Early Palliative Care Beneficial, but Cancer Type Matters

Roxanne Nelson, BSN, RN

September 14, 2016

SAN FRANCISCO — Early implementation of palliative care can improve quality of life (QOL), mood, coping, and the frequency of end-of-life discussions for patients with newly diagnosed lung and gastrointestinal (GI) cancer, according to new findings.

The study also found that early integration of palliative care resulted in an increase in discussions about patient end-of-life care preferences.

However, the effect of palliative care interventions, when compared with standard care, differed by cancer type, noted lead author Joseph Greer, PhD, clinical director of psychology and a research scientist in the Center for Psychiatric Oncology and Behavioral Services at Massachusetts General Hospital, Boston.

Lung cancer patients showed improvements in QOL with early palliative care at 12 weeks, as compared to a control group who received standard care. Their improvement became even more pronounced by week 24.

"But in the GI cohort, we found that both sets of patients, whether they had palliative or standard care, had an improvement in quality of life by the 12-week time point," said Dr Greer, who presented the findings of his study here at the Palliative Care in Oncology Symposium (PCOS) 2016.

"We saw a similar trend for depression," he added. "Within the lung cancer cohort, early palliative care was favored, but we did not see differences in the groups."

The current study is the third from Dr Greer's group. In a prior randomized study that included 151 patients with newly diagnosed non–small cell lung cancer (NSCLC), the researchers found that early integrated palliative care led to a number of improvements in key outcomes, including QOL, understanding depression symptoms, and the delivery of end-of-life care.

Dr Greer explained that in this study, they wanted to build on the promising findings of the original study, as well as to expand and confirm those findings in a larger cohort.

"In addition to examining patient-reported QOL, we observed that one of the topics that is discussed over the course of disease is how patients and family caregivers are coping with the illness," he said. "So based on that, we wanted to see from the patient point of view whether there was going to be any difference in their use of basic coping strategies by implementing early palliative care."

Early Palliative Care Improves Outcomes

In this study, Dr Greer and colleagues randomly allocated 350 patients with newly diagnosed incurable lung cancer (NSCLC, small cell lung cancer, mesothelioma) or GI cancer (pancreatic, hepatobiliary, gastric, esophageal) to palliative care integrated with standard oncology care (monthly visits with palliative care team) or usual oncology care.

They used the Functional Assessment of Cancer Therapy–General to assess QOL and the Patient Health Questionniare–9 (PHQ-9) to asses mood at baseline and at weeks 12 and 24.

Patient coping styles were assessed with the Brief COPE. The investigators also assessed perceptions of likelihood of cure and communication about end-of-life preferences.

Not surprisingly, the primary focus of the majority of palliative care visits (75%) was symptom management. The second most common focus was coping (70.2%) and "how are we supporting these individuals over the course of their illness," said Dr Greer.

Other topics of focus included rapport (44.4%), illness understanding (38.4%), treatment decisions (16.3%), advanced care planning (14.2%), and disposition, such as discussions about options such as hospice care (2.1%).

At 12 weeks, which was the primary endpoint, there was no significant difference between the two groups in change of QOL or mood symptoms with respect to PHQ-9 or the HADS depression subscale scores.

But by week 24, there was a significant difference in terms of patient-reported outcomes and in scores on the PHQ-9 but not the HADS depression subscale. Patients in the palliative care arm reported higher QOL (B = 5.36; P = .002) and less depression on the PHQ-9 (B = -1.17; P = .048).

However, as noted above, a subanalysis by cancer type showed that lung cancer patients experienced an improvement in QOL with early palliative care at 12 weeks.

With respect to the measure for prognostic understanding and communication outcomes, there were no real differences between groups on the measure "primary goal of cancer treatment is cure" and with regard to the preference to "extend life as long as possible even if it meant more pain and discomfort."

But there were differences between the usual-care and palliative-care groups for the measures of making decisions about treatment (89.8% usual care vs 96.5% palliative; P = .043) and for coping with the disease (83.6% vs 97.3%; P < .001).

In particular, the proportion of patients who had discussed their wishes of dying was almost double in the palliative care group (14.5% vs 30.2%, P = .004).

"But those rates are quite low, demonstrating how we can do a lot more work in that arena," Dr Greer emphasized.

The QOL and mood trajectories varied considerably by cancer type, a finding that raises a number of important questions about future research, he said in summary.

"First, should we be tailoring palliative care interventions to specific populations, and as the cancer therapeutic world becomes more targeted and personalized, should palliative care interventions?" Dr Greer questioned.

The findings also raise methodologic questions with respect to how patients are assessed and sampled. "The improvements in cancer therapeutics are improving survival, but also QOL and mood, thus making interpretation of these reported outcomes more complex in palliative and supportive trials," he said.

Using Available Resources

In a discussion of the paper, Matthew J. Loscalzo, LCSW, professor, Department of Population Sciences at the City of Hope, Duarte, California, noted that patients are living longer with more complex diseases.

"Caregivers are seldom prepared to manage the number and complexity of what are truly medical problems, and the healthcare system is increasingly become more fragmented and less coordinated," he said.

There are many issues facing the implementation of palliative care, but one way to begin is to "leverage what already exists," Loscalzo said.

"There are large datasets right now that demonstrate unmet needs," he said, "and institutions have never been more open to supportive care services."

Loscalzo also emphasized that "we have to really focus on people who need palliative care the most."

Cancer care is changing, he pointed out. "Supportive care needs to be as strategically focused, and we can't do everything for everyone."

That said, there are also "incredible opportunities right now, such as Moon Shot, CancerlinQ, and Flatiron," he added, referring to large-scale analytics projects. "We have large data bases right now for biopsychosocial distress across settings demonstrating unmet needs in specific high-risk, high-cost groups, and these need to be integrated."

The study was funded by the Institute of Nursing Research and the National Cancer Institute. Dr Greer has disclosed no relevant financial relationships. Matthew Loscalzo has relationships with Novartis and Puma Biotechnology.

Palliative Care in Oncology Symposium (PCOS) 2016. Abstract 104. Presented September 10, 2016.

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