Advanced Lung Cancer: Studies Explore Palliative Care Delivered by Telehealth and in a Stepped-Care Approach

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Early palliative care can be integrated into the course of treatment for patients with advanced lung cancer via delivery by telehealth with outcomes similar to when palliative care is delivered via in-person visits, according to results of the REACH PC trial presented by Joseph Greer, PhD, of Harvard Medical School, Boston, at the 2024 ASCO Annual Meeting Plenary Session.1 A separate randomized noninferiority study presented at the ASCO meeting by Jennifer S. Temel, MD, FASCO, also of Harvard Medical School, Boston, found that stepped palliative care was noninferior to monthly visits with early integrated palliative care.2 Results of the stepped-care study were published in JAMA to coincide with the presentation at ASCO.3

Joseph Greer, PhD

Joseph Greer, PhD

Jennifer S. Temel, MD, FASCO

Jennifer S. Temel, MD, FASCO

Benefits of Telehealth

In the study presented by Dr. Greer, patient-reported quality of life, satisfaction with care, symptom burden, depression and anxiety, and coping skills were comparable between patients who had telehealth sessions and those who had in-person palliative care visits.1

Many studies have shown that the early integration of palliative care improves quality of life and patients’ cancer journeys. National guidelines, including those from ASCO, recommend the integration of early palliative care as soon as patients are diagnosed with advanced cancer. Yet, adoption of this much-needed care component has been hampered by a lack of resources and other barriers. Delivery via telehealth may overcome some of these barriers.

“These results underscore the potential to increase access to evidence-based early palliative care through telehealth delivery,” stated Dr. Greer. “Despite considerable advances in novel therapeutics, most people with metastatic lung cancer will at some point … experience burdensome physical and psychological symptoms as well as impaired quality of life,” he continued.

Regardless of evidence-based guidelines, “most patients with advanced cancer and their families do not receive this care due to multiple barriers, chief among them being the limited availability of specially trained palliative care clinicians and practical issues in supportive care including limited scalability. One promising solution to overcome some of these obstacles is the provision of telehealth using video visits,” he added. “Use of telehealth can also reduce financial toxicity for patients and the health-care system.”

REACH PC Details

The randomized REACH PC study enrolled 1,250 patients from 22 sites with advanced non–small cell lung cancer and 548 caregivers who were given surveys prior to randomization and then every 12 weeks for up to 48 weeks. Dr. Greer’s report at the ASCO meeting focused on 24-week survey results.

Adult patients who were being treated for advanced lung cancer with noncurative intent were randomly assigned 1:1 to telehealth video visits (n = 633) or in-person visits (n = 617). The intervention in both groups was a monthly palliative care visit, with an initial in-person encounter to establish rapport for the telehealth group. Clinicians documented topics discussed during telehealth and in-person visits. The primary outcome was quality of life at 24 weeks as measured by the Function Assessment of Cancer Therapy–Lung (FACT-L) scale, including assessment of physical, social, emotional, and functional well-being, as well as lung cancer–specific symptoms.

Both groups had comparable demographic and clinical characteristics at baseline. The median age was 65 years, slightly more than half were women, and the majority of patients were non-Hispanic White and married. “Approximately 25% had a highly targetable tumor mutation,” Dr. Greer noted.

By week 24, both groups had a similar number of palliative care visits: 4.7 in the telehealth video group and 4.9 in the in-person group. “The visits were provided by 138 specialty-trained palliative care physicians and advanced practice providers. The majority of visits focused on building rapport, managing symptoms, and supporting adaptive coping skills. Outcomes were remarkably similar between modalities,” Dr. Greer told listeners.

According to the adjusted mean FACT-L score, the two groups demonstrated equivalent effects on patient-reported quality of life. Of note, caregivers attended about 50% of in-person visits and only about 36% of video visits.

“There was significantly more involvement of caregivers with in-person visits, but no difference in other key measures of satisfaction with patient care,” Dr. Greer reported. “These results will ideally inform coverage of video visits, which can reduce the burdens of travel, cost, and risk of infection among potentially immune-compromised patients compared to in-person visits.”

He added: “We realized people liked the video visits and were happy they didn’t have to risk coming to the clinic during the pandemic. The finding that fewer caregivers participated during telehealth visits was surprising to us. We originally hypothesized we would have more caregivers attend video visits given the convenience of the remote modality. We later realized that caregivers often play an important role in assisting with transportation to the cancer center, likely increasing their shared participation in clinic visits onsite. Telehealth may offer more autonomy for patients and caregivers to decide when to jointly attend visits. Nonetheless, the fact that caregivers in both groups had comparable satisfaction with care on the surveys gave us reassurance.”

