Should cancer care focused on quality of life wait until all treatment ends? Or can it be integrated with medical treatment as soon as someone is diagnosed with a life-threatening illness?
In a study of 150 advanced lung cancer patients, starting palliative care along with standard life-prolonging treatment when patients were first diagnosed not only improved their mood and quality of life, it actually increased the time they lived.
Although patients who received early palliative care received less aggressive treatment at the end of life, they lived almost 3 months longer than patients who didn’t have such early support.
Newly diagnosed lung cancer patients at Massachusetts General Hospital were invited to participate in a randomized clinical trial where they either received standard medical treatment for their cancer or had early palliative care along with that treatment.
Ten patients (14 percent) in the standard treatment arm who asked for it were able to receive care from the palliative team, but were not switched to the palliative arm of the trial.
Researchers measured quality of life, mood, and survival time in both groups. They also looked at aggressive care at the end of life and whether patient’s preferences for resuscitation were recorded in the outpatient electronic medical record.
Palliative care was provided by a team of specialists who followed the guidelines of the National Consensus Project for Quality Palliative Care. Such teams are becoming more common in hospitals and some outpatient settings in the United States and are not limited to hospice programs. More than 80 percent of large hospitals have them.
Multidisciplinary, they include professionals in the fields of medicine, nursing, social work, chaplaincy, counseling, nutrition, and rehabilitation.
The team paid special attention to:
- assessing physical and psychosocial symptoms
- establishing goals for care
- assisting with decision making regarding treatment
- coordinating care on the basis of the individual needs of the patient
Quality of Life
- Compared to patients who received only standard cancer care, those who got early palliative care had scores for quality-of-life improve from the initial test to the one 12 weeks later. Scores for the standard care group went down.
- The percentage of patients with depression was higher in the standard care group, although about 18 percent of patients in both groups got antidepressant medicines.
- Increased anxiety was about the same for both groups.
When end-of-life care was analyzed, 105 (70 percent) of patients in the study had died. For that group:
- 28 percent of standard care group had their wishes for resuscitation recorded in their charts, compared to 53 percent of those in early palliative care.
- Those in standard care spent a median of 4 days with hospice care, compared to 11 days for the early palliative care group.
- More than half (54 percent) of the standard group had some kind of aggressive care at the end of life, compared to a third (33 percent) of those who received care from the palliative team.
Aggressive care at the end of life was measured by any one of the following criteria:
- Chemotherapy within 14 days of death
- No hospice care
- Admission to hospice 3 days or less before death
Despite less aggressive care at the end of their lives, the early palliative care group lived a median of 11.6 months after their diagnosis, compared to 8.9 months for those who got standard lung cancer care.
Jennifer S. Temel, MD, and her team concluded,
Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.
In an accompanying editorial, Amy S. Kelley, MD, MSHS., and Diane E. Meier, MD discuss the study in light of common beliefs that palliative care is only provided as an alternative to life-prolonging or curative care — “what we do when there is nothing more that we can do.” They write,
This study is an example of research that shifts a long-held paradigm that has limited access to palliative care to patients who were predictably and clearly dying. The new approach recognizes that life threatening illness, whether it can be cured or controlled, carries with it significant burdens of suffering for patients and their families and that this suffering can be effectively addressed by modern palliative care teams.
The National Consensus Project for Quality Palliative Care Clinical Practice Guidelines define palliative care this way:
Palliative care is both a philosophy of care and an organized, highly structured system for delivering care. Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision making, and providing opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care.
Far from being focused on dying, the Guidelines continue,
Palliative care affirms life by supporting the patient and family’s goals for the future, including their hopes for cure or life-prolongation, as well as their hopes for peace and dignity throughout the course of illness, the dying process, and death.
Healthcare reform legislation, the Affordable Care Act, will establish 15 pilot sites that offer palliative care integrated with treatment paid for by Medicare for people on Medicare. The new law also allows children who are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) to receive both hospice and curative care.
Some insurance programs will also cover hospice care and treatment at the same time, so ask your insurance plan about hospice coverage even if you want to continue therapy.
Kelley and Meier, New England Journal of Medicine Editorial, Volume 363, Number 8, August 19,2010
What Does This Mean for Patients?
It is important to realize that this study was done with lung cancer patients, not those with colon or rectal cancer. Only 150 patients at a single outpatient program were involved in the research.
It was completed in an outpatient program at a large Boston research hospital with access to a palliative care team. Many outpatient settings might not have a similar team available.
While Medicare and insurance pay for palliative care in hospice programs, reimbursement is not as easily available when palliative care is integrated with chemotherapy or other treatment whose goal is to cure cancer or prolong life.
However, for this group of lung cancer patients aggressive care at the end of life did not help them to live longer which might help patients and families with other advanced cancers make decisions about moving to supportive care only near the end of life.