In these patients with substantial symptoms and short life expectancy, there's no reason to delay delivery of palliative care.
In patients with newly diagnosed metastatic non-small-cell lung cancer, introducing palliative care early after diagnosis improved quality of life and mood, reduced aggressive end-of-life care, and increased survival, according to a study from Massachusetts General Hospital in Boston.
Patients with metastatic NSCLC have a high symptom burden, poor quality of life, and a prognosis of less than one year. For these patients, late referral to palliative care is unlikely to have a meaningful effect on their quality of life and end-of-life care, said lead author Jennifer S. Temel, MD. Dr. Temel and colleagues conducted a randomized study of early palliative care in ambulatory patients with metastatic NSCLC.
Within eight weeks of diagnosis, patients were randomized to receive early palliative care or standard oncologic care alone. Those assigned to early palliative care met with a member of the palliative care team within three weeks after enrollment and at least once a month thereafter until death. Patients assigned to standard care did not consult with the palliative care team unless a meeting was requested by the patient, family, or oncologist.
Quality of life was measured using the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the lung cancer subscale (LCS) of the FACTL, which measures seven specific lung cancer symptoms. The study's primary outcome was the change from baseline to 12 weeks on the Trial Outcome Index (TOI), which is the sum of the scores on the LCS and the physical and functional well-being subscales of FACT-L (higher scores indicate better quality of life). Mood was assessed using both the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire 9 (PHQ-9).
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From 2006 to 2009, a total of 151 pa- tients were enrolled. The palliative care group made an average of four visits to the palliative care service during the 12- week study. Ten patients (14%) from the standard care group also had a palliative care consultation during that time.
At 12 weeks, the patients who received early palliative care had significantly higher scores on the FACT-L and TOI, but not LCS, compared with the standard care group. TOI increased by 2.3 points in the palliative care patients, compared with a decrease of 2.3 points without palliative care (P = .04). In addition, on HADS assessment, fewer palliative care patients had depressive symptoms (16% vs 38% for standard care, P = .01). Anxiety scores did not differ between arms (N Engl J Med 363:733-742, 2010).
To explore end-of-life care, the researchers analyzed data on the 105 patients who had died during the study. A greater percentage of the standard care patients in this subgroup received aggressive end-of-life care (54% vs 33% of the palliative care patients; P = .05). Further, the standard care patients were significantly less likely to have their resuscitation preferences documented. Despite receiving less aggressive end-of-life treatment, the palliative care patients lived 2.7 months longer than the standard care group (median survival, 11.6 months vs 8.9 months; P = .02).
The authors concluded that early integration of palliative care for patients with metastatic NSCLC has beneficial effects on survival and quality of life similar to those of first-line chemotherapy in such patients.
Simultaneous palliative care promising model
AMY S. KELLEY, MD
DIANE E. MEIER, MD
The paradigm of palliative care use may be shifting from delivery only to patients who are clearly dying to early use as an adjunct to standard care, Drs. Kelley and Meier said in an accompanying editorial.
The study by Dr. Temel's group "represents an important step in confirming the beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specifi c therapies beginning at the time of diagnosis."
Future studies should identify the specific components of palliative care being tested, include other disease populations, and examine the effect of palliative care on overall healthcare costs, wrote Dr. Kelley and Dr. Meier, of the department of geriatrics and palliative medicine at Mount Sinai School of Medicine in New York City. Dr. Kelley is an assistant professor; Dr. Meier is a professor of medicine and director of the Center to Advance Palliative Care.
The commentators concluded that "we now have both the means and the knowledge to make palliative care an essential and routine component of evidence-based, high-quality care for the management of serious illness" (N Engl J Med 363:781-782, 2010).