Early Palliative Care
“Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer”
Temel JS, Greer JA, Muzikansky A, et al.
N Engl J Med 2010; Aug 19; 363(8):733-42. [Full Text]
Patients with metastatic cancer often receive aggressive anticancer treatments near the end of life. These treatment regimens can create a significant symptom burden for patients, but also incur substantial healthcare costs and raise important questions about distributive justice regarding the allocation of limited medical resources. Palliative care employs a patient-centered approach which focuses on symptom management in order to improve patient-related quality of life, regardless of the oncologic treatment; however, palliative care teams are often consulted on patients late in their disease course, which may limit the extent to which these services are able to adequately address patient needs and quality of life.
This 2010 study by Temel et al. was a prospective, single-institution, nonblinded, but randomized controlled trial which evaluated the effect of early palliative care integrated with standard oncologic care versus standard oncologic care alone on patient-related quality of life in patients with metastatic non-small cell lung cancer.
Patient population
A total of 151 patients with metastatic non-small cell lung cancer were diagnosed within 8 weeks were enrolled. All patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 0, 1, or 2 (asymptomatic, symptomatic but fully ambulatory, or ambulatory >50% of the time, respectively). Patients with ECOG status of 3 or 4 (confined to bed >50% of the time or fully bedbound) were excluded from the study.
Patients were randomized in a 1:1 ratio to early palliative care intervention plus standard oncologic care or standard oncologic care alone. Patients in the early intervention arm met with a member of the palliative care team (either a board-certified physician or advanced-practice nurse) within 3 weeks of enrollment and at least once a month afterward. Emphasis was placed on physical and psychosocial symptom assessments as well as care coordination and establishing goals of care. Of note, patients who were not randomized to the palliative care arm were still allowed to receive palliative care, but did not cross over into the palliative care arm for the purposes of analysis.
Outcomes
The primary outcome was change in patient-related quality of life from baseline to 12 weeks, as determined by the Trial Outcome Index (TOI), a composite measure of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and lung-cancer subscale (LCS) of the FACT-L scale. The authors estimated a need for 120 patients to have 80% power to detect a significant change in the TOI score at 12 weeks.
Secondary outcomes included change in mood assessment based on the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire 9 (PHQ-9), receipt of aggressive end of life care (chemotherapy ≤ 14 d before death, no hospice care, or hospice admission ≤ 3 d before death), and median overall survival.
Results
Approximately 27 patients died by the 12 week assessment and the remaining 107 patients (86%) completed assessments. The vast majority of patients in both treatment arms were white (95+%), in fact only 4 patients total of the 151 were non-white. Both treatment groups included patients mostly with ECOG status of 0 or 1: 72 patients (94%) in early palliative care arm and 65 patients (88%) in standard care arm. There were no statistically significant differences in HADS and PHQ-9 mood assessment scores or quality of life measures at baseline.
At 12 weeks, patients in the early palliative care arm had a statistically significant increase in the FACT-L score (98.0 ± 15.1 vs 91.5 ± 15.8, p=0.03) compared to patients in the standard care arm. Fewer patients in the early palliative care group (16%) reported depressive symptoms versus the standard care group (38%). Patients in the early palliative care arm received less aggressive care than patients in the standard care arm (33% vs 54%, p=0.05). However, median overall survival was longer in patients in the palliative care arm compared to the standard care arm (11.6 months vs 8.9 months, p=0.01).
Discussion
Most patients in this study were white and all were ambulatory (ECOG ≤2). Early palliative care intervention appeared to improve patient-reported depressive symptoms and patient-related quality of life for patients with metastatic non-small cell lung cancer. Median overall survival was longer in patients receiving early palliative care compared to patients receiving standard care alone, despite the fact that the former had less aggressive care. But the study study was not powered or designed to measure this outcome [2].
The authors provide two hypotheses to account for this survival benefit. First, some studies suggest that depressed mood and poor quality of life correlate with shortened survival in patients with metastatic non-small cell lung cancer. In light of this, the authors proposed that improvement in patient depressive symptoms and quality of life in patients receiving palliative care could contribute to longer survival. Second, they suspect that palliative care interventions may facilitate administration of oncologic therapies and thus prolong overall survival.
Major limitations of the study include that it was comprised almost exclusively of white patients with good ECOG status. Additionally, the components of the study’s palliative care intervention were not described, so it is unclear what can be applied into routine practice. Alternatively, was more ‘face time’ with physicians driving the outcome rather than any palliative / symptom based intervention. Regardless, it seems early integration of palliative care could improve patient-related quality of life and patient depressive symptoms while decreasing aggressive care at the end of life in patients with metastatic non-small cell lung cancer.
| F: Follow up | 4+ years |
| R: Randomization | Yes |
| I: Intention to treat | Yes, patients in standard care group could request palliative care and still analyzed in standard care group |
| S: Similar at baseline | Yes |
| B: Blinding | NO |
| E: Equal treatment | Yes |
| S: Source (funding) | Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts |
- Kelley AS, Meier DE. Palliative care–a shifting paradigm. N Engl J Med. 2010 Aug 19;363(8):781-2. doi: 10.1056/NEJMe1004139.
- Land DB. Early palliative care in non-small cell lung cancer improves quality of life and mood, and may result in longer survival. Thorax 2011;66:395.
Summary by Paul Sackstein