Stepped Palliative Care

In the stepped palliative care study presented by Dr. Temel, the experimental group received stepped palliative care—monitoring and visits triggered by patient need—and the control group had monthly visits with early integrated palliative care.2 The primary outcome was quality of life as assessed by FACT-L scale.

“Palliative care interventions are delivered by specially trained palliative care physicians and advanced practitioners. Stepped care starts with low frequency visits, and when conditions worsen [eg, change in cancer trajectory, hospital admission], patients step up to more frequent visits. This improves utilization of resources,” Dr. Temel said. “Stepped palliative care enables more efficient use of resources and fewer office visits for patients compared to monthly office visits.”

She continued: “Patients with advanced cancer have poor quality of life, depression, and anxiety; and distress related to prognostic uncertainty and lack of coping skills. Early palliative care is an evidence-based strategy that improves coping and satisfaction with cancer care.  Our study shows that stepped palliative care is an effective and scalable way to deliver early palliative care and improve patients’ quality of life.”

Study Details

Patients (n = 510) were randomly assigned 1:1 to either stepped palliative care or early integrated palliative care. Mean age was 66, about half were men and half were women, and 83% were White. About 80% had advanced non–small cell lung cancer, and 21% had a targetable mutation.

By week 24, 26.4% of patients in the stepped-care group stepped up to step 2 (consisting of monthly palliative care visits); and by week 48, 36.4% were up to step 2. At week 24, patients receiving stepped care had a mean of 2.5 visits vs 5 visits in the early integrated palliative care group.

No difference was observed between groups on the FACT-L questionnaire at week 24 and week 48 in depression and coping. The focus of the palliative care visits in both study groups was also very similar in establishing rapport, addressing symptoms, and supporting coping. The study established the noninferiority of stepped palliative care.

The majority of participants in the study utilized hospice. Length of hospice stay was 19.5 days in the stepped-care group vs 34.6 days in the control group. 

Expert Point of View

Monika Krzyzanowska, MD, MPH, FRCPC, FASCO

Monika Krzyzanowska, MD, MPH, FRCPC, FASCO

Invited discussant Monika Krzyzanowska, MD, MPH, FRCPC, FASCO, Chief of the Odette Cancer Program, Sunnybrook Health Sciences Center, University of Toronto, reminded listeners that early palliative care was shown to improve quality of life in patients with advanced cancer 14 years ago and that ASCO has updated its palliative care guidelines, strongly endorsing implementation of early palliative care for advanced cancer.

“Despite strong evidence and national practice guidelines, adoption of early palliative care remains a challenge. A recent meta-analysis found that the median duration of palliative care was only 19 days. There are many barriers, including stigma, attitudes, lack of awareness, and lack of resources,” she explained.

The presence of palliative care teams has increased at National Cancer Institute (NCI)-designated cancer centers, but more than 50% of non–NCI-designated centers did not have palliative care teams at the time of the meta-analysis, said Dr. Krzyzanowska.

“Stepped care models have been developed to triage patient care services based on the patient’s needs,” she noted.

DISCLOSURE: Dr. Greer is a consultant to BeiGene; receives institutional research funding from Blue Note Therapeutics and NCCN/AstraZeneca; and receives royalties from Oxford University Press and Springer Publishing Company. Dr. Temel reported no conflicts of interest. Dr. Krzyzanowska has received honoraria from Eisai and Novartis; has served as a consultant or advisor to Bayer and Eisai; and has received institutional research funding from Eisai, Exelixis, and Ipsen.


1. Greer J, Trotter C, Jackson V, et al: Comparative effectiveness trial of early palliative care delivered via telehealth versus in person among patients with advanced lung cancer. 2024 ASCO Annual Meeting. Abstract LBA3. Presented June 2, 2024.

2. Temel J, Jackson V, Kumar P, et al: Multisite randomized trial of stepped palliative care for patients with advanced lung cancer. 2024 ASCO Annual Meeting. Abstract 12000. Presented June 2, 2024.

3. Temel JS, Jackson VA, El-Jawahri A, et al: Stepped palliative care for patients with advanced lung cancer: A randomized clinical trial. JAMA. June 2, 2024 (early release online).