Early initiation of palliative care for patients with advanced cancer may not only improve their survival, but also reduce the depression and stress burden of family caregivers, according to results of two analyses of the ENABLE III trial.
“Palliative care is about providing an extra layer of support so that patients can live well and families can be supported,” Marie A. Bakitas DNSc, CRNP, the Marie L. O’Koren endowed chair and professor at the University of Alabama-Birmingham School of Nursing, said in a press release. “These data support the importance of providing this care at the same time as medical treatments aimed at fully curing disease. Too often, that is not the case.”
Maria A. Bakitas
Bakitas and colleagues conducted two analyses of early palliative care in the ENABLE III trial, one that focused on patient outcomes and the other on benefits for informal family caregivers.
Based on results from the ENABLE II trial, the researchers modified ENABLE III to add a three-session life review component; design a separate, yet parallel intervention for caregivers; and adopt a fast-track study design to address the optimal timing for the initiation of palliative care.
The analyses compared early initiation of palliative care — defined as initiation within the first 30 to 60 days of diagnosis — with initiation that was delayed for 3 months. Researchers randomly assigned 207 patients and 122 of their caregivers 1:1 to early or delayed initiation of palliative care.
Palliative care for patients consisted of an in-person consultation, weekly tele-health nurse coaching sessions and monthly follow-up. The primary objective of the patient analysis was to compare the effect of early vs. delayed palliative care on patient-reported outcomes, 1-year survival and resource use.
Family caregivers received a separate intervention to address their unique self-care needs and to help coach their roles in problem solving, decision-making, advanced care planning and communicating with the patient. Palliative care for caregivers consisted of weekly telephone coaching sessions, monthly follow-up and a bereavement call.
In the patient analysis, 1-year survival rates were 63% in the early palliative care group and 48% in the delayed-care group (P = .038).
However, relative rates of early vs. delayed decedents’ resource use were similar for hospital days (0.73; 95% CI, 0.41-1.27), ICU days (0.68; 95% CI, 0.23-2.02), ER visits (0.73; 95% CI, 0.45-1.19), chemotherapy in the last 14 days (1.57; 95% CI, 0.37-6.7) and home death (54% vs. 47%).
“[While] early-entry participants’ patient reported outcomes and resource use were not statistically different … their survival 1 year after enrollment was improved compared with those who began 3 months later,” Bakitas and colleagues wrote. “Understanding the complex mechanisms whereby palliative care may improve survival remains an important research priority.”
Researchers assessed caregivers’ depression using the Center for Epidemiology Study–Depression Scale (score ˃ 16 indicates clinically significant depression). Depression scores from enrollment to 3 months — or before the initiation of palliative care in the delayed cohort — were better in the early initiation group (mean difference = – 3.4; P = .02).
For the caregivers of decedents, a terminal decline analysis showed significant improvements in the early initiation group for depression (mean difference = – 3.8; P = .02) and stress burden (mean difference = – 1.1; P = .01).
“Reimbursement mechanisms need to incentivize this care to be offered regardless of 6-month prognosis, which is the current hospice–benefit requirement,” Bakitas said in the release. “Also, increased clinician education is needed to train both specialists and general practitioners in palliative care.”
These benefits demonstrated for both patients and caregivers may suggest there is no reason not to initiate palliative care closer to the time of cancer diagnosis, Barbara Gomes BSC, MSc, PhD, a research fellow at King’s College in London, wrote in an accompanying editorial.
“Palliative care offers patients and their families a comprehensive package of care by a team of professionals who became experts in solving the difficult and multiple symptoms and problems that usually arise in advanced stages of disease, helping to achieve comfort and eventually a peaceful death and bereavement,” Gomes wrote. “Together with earlier findings on the benefits associated with the early integration of palliative care, the ENABLE III trial urges a change of practice and culture. If palliative care makes a difference for patients and family caregivers, and if earlier is better, why wait?” – by Anthony SanFilippo
Bakitas MA, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2014.58.6362.
Dionne-Odom JN, et al. J. Clin Oncol. 2015;doi:10.1200/JCO.2014.58.7824.
Gomes B. J Clin Oncol. 2015;doi: 10.1200/JCO.2014.60.5386.
Disclosures: One researcher reports research funding from Johnson & Johnson. Bakitas and Gomes report no relevant financial disclosures.