New research published by Lage et al in JNCCN–Journal of the National Comprehensive Cancer Network found 40.2% of hospitalized patients with advanced, incurable cancer were functionally impaired at the time of admission—meaning they needed assistance with activities of daily living like walking, bathing, getting dressed, or other routine tasks. Patients with functional impairment also had higher rates of pain, depression, and anxiety, and were more likely to have longer hospital stays and worse survival.
“Interventions addressing patients’ functional impairment and symptom management could help enhance care delivery and outcomes for the highly symptomatic population of hospitalized patients with advanced cancer,” said lead researcher Daniel E. Lage, MD, MsC, of Massachusetts General Cancer Center. “This highlights the need for efforts to integrate functional assessments into the care of these patients to identify individuals who may benefit from physical therapy, palliative care, and/or other supportive services earlier in their hospital stay. Our finding that individuals with functional impairment experience worse survival could also help guide conversations about goals of care and hospice planning among hospitalized patients with cancer.”
“We are also actively exploring interventions to help patients transition from the inpatient to the outpatient setting, which we have identified as a key challenge for patients with functional impairment,” added senior researcher Ryan D. Nipp, MD, MPH, also of Massachusetts General Cancer Center. “Future work is needed to develop novel models of care to enhance access to palliative care services and address barriers that limit appropriate access to palliative care among patients with advanced cancer.”
Results
The researchers studied 970 patients aged 18 and older with advanced cancer—defined as those not being treated with curative intent—who experienced an unplanned hospital admission at Mass General Cancer Center between September 2, 2014 and March 31, 2016. They measured functional impairment using nursing documentation collected at intake and stored in electronic health records and also collected self-completed questionnaires from the patients. Activities of daily living impairment was defined as any need for assistance by another person.
Overall, 390 patients (40.2%) had at least one activities of daily living impairment, with 14.8% having one or two and 25.4% experiencing at least three areas of difficulty with daily tasks. Functional impairment was associated with longer hospital length of stay (β = 1.29; P < .001) and worse survival (hazard ratio = 1.73, P < .001). Those with functional impairment were older (mean age = 67.18 vs 60.81 years, P < .001) and had a higher physical symptom burden (mean ESAS physical score = 35.29 vs 30.85, P < .001) vs those with no functional impairment.
Commentary
“Oncologists have long appreciated that functional status is a powerful predictor of a number of important outcomes including survival and treatment outcomes,” commented Toby Campbell, MD, Chief of Palliative Care at the University of Wisconsin Carbone Cancer Center, who was not involved in this research. “We know that the routine assessment of symptom burden and functional status in the outpatient setting results in improved survival and quality of life.”
Dr. Campbell, a member of the NCCN Guidelines® Panel for Palliative Care, continued, “Dr. Lage and colleagues highlight the important, often-missed opportunity to routinely use hospitalization as a trigger for a careful assessment of symptoms and functional status. An unplanned hospitalization for a [patient with] advanced cancer is a watershed moment and predicts higher symptoms and shorter survival in patients with and without impaired function. Hospitalization is a crucial opportunity to facilitate critical serious illness care, including comprehensive palliative care and advanced care planning, with the promise of improving the lives of our patients.”
Disclosure: For full disclosures of the study authors, visit jnccn.org.
