Patients With Advanced Cancer Benefit When Palliative Care Starts Earlier

Camilla Zimmermann, MD, PhD

Rose Family Chair in Supportive Care University of Toronto Medical Director, Harold and Shirley Lederman

Palliative Care Centre Princess Margaret Cancer Centre

Toronto, Canada

Patients with advanced cancer who received early specialized palliative care reported better quality of life and satisfaction, according to results from a randomized trial comparing such services with usual care reported in The Lancet.¹

The findings demonstrate the benefits of cancer centers that provide early palliative care in outpatient clinics, noted Camilla Zimmermann, MD, PhD, the study’s principal investigator. Zimmermann, associate professor and Rose Family Chair in Supportive Care at the University of Toronto, is head of Palliative Care Services, University Health Network, and medical director of the Harold and Shirley Lederman Palliative Care Centre at the Princess Margaret Cancer Centre in Toronto, Canada.

“Oncologists should be referring the patient earlier to outpatient palliative care teams to provide collaborative care, because typically palliative care is provided much later in the disease process,” said Zimmermann. “However, a lot of cancer centers and hospitals don’t provide outpatient palliative care teams, so the palliative care team has to make themselves relevant in the outpatient setting.” And even where palliative care is available, she added, “oncologists still tend to refer quite late because of biases and stigmas associated with palliative care.”

Carried out over 4 years at 24 medical oncology clinics under the auspices of the Princess Margaret Cancer Centre, University Health Network, the study enrolled 461 patients (228 intervention, 233 control) with advanced lung, gastrointestinal, genitourinary, breast, or gynecologic cancer. Researchers applied a cluster randomization process, whereby all trial participants at a particular clinic would receive either the palliative care intervention or the standard care control without knowledge of the existence of another group.

Early Palliative Care Model at Princess Margaret Cancer Centre¹

Outpatient Clinic

• Patients visit routinely once a month
• Physical and psychosocial symptoms assessed routinely
• Telephone follow-up after each visit by nurse and, if needed, physician and nurse
• 24-hour on-call service

Hospital Service

• Patients’ symptoms managed directly by palliative care unit
• Palliative care team follows up with patients admitted to a nonpalliative care unit
• Nurses trained in 10-day program at opening of palliative care unit, with continued education provided

Home Care

• Access to community care center services that include nursing, physical therapy, and occupational therapy, as well as medical equipment such as a walker, hospital bed, or wheelchair
• Routine communication with family physician and community care center
• House calls from home palliative care physician or family physician for patients with ECOG status ≥3 or upon request

ECOG indicates Eastern Cooperative Oncology Group.

Patients deemed eligible for the study had an estimated survival of 6—24 months and an ECOG performance status of 0–2. They were assessed via completion of questionnaires at baseline and then monthly over 4 months.

The specialized palliative care intervention differed from standard cancer care in several respects. Within 1 month of enrollment, patients receiving the intervention had a 60- to 90-minute consultation with a palliative care physician and nurse to assess symptoms, psychosocial distress, social support, and home services; this was followed by monthly 20 to 50 minute follow-up palliative care consultations. Patients in the intervention group also received telephone calls from a palliative care nurse 1 week after the initial consultation and followed by additional calls as needed. The intervention group had access to a 24-hour telephone ser - vice for urgent concerns.

This model was previously assessed in a pilot study, the researchers noted, and patients receiving the palliative care intervention showed improvement in symptom control and satisfaction.

Participants in clinics assigned to the control had no formal palliative care intervention. Standard care included treatment by oncologists and oncology nurses rather than a palliative care physician and nurse, with no routine assessment of psychosocial issues or structured assessment of symptoms.

A change in score on the Functional Assessment of Chronic Illness Therapy—Spiritual Well-Being (FACIT-Sp) at 3 months was the study’s primary endpoint. Secondary outcomes included a change in the FACIT-Sp score at 4 months and change scores on other measures, such as the Quality of Life at the End of Life (QUAL-E) and the Edmonton Symptom Assessment System (ESAS), which measures the intensity of nine common symptoms experienced by patients with cancer.

Significant Differences Reported

Scores on the FACIT-Sp at 3 months did not differ significantly between the intervention (mean change score +1.60) and the control group (—2.00; P = .07). For the QUAL-E measure, however, a significant difference between the intervention and control was reported at 3 months (+2.33 vs +0.06, respectively; P = .05).

FACIT-Sp scores were significantly different at 4 months (+2.46 vs —3.95, respectively; P = .006). Four-month score differences for intervention versus control were also significant for the QUAL-E (+3.04 vs —0.51, respectively; P = .003) and the ESAS (—1.34 vs +3.23; P = .05).

Zimmermann said that an important outcome of the study is that patients reported improved satisfaction with care. “We found that patients appreciated having a team of professionals available to provide additional support navigating the cancer system and coping with multiple medical and social issues.” Additional studies are planned to assess the impact of providing early palliative care on the family caregivers of patients with advanced cancers and are under way to assess the model’s economic impact. The researchers noted that further studies also are needed to determine which patients are the most likely to benefit from the intervention.

“The traditional view of palliative care is end-of-life measures, but over the past 10 years, specialized palliative care has been evolving into finding ways to improve quality of life earlier on. Our study results can help map the way forward,” said Zimmermann.

References

1. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a clusterrandomised controlled trial [published online February 18, 2014]. Lancet. doi.org/10.1016/S0140-6736(13)6246-2.