NEJM: Early palliative care for lung cancer extends life, improves mood
In an ideal model, comprehensive oncologic services for patients with metastatic disease both improves quality of life and facilitates the efficient allocation of resources, according to lead author Jennifer S. Temel, MD, an oncologist with Massachusetts General Hospital Cancer Center in Boston, and colleagues. Although palliative care might help meet these goals, it is traditionally delivered late in the course of the disease and has had a limited impact. Furthermore, evidence supporting palliative care benefits is sparse, explained Temel.
The research team hypothesized that palliative care must be delivered earlier in the course of disease to have a meaningful impact on quality of life and end-of-life care and undertook the study to examine the effect of early palliative care on patient-reported outcomes, use of health services and quality of end-of-life care among patients with metastatic NSCLC.
Temel and colleagues enrolled 151 patients recently diagnosed with metastatic NSCLC between June 2006 and July 2009 and assigned 77 to the palliative care group and 74 to standard care. Patients in the palliative care group met with a member of the palliative care team within three weeks of enrollment and at least monthly until death. Palliative care focused on assessing physical and psychosocial symptoms, establishing care goals, assisting with decision making regarding treatment and coordinating care based on individual needs, explained Temel.
Researchers measured health-related quality of life with the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and assessed mood with the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire 9 (PHQ-9). The primary outcome of the study was the change from baseline to 12 weeks in the Trial Outcome Index (TOI) score, which reflects the FACT-L and its lung cancer subscales.
The research team also mined the EMR to gather information about the use of health services and end-of-life care. “Patients were classified as having received aggressive care if they met any of the following three criteria: chemotherapy within 14 days before death, no hospice care or admission to hospice three days or less before death,” wrote Temel.
Patients in the palliative care group had clinically meaningful improvements in quality of life and mood, demonstrated by a 2.3-point increase in mean TOI from baseline to 12 weeks compared with a 2.3-point decrease in the standard care group, noted Temel. Although the percentage of palliative care patients with depression at 12 weeks as measured by the HADS and PHQ-9 was significantly lower than in the standard care group, approximately 18 percent of patients in both groups received new prescriptions for anti-depressants.
Among the 105 participants who had died at the time of the analysis of end-of-life care, 54 percent of standard care patients received aggressive end-of-life care compared with 33 percent of palliative care patients. In addition, 53 percent of palliative care patients documented end-of-life preferences in the EMR versus 28 percent in the standard care group.
Finally, less aggressive end-of-life care did not adversely affect survival, wrote Temel. Palliative care patients survived significantly longer than standard care patients with a median survival of 11.6 and 8.9 months, respectively (P=0.02). Temel and colleagues hypothesized that early integration of palliative care “may facilitate the optimal and appropriate administration of anticancer therapy … and with earlier referral to a hospice program, patients may receive care that results in better management of symptoms, leading to stabilization of their condition and prolonged survival.” In addition, timely integration of palliative care may counterbalance the trend toward aggressive and costly end-of-life care and “mitigate unnecessary and burdensome personal and societal costs,” concluded Temel.