Palliative care provided soon after a patient is diagnosed with incurable cancer not only helps improve the patient’s overall quality of life but also improves communication about the patient’s wishes for end-of-life care, according to a study by Jennifer S. Temel, MD, Clinical Director of Thoracic Oncology at Massachusetts General Hospital, and her team of investigators, including clinical psychologist Joseph A. Greer, PhD.
Joseph A. Greer, PhD
The study,1 which was conducted from 2011 to 2015, included 350 patients newly diagnosed with incurable non–small cell lung cancer; small cell lung cancer; mesothelioma; or a noncolorectal gastrointestinal (GI) cancer, including pancreatic, hepatobiliary, gastric, or esophageal carcinoma. The patients, diagnosed within 8 weeks of enrollment on the trial, were randomized, 175 per group, to receive either monthly visits with a palliative care clinician integrated into their oncology care or only usual oncology care.
The study team used the Functional Assessment of Cancer Therapy–General (FACT-G) questionnaire to assess patients’ quality of life and the Patient Health Questionnaire–9 (PHQ-9) for mood at baseline, at 12 weeks, and at 24 weeks. Patients were also assessed for their coping styles, perceptions of likelihood of a cure, and communication about their end-of-life preferences.
The study results show that patients assigned to early palliative care had better quality of life and fewer symptoms of depression at 24 weeks but not at 12 weeks compared to the usual care cohort. Most striking, at 24 weeks, the intervention group was significantly more likely to report using active and engaged coping styles compared to the usual care group, and twice as many patients receiving early palliative care (30.2%) reported having discussions about their end-of-life wishes, compared to just 14.5% of patients in the usual care group.1
In addition, the investigation revealed another intriguing finding about the impact of palliative care: “The primary surprise in our study results is that the trajectory of outcomes varied by cancer types,” said Dr. Greer.
“We found the intervention significantly improved quality of life by 12 weeks, and more so by 24 weeks, in the lung cancer group,” he explained. “But the patients diagnosed with advanced GI cancer in either the usual care cohort or in the early integrated palliative care cohort did not show such differences after 12 weeks, which raised the question of whether we need to think about offering palliative care in a more tailored way, based on cancer type.”
The ASCO Post talked with Dr. Greer, who is Program Director of the Center for Psychiatric Oncology & Behavioral Sciences and Associate Director of the Cancer Outcomes Research Program at Massachusetts General Hospital Cancer Center in Boston, about the study results and how tailoring palliative care interventions specific to a patient’s cancer type might impact the patient’s response to those interventions.
Holistic Approach to Palliative Care
Please describe the types of services patients received in the early integrative palliative care arm of your study.
Jamie H. Von Roenn, MD
Initially, the monthly consultations focused on establishing a good rapport with patients and family members to determine what their life goals were and what obstacles were preventing them from improving their quality of life and symptom management, to support patients in living as well as possible for as long as possible. There were also discussions about important treatment decisions, especially as patients considered starting or stopping another line of chemotherapy.
A unique feature of our study is that the palliative care clinicians addressed how patients and their families are able to manage their illness on a day-to-day basis with good social support and how to engage in active coping strategies and meaningful life activities to improve their quality of life.
Our goal was to take a holistic approach to palliative care, rather than just center on symptom management, and learn how much patients and their families understood about their illness and prognosis.
The topics varied depending on the patient’s needs, but we found the conversations were meaningful to patients and their families and helped create a strong therapeutic relationship over time. That made the eventual transition to hospice care easier because trust had been established among the patient, family members, and palliative care clinician.
Customizing Palliative Care Interventions
An interesting finding in your study was that while patients with lung cancer who received early palliative care reported better quality of life at 12 and 24 weeks, the patients with GI cancers did not show such differences. How do you interpret that finding?
It made us think that maybe we need to tailor interventions to occur at key clinical turning points rather than delivering palliative care services to all patients with metastatic cancer on a monthly basis from the time of diagnosis through the course of a patient’s care until the end of life.
Maybe we need to tailor interventions to occur at key clinical turning points rather than delivering palliative care services to all patients with metastatic cancer on a monthly basis from the time of diagnosis through the course of a patient’s care until the end of life.— Joseph A. Greer, PhD
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It may be that in our efforts to increase patient access to palliative care services, we need to be creative about the timing of those interventions. Perhaps not every patient needs palliative care at the time of diagnosis but rather as symptoms become more severe or when chemotherapy stops working. And maybe we need to be thinking of the timing of the initiation of palliative care interventions and their frequency based on cancer type. That would be one way of tailoring palliative care to the needs of specific patients.
Another way to tailor care would be based on managing the treatment side effects unique to the type of treatment used—for example, toxicities that are specific to immunotherapy and targeted therapy as opposed to cytotoxic therapy.
So, I think we will see specific tailoring of treatment over time. However, they are all hypotheses and require further study. What is clear is that we do not have enough palliative care clinicians to care for every patient with advanced cancer on a monthly basis from the time of diagnosis until the end of life.
Maintaining Higher Quality of Life
In your overall study population, patients who received early palliative care had significantly higher quality of life, fewer depressive symptoms, and better coping skills at 24 weeks but not at 12 weeks. What did that finding tell you?
This finding is a little confusing. I’m not sure it means that patients needed more time to adjust to their diagnosis or to their cancer therapy. Patients with advanced cancer can have good initial results from treatment and a reduction in their symptoms, so over time, their quality of life improves.
This also raises the question, is palliative care more useful when symptoms start to worsen? One of our challenges going forward with this research is to be mindful of the advances in cancer therapy, because as treatments become more effective and less toxic, patients will feel better longer, and their quality of life will be better for a longer time. We need to think more creatively about when and how to use palliative care so it is most useful for patients. It may be that palliative care is more beneficial to patients when their symptom burden is higher.
Even though all the patients in your study had incurable cancer, about one-third thought they could be cured. Why do you think that is?
We see this finding repeatedly in studies where patients with metastatic or incurable cancers are asked whether their cancer is curable. About one-third of patients say yes, it is, although they were diagnosed months before, have a treatment plan in place, and have signed consent forms noting that the purpose of their treatment is palliative, not curative.
Whether these patients are more likely to believe their cancer is curable due to the availability of more effective therapies is an important question, and I want to explore that further. There have been dramatic shifts in cancers that were once diagnosed as terminal but are now chronically managed, which may have something to do with how patients perceive their prognosis.
Since there is a shortage of palliative care clinicians, we tend to prioritize care to those with the greatest need, and that tends to be patients with advanced illness. Nonetheless, palliative care plays an important role in curable disease when symptoms are troubling for patients.— Joseph A. Greer, PhD
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Also, while patients with advanced cancer may intellectually understand their prognosis, some may not be emotionally ready to accept this reality or may feel uncomfortable admitting that their cancer is incurable on a questionnaire.
Palliative Care in All Settings
Your study evaluated early palliative care in the incurable disease setting. How effective are early palliative interventions for early disease, to combat physical and emotional symptoms from cancer and its treatment side effects?
Early palliative care in the outpatient setting can be effective and useful regardless of whether the cancer is curable, because it targets patients with uncontrolled symptoms who could benefit from this type of care.
Since there is a shortage of palliative care clinicians, we tend to prioritize care to those with the greatest need, and that tends to be patients with advanced illness. Nonetheless, palliative care plays an important role in curable disease when symptoms are troubling for patients.
DISCLOSURE: Dr. Greer reported no conflicts of interest.
1. Temel JS, Greer JA, El-Jawahri A, et al: Effects of early integrated palliative care in patients with lung and GI cancer: A randomized clinical trial. J Clin Oncol 35:834-841, 2017.