Patients with advanced lung cancer who received integrated palliative care early on during treatment had a better quality of life and survived for two months longer compared to patients receiving standard care only, according to a study published in the August 19th issue of NEJM (New England Journal of Medicine).
Investigators from Massachusetts General Hospital (MGH) explained that metastatic non-small-cell lung cancer (NSCLC) is hard to treat - patients are not generally expected to survive for more than 12 months.
Lead author, Jennifer Temel, MD, of the MGH Cancer Center,said:
For me as an oncologist, results like this are incredibly exciting. We showed that adding the services of a care team focused on quality of life and not altering patients' cancer treatments could both enhance and extend life in patients with an incurable cancer diagnosis. These findings are very promising, and we are already taking steps to examine the impact of early palliative care in other situations.
Vicki Jackson, MD, MPH, acting chief of the MGH Palliative Care Service and a co-author of the study, said:
One of the most common misconceptions about palliative care is that it indicates treatment has failed -- that it means giving up. In this study the addition of palliative care early in the course of illness extended the survival of patients with incurable lung cancer. These patients not only lived longer, they also experienced improved quality of life and were better able to enjoy the time they had remaining."
Palliative care consists of a team of specially trained personnel, including doctors, nurses, social workers and chaplains - their aim is to help patients cope with the psychological and spiritual aspects of their disease. Palliative care also focuses on managing pain, nausea, shortness of breath and other symptoms.
Traditionally, palliative care kicks in later on, when the disease is well advanced and the patient is hospitalized and symptoms have become debilitating.
In a study in 2007, an MGH team found that it was feasible to combine palliative care with the treatment of patients newly diagnosed with metastatic NSCLC, America's leading cause of death. This latest study aimed to evaluate the impact on patients' lives by integrating palliative care early on.
All the study participants had metastatic NSCLC. They were randomly selected to either receive standard oncology care or early palliative care combined with standard care (palliative care group). There were 151 patients - 77 assigned to the palliative care group, and 74 to standard care. The study lasted three years.
Patients in the palliative care group met members of the palliative care team within three weeks of study enrollment, and then at least once a month throughout the course of their illness. Extra sessions could be arranged when needed.
The visits included assessing and treating symptoms, establishing goals of care, providing psychosocial support and coordinating care with other services. Participants receiving standard care who wished to access palliative services were free to do so at any point during the study.
All the participants completed a standard questionnaire which assessed their mood and quality of life when they enrolled in the study. Another similar questionnaire was completed after twelve weeks. The investigators gathered data on the services and treatments the patients received, including hospital admission, hospice services, chemotherapy and other medications. They also documented patients' resuscitation preferences.
The investigators found that:
- Those in the palliative care group reported significant improvement in quality of life.
- Those in just the standard oncology care group reported worsening quality of life.
- There were 50% fewer cases of depression symptoms in the palliative care group at 12 weeks. However, the rates of antidepressant prescription were not significantly different in either group.
- While more than half the palliative care participants had documented resuscitation preferences, essential to ensuring that patients' goals and end-of-life wishes are respected, fewer than 30% of standard care participants had documented preferences.
- Over half of those in the standard care group received aggressive end-of-life care - chemotherapy within 14 days of death. During this period such treatments are seen as futile, and either no or late referral to hospice care -- compared with only a third of the palliative care group.
- In spite of the lack of such aggressive end-of-life care, participants in the combined care group survived for an average of 11.6 months, compared to the standard care groups participants' 9 months.
Traditionally, cancer care has focused on treating the disease itself, but now we realize we must also focus on managing patient's symptoms and distress related to their diagnosis. We hypothesize that the increased survival was due to improved mood and quality of life, to early and more comprehensive management of symptoms and complications, and possibly to more appropriate end-of-life care. Similar studies in patients with other types of cancers and in other care settings will help us better understand the impact palliative care can have on the well-being and health of all patients with cancer.
Source: Massachusetts General Hospital
"Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer"
Jennifer S. Temel, M.D., Joseph A. Greer, Ph.D., Alona Muzikansky, M.A., Emily R. Gallagher, R.N., Sonal Admane, M.B., B.S., M.P.H., Vicki A. Jackson, M.D., M.P.H., Constance M. Dahlin, A.P.N., Craig D. Blinderman, M.D., Juliet Jacobsen, M.D., William F. Pirl, M.D., M.P.H., J. Andrew Billings, M.D. and Thomas J. Lynch, M.D.
N Engl J Med 2010; 363:733-742
Written by Christian Nordqvist