Psychological Roots of Palliative Care Benefit in Cancer

Roxanne Nelson, BSN, RN

October 30, 2017

SAN DIEGO — Evidence has shown that palliative care relieves symptoms and improves quality of life (QOL) in patients with serious or life-threatening illnesses. But now a new study demonstrates that early palliative care can improve coping strategies, which appear to be associated with the downstream effects of enhancing QOL and reducing depressive symptoms.

"We now know that early integrative palliative care may improve these outcomes by providing patients with the skills to cope effectively with life-threatening illness," said lead author, Jamie M. Jacobs, PhD, a clinical psychologist at Massachusetts General Hospital Cancer Center in Boston. "Patients who had improvements in active coping correspondingly did have improvements in quality of life, and this was an indirect effect that was significant."

Other factors, she noted, such as symptom management, spiritual support, and self-efficacy, may have also improved outcomes.

Dr Jacobs presented the findings here at the Palliative Care in Oncology Symposium (PCOS) 2017.

Patients with advanced cancer may experience poor QOL, depression, and anxiety, and Dr Jacobs noted that a recent trial conducted by her group showed that early integrative palliative care improved QOL and reduced depressive symptoms in patients with newly diagnosed incurable lung and gastrointestinal (GI) cancers.

But the key mechanisms by which this palliative care model led to improvements in patient outcomes are unclear.

"What we don't know is how it happened," said Dr Jacobs. "How does palliative care confer its benefit? This is less clear and what we wanted to investigate."

Palliative care visits, as reported by clinicians, involve monitoring and managing symptoms, helping patients cope, building rapport, and helping patients understand and make important treatment decisions.

Dr. Jacobs and her colleagues decided that they wanted to look more at coping and figure out whether patients who participate in early integrative palliative care have an improvement or reduction in certain coping mechanisms.

They also decided to take it a step further and see whether the degree to which changes in coping mediated intervention effects on QOL and depressive symptoms.

Active Coping Improved Outcomes

A total of 350 patients with newly diagnosed incurable lung or noncolorectal GI cancer were enrolled in a randomized trial of early palliative care integrated with oncology care vs oncology care alone at Massachusetts General Hospital.

All patients completed self-report measures of QOL (Functional Assessment of Cancer Therapy-General), depressive symptoms (Patient Health Questionnaire-9), and use of active and avoidant coping strategies (Brief COPE, a validated measure of coping strategies) at baseline, 12 weeks, and 24 weeks.

Two themes emerged in this sample regarding coping strategies: One was "active," in which patients used positive reframing around their cancer diagnosis and treatment and acceptance. The other was "avoidant," which was more about self-blaming and denial.

As an example, a patient using the active approach might say:  "I have been concentrating my efforts on doing something about the situation I'm in" or "I am learning to live with it."

"They are accepting the reality of what happened and re-engaging with life," said Dr Jacobs.

Conversely, a patient using "avoidant" coping might express that "I've been saying to myself this isn't real," or "I've given up trying to deal with it."

"This is more of a passive approach, and we don't see them as engaging as meaningfully, and they are living more with a resistance approach," she said.

The results showed that patients in the palliative care group reported an increase in the use of active-approach coping strategies compared with the usual care group, from baseline to 24 weeks (B = 1.09; standard error [SE],  0.44; P = .01).

The relationship between group assignment and change in avoidant coping strategies did not reach the threshold for significance (B = 0.44; SE, 0.23; P = .06).

The palliative care group used these avoidance coping strategies slightly less, but the difference between groups was marginal.

Notably, however, the indirect effect was that QOL improved. Patients who had improvements in active coping had improvements in QOL, and this indirect effect was significant (indirect effect, 1.27; 95% confidence interval [CI], 0.31 - 2.86).

Dr Jacobs pointed out that 63% of the effect could be attributed to active coping. But improvements in 24-week QOL in patients receiving palliative care were mediated by increased use of active coping strategies and not by decreased use of avoidant coping.

Improved active coping also had a positive effect on depressive symptoms at 24 weeks (indirect effect,  –0.39; 95% CI, –0.89 to –0.08) but not by decreased use of avoidant coping. Forty-two percent of that effect could be attributed to active coping.

Early Palliative Care: Largely Psychological

Commenting on the study, Gary Rodin, MD, professor of psychiatry at the University of Toronto, Ontario, Canada, noted that early palliative care is largely psychological and is about rapport and relationship building, exploration and education about illness, and clarification of treatment goals.

But he feels that in psychological care there is an implementation gap, as the field of palliative care has been so focused on the integration with oncology. The psychological dimensions of cancer care and palliative care are much less systematized and integrated than those focused on symptom control and advance care planning.

"I think the more radical and next step is the integration of psychology with oncology and palliative care," Dr Rodin said during his discussion of the study.

This research is important because of its dedicated attention to psychological outcomes and quality of life. Dr Gary Rodin

As for the current study, the results were impressive, he explained, as palliative care clearly resulted in  better outcomes. "But this research is important because of its dedicated attention to psychological outcomes and quality of life," Dr Rodin emphasized. "It demonstrates the impact of a relatively brief and cost-efficient intervention, and also builds the evidence base for early palliative care."

But perhaps the most important takeaway from this was that "psychological benefit can derive from conversations with physicians and from minimal specialized psychological interventions."

Also important is that "integration of psychosocial care with oncology and specialized palliative care is needed to ensure cost-effective and compassionate cancer care," Dr Rodin said. "Cancer care should provide time and space for reflective conversations, and training and evaluation at all levels of medical education should include skills in empathic understanding and emotional communication and support."

This study was funded by the National Institute of Nursing Research and the National Cancer Institute. Dr Jacobs and Dr Rodin have disclosed no relevant financial relationships.

Palliative Care in Oncology Symposium (PCOS) 2017. Abstract 92. Presented October 28, 2017.

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