“Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer”
N Engl J Med. 2010 Aug 19;363(8):733-42 [free full text]
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Ideally, palliative care improves a patient’s quality of life while facilitating appropriate usage of healthcare resources. However, initiating palliative care late in a disease course or in the inpatient setting may limit these beneficial effects. This 2010 study by Temel et al. sought to demonstrate benefits of early integrated palliative care on patient-reported quality of life outcomes and resource utilization.
Population: outpatients with metastatic NSCLC diagnosed < 8 weeks ago and ECOG performance status 0-2
Intervention: “early palliative care” – met with palliative MD/ARNP within 3 weeks of enrollment and at least monthly afterward
Comparison: standard oncologic care
Outcome:
Primary – change in Trial Outcome Index (TOI) from baseline to 12 weeks
TOI = sum of the lung-cancer, physical well-being, and functional well-being subscales of the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale (scale range 0-84, higher score = better function)
Secondary
- change in FACT-L score at 12 weeks (scale range 0-136)
- change in lung-cancer subscale of FACT-L at 12 weeks (scale range 0-28)
- “aggressive care,” meaning one of the following: chemo within 14 days before death, lack of hospice care, or admission to hospice ≤ 3 days before death
- documentation of resuscitation preference in outpatient records
- prevalence of depression at 12 weeks per HADS and PHQ-9
- median survival
Results:
151 patients were randomized. There were no significant difference in baseline characteristics among the two groups. Palliative-care patients (n=77) had a mean TOI increase of 2.3 points, versus a 2.3-point decrease in the standard-care group (n=73) (p=0.04).
Secondary outcomes:
- ∆ FACT-L score at 12 weeks: +4.2± 13.8 in the palliative group vs. -0.4 ±13.8 in the standard group (p=0.09 for difference between the two groups)
- ∆ lung-cancer subscale at 12 weeks: +0.8±3.6 in palliative vs. +0.3±4.0 in standard (p=0.50)
- aggressive end-of-life care was received in 33% of palliative patients vs. 53% of standard patients (p=0.05)
- resuscitation preferences were documented in 53% of palliative patients vs. 28% of standard patients (p=0.05)
- depression at 12 weeks per PHQ-9 was 4% in palliative patients vs. 17% in standard patients (p = 0.04)
- median survival was 11.6 months in the palliative group versus 8.9 months in the standard group (p=0.02). (See Figure 3 on page 741 for the Kaplan-Meier curve.)
Implication/Discussion:
Early palliative care in patients with metastatic non-small cell lung cancer improved quality of life and mood, decreased aggressive end-of-life care, and improved survival.
This is a landmark study, both for its quantification of the quality-of-life (QoL) benefits of palliative intervention and for its seemingly counterintuitive finding that early palliative care actually improved survival.
The authors hypothesized that the demonstrated QoL and mood improvements may have led to the increased survival, as prior studies had associated lower QoL and depressed mood with decreased survival. However, I find more compelling their hypotheses that “the integration of palliative care with standard oncologic care may facilitate the optimal and appropriate administration of anticancer therapy, especially during the final months of life” and earlier referral to a hospice program may result in “better management of symptoms, leading to stabilization of [the patient’s] condition and prolonged survival.”
In practice, this study and those that followed have further spurred the integration of palliative care into many standard outpatient oncology workflows, including features such as co-located palliative care teams and palliative-focused checklists/algorithms for primary oncology providers.
Limitations of this study: 1) a complex subjective primary endpoint, 2) non-blinded, 3) single-center, minimally diverse patient population.
Further Reading/References:
1. ClinicalTrials.gov
2. Wiki Journal Club
3. Profile of first author Dr. Temel
4. UpToDate, “Benefits, services, and models of subspecialty palliative care”
Summary by Duncan F. Moore, MD