In the JournalsPerspective

Role identified for early palliative care among patients with NSCLC

Early ambulatory palliative care can play a critical role in the care of patients with non–small cell lung cancer by allowing oncologists to focus on cancer treatment and managing medical complications, according to study results.

Previous randomized controlled studies of palliative care in the ambulatory care setting have revealed improvements in patient-reported outcomes, quality of end-of-life care and health care resource use. However, there is a lack of descriptive data on the content and nature of these services that has obstructed the dissemination of early integrated palliative care.

“Currently, many cancer centers have some form of [palliative care] services that predominantly consist of inpatient consultative services and acute inpatient units, whereas outpatient [palliative care] clinics remain a scarcer entity,” Jaclyn Yoong, MBBS, FRACP, of Massachusetts General Hospital in Boston, and colleagues wrote. “Early integration of [palliative care] with cancer care also enhances patients’ understanding of their illness and prognosis, leads to more timely transitions to hospice care, and decreases chemotherapy use near the end of life.”

Yoong and colleagues conducted a qualitative analysis of data from a randomized controlled trial in which patients with metastatic NSCLC received standard oncologic care with or without ambulatory palliative care.

The researchers randomly selected 20 patients with NSCLC who received early palliative care and survived within four periods: less than 3 months (n=5), 3 to 6 months (n=5), 6 to 12 months (n=5) and 12 to 24 months (n=5). Researchers performed content analysis on palliative care and oncologic visit notes from the electronic health records of patients within this cohort.

Based on documentation in palliative care visit notes, Yoong and colleagues identified that addressing symptoms and coping were the most prevalent components of the palliative care clinic visits. The initial palliative care visits focused on building relationships and rapport with patients and their families, as well as illness understanding and prognostic awareness, whereas discussions about resuscitation preferences and hospice predominantly arose during later visits.

Components specific to the medical oncology documentation included discussing plans pertaining to ongoing cancer treatment, and evaluating and managing medical complications connected with radiographic progression or worsening illness.

Although palliative care clinicians and oncologists both focused on cancer treatments, the palliative care clinicians tended to emphasize assisting the patient with decision making regarding therapy and discussing the effect of specific choices.

“The American Society of Clinical Oncology recently published a provisional statement suggesting that all patients with metastatic cancer or a high symptom burden should be offered [palliative care] early in the disease process. Currently, clinicians require further knowledge and experience to provide care in this context,” Yoong and colleagues wrote.

“Although our data detail a preliminary framework of care provided in our randomized trial, the approach may not be the only or optimal way of providing early integrated [palliative care]. Further research is needed not only to determine the generalizability of the benefits of early integrated [palliative care] but also to identify the components of the intervention that might be most effective.”

Disclosure: The researchers report no relevant financial disclosures.

Early ambulatory palliative care can play a critical role in the care of patients with non–small cell lung cancer by allowing oncologists to focus on cancer treatment and managing medical complications, according to study results.

Previous randomized controlled studies of palliative care in the ambulatory care setting have revealed improvements in patient-reported outcomes, quality of end-of-life care and health care resource use. However, there is a lack of descriptive data on the content and nature of these services that has obstructed the dissemination of early integrated palliative care.

“Currently, many cancer centers have some form of [palliative care] services that predominantly consist of inpatient consultative services and acute inpatient units, whereas outpatient [palliative care] clinics remain a scarcer entity,” Jaclyn Yoong, MBBS, FRACP, of Massachusetts General Hospital in Boston, and colleagues wrote. “Early integration of [palliative care] with cancer care also enhances patients’ understanding of their illness and prognosis, leads to more timely transitions to hospice care, and decreases chemotherapy use near the end of life.”

Yoong and colleagues conducted a qualitative analysis of data from a randomized controlled trial in which patients with metastatic NSCLC received standard oncologic care with or without ambulatory palliative care.

The researchers randomly selected 20 patients with NSCLC who received early palliative care and survived within four periods: less than 3 months (n=5), 3 to 6 months (n=5), 6 to 12 months (n=5) and 12 to 24 months (n=5). Researchers performed content analysis on palliative care and oncologic visit notes from the electronic health records of patients within this cohort.

Based on documentation in palliative care visit notes, Yoong and colleagues identified that addressing symptoms and coping were the most prevalent components of the palliative care clinic visits. The initial palliative care visits focused on building relationships and rapport with patients and their families, as well as illness understanding and prognostic awareness, whereas discussions about resuscitation preferences and hospice predominantly arose during later visits.

Components specific to the medical oncology documentation included discussing plans pertaining to ongoing cancer treatment, and evaluating and managing medical complications connected with radiographic progression or worsening illness.

Although palliative care clinicians and oncologists both focused on cancer treatments, the palliative care clinicians tended to emphasize assisting the patient with decision making regarding therapy and discussing the effect of specific choices.

“The American Society of Clinical Oncology recently published a provisional statement suggesting that all patients with metastatic cancer or a high symptom burden should be offered [palliative care] early in the disease process. Currently, clinicians require further knowledge and experience to provide care in this context,” Yoong and colleagues wrote.

“Although our data detail a preliminary framework of care provided in our randomized trial, the approach may not be the only or optimal way of providing early integrated [palliative care]. Further research is needed not only to determine the generalizability of the benefits of early integrated [palliative care] but also to identify the components of the intervention that might be most effective.”

Disclosure: The researchers report no relevant financial disclosures.

    Perspective

    In 2010, a landmark study was published (Temel JS. N Engl J Med. 2010;363:733-742) showing that early integrated palliative care improves the quality of life of patients with advanced lung cancer compared with routine care alone. The study also showed that early palliative care lessens aggressive care at the end of life and may even prolong survival, and it led ASCO to release a Provisional Clinical Opinion in 2012 recommending early involvement of palliative care for all patients with advanced cancer. A major problem arose, however, in implementing this recommendation: What exactly did the palliative medicine doctors do that led to the benefits that were observed? As the Temel study did not mandate any specific interventions, palliative care specialists simply did whatever they felt an individual patient needed within the bounds of their established practice. Without knowing the specifics of the intervention, how is a program trying to provide palliative care for its patients to ensure that the critical elements of the palliative care encounter get done correctly?

    In the current study published in JAMA, Dr. Temel’s group attempted to break down the elements of the palliative care intervention so that it can be better understood and applied elsewhere. Essentially, the palliative care specialists addressed seven major elements: building rapport, understanding the disease and treatments, addressing symptoms, helping with coping, end-of-life planning and engaging family members. Although these elements may seem obvious to physicians who routinely benefit from access to palliative care providers, for much of the world, access to palliative care is not a given and needs to be expanded. Until formal palliative care programs are available everywhere, studies like this one are critical if lung cancer patients are to get access to important and highly cost-effective care outside of major academic institutions.

    • Nathan Pennell, MD, PhD
    • Staff physician Department of Solid Tumor Oncology Taussig Cancer Institute Cleveland Clinic