Intervention group had better scores. At study’s end, the control group had average scores of 91.5, 19.3, and 53.0 on the FACT-L, LCS, and TOI, respectively, vs 98.0, 21.0, and 59.0 for the intervention group. The palliative care group had an average increase on the TOI of 2.3 points, while the average for the control group decreased by 2.3 points (P=.04). A comparison of the mean change in scores between the 2 groups indicated statistically significant improvements in the FACT-L and TOI results for the intervention group. The improvement in LCS was not statistically significant.
The palliative care group also had a lower prevalence of depression compared with the controls (4% vs 17% on the PHQ-9 [P=.04]; 16% vs 38% on the HADS-D [P=.01]). For every 8 patients who received early palliative care, 1 less patient was diagnosed with depression. The prevalence of anxiety was not significantly different between groups.
Among patients who died during the study period, those in the palliative care group were less likely to have received aggressive end-of-life interventions compared with the controls (33% vs 54%, respectively, P=.05). Aggressive care was defined as chemotherapy within 14 days of death or little or no hospice care. Those in the early palliative care group also lived significantly longer; median survival was 11.6 months, vs 8.9 months for the control group (P=.02).
WHAT’S NEW: This study highlights the need for early referral
This is the first high-quality RCT to demonstrate improved patient outcomes when palliative care is begun close to the time of cancer diagnosis. Previous studies of late palliative care referrals did not demonstrate improved QOL or more appropriate use of health care services. This study established that patients with lung cancer are less depressed and live longer when they receive palliative care services soon after diagnosis. It also showed a link between palliative care and a reduction in aggressive, possibly inappropriate, end-of-life treatment of metastatic cancer.
Several recent practice guidelines, including that of the Institute for Clinical Systems Improvement (ICSI), recommend that palliative care referrals be made early in the course of a progressive, debilitating illness, regardless of the patient’s life expectancy.7 Other organizations, including the Institute of Medicine and the World Health Organization, recommend palliative care as an essential component of comprehensive cancer care.8 This study supports both of these recommendations.
CAVEATS: Would extra attention from any clinician work equally well?
No attempt was made to control for the extra attention (an average of 4 visits) that the palliative care team provided to those in the intervention group. Thus, it is possible that the study results could be replicated by having patients meet with their primary care physician or another health professional instead of a palliative care team.
The reduction in depression and increase in survival are clinically significant outcomes. But the improvement in QOL (an average of 7 points better on the 136-point FACT-L scale, or 6 points on the 84-point TOI scale) may not be.
It is important to note, too, that the survival benefits the researchers found may not be generalizable to other kinds of cancers. In addition, most patients (97%) in this study were white, so the findings may be less generalizable to patients of other races. Nonetheless, we think it’s likely that the improvements in QOL and mood revealed in this study would be realized by most patients with terminal cancer who received early palliative care.
CHALLENGES TO IMPLEMENTATION: Palliative care must be explained—and available
Physicians must be able to explain to their patients the difference between palliative care and hospice—most notably, that patients can continue to receive anticancer treatment while receiving palliative care. The recommendation to seek palliative care should not be considered “giving up” on the patient.
In order to refer patients to palliative care early in the course of cancer care, physicians must have access to a palliative care team, which may not be available in all cases. In 2006, only 53% of hospitals with more than 50 beds reported having a palliative care program.5 If there is no such program available, physicians can refer to the ICSI guideline on palliative care for more information on how to implement elements of palliative care for their patients with advanced cancer.7