A decade-long journey toward improving end-of-life care for patients with advanced cancer has demonstrated positive effects on survival, health-care use, and cost of care, according to data presented at the 2023 ASCO Quality Care Symposium.¹

Post hoc analysis of an advance care planning intervention, conducted between 2013 and 2015 at the U.S. Department of Veteran Affairs (VA), showed that participants in the intervention group had greater overall survival, a 25% reduction in the risk of death, lower acute care use, greater palliative care and hospice utilization, and lower total costs than control group participants. These results support the integration of community health workers into oncology care to improve clinical outcomes, authors of the study emphasized.

Manali I. Patel, MD, MPH, MS, FASCO

“We are still seeing robust effects of this 6-month intervention almost 10 years later,” said study coauthor Manali I. Patel, MD, MPH, MS, FASCO, Associate Professor of Medicine at Stanford University School of Medicine, California. “This study not only benefits patients with improved patient experiences, palliative care and hospice utilization but also overall survival.”

Study Details

As Dr. Patel explained, the Engagement of Patients with Advanced Cancer (EPAC) study was initiated about 10 years ago to understand the long-term effects of patient engagement in advance care planning, given high rates of patients being unaware of their treatment plans, high rates of preventable and unwanted acute care use, and high rates of undertreated symptoms. The researchers were also interested in challenging significant disparities in access to meaningful care.

“Over the years, we’ve observed persistent disparities in who engages in these conversations,” said Dr. Patel. “It’s mostly White, affluent populations with health literacy who can advocate for such discussions.”

According to Dr. Patel, there also remains a need for better patient-physician communication and more integrated care methods. With a focus on increasing patient engagement via structured conversations about end-of-life goals of care, the primary objective of the study was to observe any changes in goals-of-care documentation with the oncologist.

The EPAC study was a randomized controlled trial involving veterans with stage III or IV disease or recurrent cancer. Investigators randomly assigned patients into the advance care planning intervention plus usual care vs usual care alone. The intervention included bi-weekly telephone sessions over 6 months delivered by trained nonclinical community or lay health workers to engage veterans and caregivers in end-of-life goals-of-care discussions.

Conducted 9.4 years after the initiation of the study, the post hoc analysis showed significant improvements in patient engagement and advance care planning when lay health workers were involved in structured conversations with patients. Compared with the group receiving standard care, the intervention group had better patient experiences, better defined goals of care, and better hospice utilization.

Of note, patients in the intervention group experienced a 25% reduction in cancer mortality at 2 years. This “unexpected but noteworthy result” suggests further research is needed to fully understand which factors are driving this outcome, said Dr. Patel. “While the confidence interval is nearing 1, this is really an effect we did not expect to see, making it a promising area for future research,” she added.

At the end of life, findings also demonstrated a sustained impact on reducing acute care use, such as emergency department visits and hospitalizations, with the intervention. On the other hand, it resulted in enhanced use of palliative care and hospice services over a 10-year span, even though the intervention was active for only 6 months.

One of the most significant findings was the effect on health-care costs. For patients in the intervention group, the study claimed a 20% net reduction in total health-care costs, contributing to a net savings for the health-care insurer. This cost reduction was noted to be consistent with similar studies and is attributed to decreasing emergency health-care use and hospital admissions.Finally, the success of the study’s model has led to translations into practice and policy, including implementations for insurance agencies and clinicians.

“The research has already led to a significant translation to policy in areas outside of the VA, with similar interventions being highlighted as critical services,” Dr. Patel concluded. “We are currently conducting a 26-site, cluster-randomized trial aiming to validate and further study the effectiveness of this lay health worker-led approach.” 

DISCLOSURE: Dr. Patel reported no conflicts of interest.

REFERENCE

1. Patel MI, Agrawal M, Blayney DW, et al: Engagement of Patients with Advanced Cancer (EPAC) randomized clinical trial: Long-term effects on survival, healthcare use, and costs. 2023 ASCO Quality Care Symposium. Abstract 76. Presented October 28, 2023.