In the ENABLE III study reported in the Journal of Clinical Oncology, Bakitas et al found that early vs delayed initiation of a palliative care intervention did not result in improved patient-reported outcomes or resource use. Early initiation was associated with better 1-year survival.
In the trial, 207 patients with advanced cancer from the Norris Cotton Cancer Center, affiliated outreach clinics, and the VA Medical Center in New Hampshire and Vermont were randomly assigned between October 2010 and March 2013 to receive an in-person palliative care consultation, structured telehealth nurse coaching sessions (once per week for six sessions), and monthly follow-up either early after enrollment (n = 104) or 3 months later (n = 103). Outcomes were quality of life, symptom impact, mood, 1-year survival, and resource use (hospital/intensive care unit days, emergency room visits, chemotherapy in last 14 days, and death location). Quality of life was assessed by the Functional Assessment of Chronic Illness Therapy-Palliative Care scale and Treatment Outcome Index, symptom impact by the Quality of Life at End of Life symptom impact subscale, and mood by the Center for Epidemiologic Studies-Depression scale.
The early and delayed groups did not significantly differ with regard to age, gender, marital status, race/ethnicity, religion, attendance of religious services, praying for own health, work status, medical insurance, ever smoked status, current smoking status, percent with caregiver enrolled in the study, rural residence, cancer diagnoses, disease status at enrollment, brain metastases, chemotherapy or radiotherapy at enrolment, Charlson comorbidity score, Karnofsky performance status, living will/durable power of attorney or do not resuscitate order, or referral to hospice. The early group had a higher education level (P = .05), higher alcoholic beverage consumption per week (P = .04), and a greater proportion of patients enrolled in a clinical trial (18% vs 8%, P = .04). Among former smokers, there was a borderline significant trend (P = .06) for history of fewer cigarettes per day in the delayed group.
No Differences in Patient-Reported Outcomes/Resource Use
There were no significant differences for the early vs delayed group in quality of life (P = .34), symptom impact (P = .09), or mood (P = .33) at 3 months after initiation of the palliative care intervention or for quality of life (overall P = .73), symptom impact (overall P = .30), or mood (overall P = .82) at 12, 6, or 3 months before death.
Relative rates of resource use for decedents in the early vs delayed groups were similar for hospital days (0.73, P = .26), intensive care unit days (0.68, P = .49), emergency room visits (0.73, P = .21), chemotherapy in last 14 days (1.57, P = .27), and home death (54% vs 47%, P = .60).
One-year survival was 63% in the early group vs 48% in the delayed group (P = .038).
The investigators concluded: “Early-entry participants’ patient-reported outcomes and resource use were not statistically different; however, their survival 1 year after enrollment was improved compared with those who began 3 months later. Understanding the complex mechanisms whereby [palliative care] may improve survival remains an important research priority.”
Marie A. Bakitas, DNSc, CRNP, of University of Alabama at Birmingham, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by the National Institute for Nursing Research, National Institutes of Health, Cancer and Leukemia Group B Foundation, Foundation for Informed Medical Decision-Making, Norris Cotton Cancer Center, Dartmouth-Hitchcock Section of Palliative Medicine, National Palliative Care Research Center, University of Alabama at Birmingham Cancer Prevention and Control Training Program, and American Cancer Society.
Mark T. Hegel, PhD, reported research funding from Johnson & Johnson.
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