Early Palliative Care Benefits Patients With Advanced Cancer
In a study published in The Lancet, Zimmermann et al compared quality of life, symptom severity, and care satisfaction with early initiation of palliative care vs standard cancer care in patients with advanced cancer. Although early palliative care was not associated with improved quality of life at 3 months (the primary outcome measure), improvement was observed at 4 months, and other patient-reported outcomes were improved at 3 and 4 months.
Study Details
In the study, conducted at the Princess Margaret Cancer Centre, Toronto, between December 2006 and February 2011, 24 medical oncology clinics stratified by clinic size and tumor site (four lung, eight gastrointestinal, four genitourinary, six breast, and two gynecologic clinics) were cluster-randomized to consultation and follow-up at least monthly by a palliative care team (n = 228) or standard cancer care (n = 233). Patients provided written informed consent to participate in their own study group without being informed of the existence of another study group. Patients had a clinical prognosis of 6 to 24 months.
Patients were assessed monthly for 4 months for quality of life using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) scale and Quality of Life at the End of Life (QUAL-E) scale, symptom severity using the Edmonton Symptom Assessment System (ESAS), satisfaction with care using FAMCARE-P16, and problems with medical interactions using the Cancer Rehabilitation Evaluation System Medical Interaction Subscale (CARES-MIS). Higher score indicates better status for all scales except the ESAS and CARES-MIS scales, for which lower score indicates better status.
The primary outcome was change in scores on FACIT-Sp at 3 months. Secondary endpoints included change in FACIT-Sp at 4 months and change for other scales at 3 and 4 months. Change in scores was calculated as change in the intervention group minus change in the control group.
The intervention and control groups were generally balanced for age (mean, 61 and 60 years), sex (60% and 54% women), employment status (eg, 46% and 43% retired, 20% and 25% employed), education (eg, college for 67% and 65%), tumor site (24% and 20% lung, 33% and 28% gastrointestinal, 12% and 22% genitourinary, 18% and 13% breast, 14% and 17% gynecologic), active chemotherapy (76% and 78%), radiotherapy (7% and 6%), Charlson comorbidity index score > 0 (33% and 32%), Eastern Cooperative Oncology Group performance status (0 in 27% and 33%, 1 in 65% and 61%, 2 in 8% and 6%), and mean baseline FACIT-Sp (101 and 105), QUAL-E (73 and 74), ESAS (28 and 23), FAMCARE-P16 (64 and 68), and CARES-MIS (4.7 and 3.9) scores.
3-Month Outcomes
At 3 months, the intervention group had improvement from baseline in scores on all scales except ESAS and the control group had improvement in score only on the QUAL-E scale. There was a nonsignificant improvement on FACIT-Sp in the intervention group (change = +3.56, P = .07), a borderline significant difference favoring the intervention group for QUAL-E (change = +2.25, P = .05), and a significant difference favoring the intervention group in FAMCARE-P16 (change = +3.79, P = .0003). There were no differences between groups on the ESAS or CARES-MIS scales.
4-Month Outcomes
At 4 months, there were improvements on all scales in the intervention group and on none of the scales in the control group. The differences favoring the intervention group were significant for the FACIT-Sp (change = +6.44, P= .006), QUAL-E (change = +3.51, P = .003), and FAMCARE-P16 (change = +6.00, P < .0001) and borderline significant for ESAS (change = -4.41, P = .05). There was no significant difference between groups on the CARES-MIS scale.
The investigators concluded, “Although the difference in quality of life was non-significant at the primary endpoint, this trial shows promising findings that support early palliative care for patients with advanced cancer.”
The study was funded by the Canadian Cancer Society and Ontario Ministry of Health and Long Term Care.
Camilla Zimmermann, MD, of Princess Margaret Cancer Centre, Toronto, is the corresponding author for The Lancet article.
The study was funded by grants from the Canadian Cancer Society and the Ontario Ministry of Health and Long Term Care. The study authors reported no potential conflicts of interest.
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