the last dose of intravenous chemotherapy and death (median, 64.00 days vs 40.50 days; P = .02), as well as higher enrollment in hospice care for longer than 1 week (60.0% vs. 33.3%; P = .004).

This study is a follow-up to results published last year in the New England Journal of Medicine (2010;363:733-742), and reported by Medscape Medical News, which showed that integrating early palliative therapy with standard care also improved survival compared with receiving standard care alone.

Now, in the follow-up article, the authors point out that the reduction in chemotherapy use "produced no detriment to survival, contrary to popular perception that more aggressive care prolongs life in patients with metastatic cancer."

Deficiency in Training

This latest article confirms observations that aggressive treatment does not prolong survival in metastatic solid tumors, and hospice and palliative care do not shorten survival, notes Craig C. Earle, MD, from the Odette Cancer Centre in Toronto, Canada, in an accompanying editorial.

Even though this inverse relationship between supportive measures and aggressive chemotherapy use has been previously reported, earlier studies have been observational, and consequently prone to confounding influences, says Dr. Earle. At least in the United States, patients receiving chemotherapy cannot also be in hospice.

Thus, "[t]he randomized design of this study is a better confirmation of the inverse association," he writes. He also points out that prior research shows that patients residing in regions with less hospice availability have more aggressive use of chemotherapy.

"This suggests the possibility that, when we do not have support in providing end-of-life care, oncologists tend to do what we were trained to do: give chemotherapy," writes Dr. Earle.

He points out that the failure to address end-of-life issues has been extensively documented, and that it "continues to be a deficiency in our training."

"Focusing on treatment activities allowed everyone to ignore the long-term picture and led patients and their families to develop a false optimism about recovery," writes Dr. Earle. "Patients in this study eventually got more accurate information about their disease trajectory by observing what happened to other patients in clinic than they got from their oncologist."

Oncologists need to accept the possibility that our patients might be better off if we do not try to do everything ourselves.

Dr. Earle also points out that this study suggests the importance of having a comprehensive care team with different providers. "Oncologists need to accept the possibility that our patients might be better off if we do not try to do everything ourselves," he says. "It takes a village to help our patients through this journey. The quality of end-of-life care can be better when we take a team-based approach to managing incurable cancer right from the start."

Improved Survival

When the initial results from this study were published in 2010, the authors highlighted the increased survival among patients receiving early palliative care simultaneously with standard care. In this group, the median survival was 11.6 months compared with 8.9 months in the standard-care-alone group (P = .02). This survival benefit of 2.7 months is similar to that achieved with standard chemotherapy regimens.

At the time, lead author Jennifer Temel, MD, from the Massachusetts General Hospital in Boston, told Medscape Medical News that they were "thrilled with the results."

"Improving quality of life and mood in patients with metastatic NSCLC is a formidable challenge, given the progressive nature of the disease," she said, adding that this patient population usually shows deterioration in quality of life over time, and that this was seen in the control group. However, the quality of life actually improved over time for patients receiving early palliative care.

The study highlighted "the need to make sure that we provide optimal supportive care, and that is symptom management to all patients who are getting chemotherapy," commented Medscape blogger Mark G. Kris, MD, from the Memorial Sloan-Kettering Cancer Center in New York City, when the New England Journal of Medicine study was published.

"This is not a paper about end-of-life care. This is not a paper about palliative care instead of chemotherapy," he said. "It's about adding palliative care specialist interventions to standard chemotherapy. It clearly made life better. It made it longer and helped patients make much better decisions at the end of life."

"I think each of us can think about how we can take the message of this paper and bring it into each of our individual practice settings," Dr. Kris noted.

Lowered Use of Intravenous Chemotherapy

In the study, which ran from 2006 to 2009, 151 patients with newly diagnosed metastatic NSCLC were randomly assigned to receive either early palliative care integrated with standard oncology care, or standard oncology care alone. Participants who were assigned to the intervention had consultations with a member of the palliative care team within 3 weeks of enrollment, and at least monthly thereafter in the outpatient setting until death.

The objective in this latest analysis was to investigate whether early palliative care also affected the frequency and timing of chemotherapy use and hospice care for these patients. By the 18-month follow-up, a majority of the patients (n = 133; 88.1%) of the original sample had died, and the authors assessed the rates of chemotherapy during the final months of life of those who had passed away.

They observed that patients receiving early palliative care had a lower rate of chemotherapy use within 60 days of their death compared with those in the standard care group (52.5% vs 70.1%; P = .05). Within the cohort, 59.7% of the patients received intravenous chemotherapy for their final regimen, 33.3% received oral therapy, and 9 patients received no chemotherapy during the study period. However, early palliative care had a "robust effect" in lowering the use of intravenous therapy, and there was a significant difference between the 2 groups within 60 days of death (24.2% for early palliative care vs 46.3% for standard care; P = .01). There were also marginally significant findings at 30 and 14 days of death.

The study was supported in part by an American Society of Clinical Oncology Career Development Award and gifts from the Joanne Hill Monahan Cancer Fund and Golf Fights Cancer. The study authors and Dr. Earle have disclosed no relevant financial relationships.

J Clin Oncol. Published online December 27, 2011. Article abstract, Editorial

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