The Sooner the Better: Palliative Care for Cancer

When it comes to palliative care, sooner may be better for some patients, according to a recent study presented at the 2016 American Society of Clinical Oncology (ASCO) Palliative Care in Oncology Symposium by author Joseph A. Greer, PhD, department of Psychiatric Oncology at Massachusetts General Hospital.

Results of the randomized trial, which were published in the Journal of Clinical Oncology, showed that patients with newly diagnosed incurable lung and gastrointestinal (GI) cancer saw a benefit from the implementation of early palliative care (PC).

“By the 24-week time point, we did see a significant difference favoring the earlier palliative care intervention,” Greer said.

The study, which was conducted over the past five years at Massachusetts General Hospital, observed a group of 350 newly diagnosed patients who all had one of the following diagnoses: non-small cell lung cancer (NSCLC), small cell lung cancer or gastrointestinal cancers, including mesothelioma, pancreatic cancer, hepatobiliary cancer, gastric cancer and esophageal cancer. To be eligible for the study, patients had to meet a number of criteria, including being within eight weeks of their original diagnosis, and not requiring more immediate hospice or palliative care as recommended by their clinicians.

Patients were divided into two equal groups, one receiving early palliative care while the other did not, receiving only usual care for their malignancies.

While the primary endpoint of seeing a significant difference on the FACT-G, Patient Health Questionniare-9 (PHQ-9), and HADS-Depression scales between the two groups after 12 weeks was not met, there were significant differences after 24 weeks, meeting the study’s secondary endpoint.

The early PC group expressed less depression (as measured on the PHQ-9) after 24 weeks, and were also “significantly more likely to report using active and engaged coping styles compared to the usual care group,” according to results. These strategies included activing coping, positive reframing and acceptance.

At least once a month, patients assigned to early PC saw a palliative care clinician who documented the contents of every visit. The two topics discussed most were symptom management (discussed in 74.7 percent of meetings) and coping (discussed in 70.2 percent of meetings).

Greer mentioned that the frequency of discussing coping strategies was different in palliative care than in other environments.

“This is a unique feature of the early palliative care model that is somewhat distinct than what you may see in a conversation, say, in an acute in-patient setting for patients and families in crisis,” he said.

Other aspects discussed in palliative care appointments included rapport (44.4 percent), illness understanding (38.4 percent), treatment decisions (16.3 percent), advanced care planning (14.2 percent) and disposition, such as discussions about options like hospice care (2.1 percent ).

When it came to patient-led discussion with their care team about end of life care, more than double the percentage of those in early PC had those discussions when compared with those in usual care (30.2 percent versus 14.5 percent). But Greer said that these numbers are still not high enough in either cohort.

“Those rates are quite low, demonstrating that we can still do a lot of work in that arena,” he said.

Greer also mentioned that more research can be done regarding palliative care interventions by cancer type because the study reported QOL differences between the two cancer types in each cohort.

Patients with lung cancer saw an improvement in QOL with early palliative care at 12 weeks, and then the improvement became even more pronounced by week 24. Meanwhile, both sets of patients with GI cancers had improvements in QOL by the 12-week time point, regardless of receiving or not receiving early palliative care.

“The quality of life and mood trajectories in these samples is really varied by cancer types and raises a number of important questions about further research,” he said. “First, should we be tailoring our palliative care interventions to different patient populations? As the cancer therapeutic world becomes more targeted and personalized, so should, perhaps, our patients’ palliative care interventions.”