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The Meaningful Benefits of Early Palliative Care for Advanced Cancer - Research at Massachusetts General Hospital Cancer Center led by Jennifer S. Temel, MD, demonstrates that for advanced lung cancer patients, offering early palliative care on an outpatient or ambulatory basis complementes standard oncology and, unexpectedly, leads to longer median survival time.

The Meaningful Benefits of Early Palliative Care for Advanced Cancer

When should palliative care begin for cancer patients?

Contributor

    Jennifer S. Temel, MD
    Clinical Director, Center for Thoracic Cancers, Massachusetts General Hospital Cancer Center; Associate Director, Dana-Farber/Partners CancerCare Hematology/Oncology Fellowship jtemel@partners.org

Palliative care focuses on a patient’s comfort and symptoms such as pain, shortness of breath and nausea, which are often substantial for people with cancer throughout their illness. But palliative care is usually delivered only in the last days or weeks of a patient’s life, and is usually provided on an inpatient basis. Research led by Jennifer S. Temel, MD, at Massachusetts General Hospital demonstrated in 2010 that for advanced lung cancer patients, offering early palliative care on an outpatient or ambulatory basis complemented standard oncology—and, unexpectedly, led to longer median survival time.

In a new study, published in the February 25, 2013, issue of JAMA Internal Medicine,1 Dr. Temel analyzed which features of the palliative care delivered during the 2010 trial provided these benefits. The results serve as a road map for delivering early palliative care.

 

Melanoma GenesisTraditional vs. Early Palliative Care: Whereas traditional palliative care typically begins toward the end of life, the early approach begins right after diagnosis.

 

 

 

 

 

 

 

THE BENEFITS OF EARLY PALLIATIVE CARE
In the 2010 clinical study, Dr. Temel’s group selected 151 newly diagnosed patients with advanced lung cancer and randomly assigned them to standard oncology alone or standard oncology with early palliative care. The study focused on lung cancer because patients generally have many complex symptoms and reduced quality of life.

The study, published in The New England Journal of Medicine,2 found that adding early palliative care to standard oncology care provided meaningful benefits to advanced lung cancer patients compared with standard care alone. Patients had better quality of life and suffered less depression. They also chose hospice or other end-of-life care at an earlier, more appropriate stage rather than opting for more intensive chemotherapy. Unexpectedly, the median survival time was longer  (11.6 versus 8.9 months) for patients with early palliative care, despite their receiving less aggressive end-of-life care.

Median Survival Time Median Survival Time. Jennifer S. Temel, MD, was surprised to discover that patients who received early palliative care, despite undergoing less aggressive end-of-life care, tended to live longer.
QUALITATIVE ANALYSIS OF PALLIATIVE CARE BENEFITS
For the 2013 study, the researchers retrospectively analyzed what palliative care providers did in the 2010 study that led to the observed benefits. By reviewing medical records for each visit with a palliative care provider, they identified seven key elements of care that were different from standard oncology alone: relationship- and rapport-building, addressing symptoms, addressing coping, establishing illness understanding, discussing cancer treatments, end-of-life planning and engaging family members.

TIMING THE KEY ELEMENTS OF PALLIATIVE CARE
The researchers also explored the timing of those elements, and compared the content of palliative care and oncology visits at clinical turning points. They found that the initial palliative care visits focused on building relationships; discussing cancer treatment and prognosis; and discussing preferences for receiving information.

Early visits did not include discussions of end-of-life and hospice care; these occurred at later, more appropriate stages. Many community oncologists hesitate to refer newly diagnosed patients to palliative care, for fear of upsetting them with end-of-life issues, Dr. Temel explained. She hopes that this finding alleviates oncologists’ concerns.

All visits focused on symptom management and the physical, psychosocial and spiritual well-being of the patient. Palliative care also focused on family and friends, who, Dr. Temel noted, also suffer from their loved ones’ diagnoses and provide much of the ongoing care.

PALLIATIVE CARE ALLOWS ONCOLOGISTS TO FOCUS ON ONCOLOGY
The researchers also compared palliative care visits with oncologist visits at clinical turning points, such as when the disease progresses. Palliative care visits focused more on helping patients and their families cope, while oncology visits focused on medical management and treatment decisions.

“Palliative and medical oncology visits provided distinct, complementary care,” Dr. Temel said. Given the increasing complexity of oncology (such as genotyping and targeted therapies), concurrent palliative care services allow oncologists to better focus on cancer-directed therapies.

FUTURE DIRECTIONS
Dr. Temel is now leading a larger clinical trial looking at early palliative care in patients with advanced lung and gastrointestinal cancer.3 The research team will explore the mediators of the outcomes prospectively, and whether the cost of early palliative care is offset by less intensive medical care at the end of life. They will also look for indicators that predict who will benefit the most from early palliative care. The trial is still accruing patients, and, uniquely, is also enrolling family members and friends.

Footnotes
1 Yoong, Jaclyn et al. “Early Palliative Care in Advanced Lung Cancer: a Qualitative Study.”
JAMA Internal Medicine 173, no. 4 (February 25, 2013): 283–290.
2 Temel, Jennifer S. et al. “Early Palliative Care for Patients With Metastatic Non-Small-Cell Lung Cancer.” The New England Journal of Medicine 363, no. 8 (August 19, 2010): 733-742.
3 Early Palliative Care With Standard Oncology Care Versus Standard Oncology Care Alone in Advanced Lung and Non-colorectal Gastrointestinal Malignancies. Clinicaltrials.gov NCT01401907. 

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