Palliative care and cancer – earlier is better

The specialty of medical oncology has progressed at a phenomenal rate over the past few decades. Major advances in combined and targeted therapies have resulted in dramatic improvements in survival rates for many cancers.¹ However, this impressive progress in cancer disease management is not always accompanied by an equal focus on addressing the physical, psychosocial and existential challenges consequent on living with advanced cancer.²

Cancer is often accompanied by significant symptom burden, psychosocial distress, and poor quality of life.³ For more than a decade, the World Health Organisation has defined palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. 

“Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications”.⁴

The overall objective of palliative care is to anticipate, prevent and reduce suffering.⁵

In a 2010 landmark paper, Temel et al demonstrated that in a series of patients with metastatic non-small-cell lung cancer (NSCLC), the early introduction of palliative care positively impacted on patients’ quality of life and may even have conferred a significant survival benefit.⁶

Many organisations, including the WHO, the European Society for Medical Oncology (ESMO) and the American Society of Clinical Oncology (ASCO), support the introduction of palliative care services as appropriate at an early stage in the patient’s illness. Oncologists have a key role to play in integrating palliative care services at the earlier stages of malignant disease. 

However, it cannot be left to oncologists alone. We need a major shift in attitudes amongst all healthcare professionals and the general public before palliative care becomes accepted as an integral part of good quality care from the initial diagnosis. Currently, there is a widespread misconception that palliative care involvement is restricted to the very end stages of disease and only at a time when all other disease-modifying interventions have failed. 

Early palliative care

Palliative care includes the appropriate care of patients at the very end of life, but end-of-life care does not define palliative care. It is applicable at each and every stage of the patient’s journey. 

Patients must not be presented with an ‘either/or’ option, but must have the facility to avail of high-quality oncology services in conjunction with skilled, specialist palliative care. 

What really is palliative care?

In some of the literature, a distinction is drawn between supportive care, palliative care and terminal or end-of-life care. Supportive care aims to optimise the comfort, function and social support of the patient and family at all stages of the illness; all patients need this, continuously. 

Palliative care aims to optimise the comfort, function and social support of the patient and their family when cure is not possible; it is focussed on the special needs of patients whose disease is incurable. 

Terminal care or end-of-life care is palliative care when death is imminent.⁷

These distinctions are not universally applied and, indeed, the WHO definition of palliative care embraces all of these various elements. 

The overall objective of these various interventions and supports, irrespective of how they might be classified or represented, is to enable each patient to live the life they choose to live, with the best possible degree of comfort and quality, in the setting of their choice for the duration of their natural life. 

Proven benefit

The 2010 Temel et al study in the New England Journal of Medicine⁶ created much discussion and debate amongst the palliative care and oncology communities worldwide. 

This study of 151 patients compared the effects of offering early palliative care and standard oncology treatment versus standard oncology treatment alone amongst a group of patients with newly diagnosed metastatic NSCLC. 

Health-related quality of life and mood were assessed at baseline and again at 12 weeks. Eligible patients were enrolled within eight weeks of diagnosis and randomly assigned to one of two groups. 

Patients who were assigned to the early palliative care group met with a member of the palliative care team within three weeks of enrolment and at least monthly thereafter in the outpatient setting. 

Patients who were assigned to the standard care group did not meet with the palliative care team unless the patient, the family, or the oncologist requested a meeting.

Patients randomly assigned to the early palliative care intervention group had significantly higher scores for quality of life measures compared to the standard group. These patients also showed fewer signs of depression. However, perhaps the most surprising finding was that the average survival rates for patients in the early palliative care intervention group were prolonged by 2.7 months. The key findings are summarised in Table 1.

 (click to enlarge)

The researchers hypothesised that improvements in quality of life and mood may account for the increased survival, given that earlier studies have shown that poor mood and quality of life can be associated with shorter survival in patients with metastatic NSCLC.

In an interview following the publication of this study, the lead author stated: “One of the most important messages of this study is demonstrating to clinicians that state-of-the-art cancer care and palliative care are not mutually exclusive. It is not only feasible to do both, but beneficial.”⁸

However, attitudes and practice do not change overnight and it would be naïve to believe that a single paper will fundamentally alter perceptions and behaviours. 

Traditionally, palliative care was viewed as an appropriate option only after all other reasonable efforts at disease management, with the objective (albeit sometimes futile) of achieving a cure, were completely exhausted. 

Dr Mark Kris, chairperson of ASCO’s Cancer Communications Committee, was remarkably honest when he observed: “There are emotional and logistical impediments to oncologists making better use of palliative care services to help patients. Many physicians may be very uncomfortable bringing this up (palliative care) on the day they meet someone if they have a serious illness like lung cancer. People are doing everything possible to instil hope. Even bringing up the words ‘palliative care’ can seem to patients and families like it means you’re not hopeful and you’ve already given up.”⁸

The above sentiments were echoed by Dr Len Lichtenfeld, deputy chief medical officer at the national offices of the American Cancer Society: “If this was a report on a new drug for NSCLC people would be cheering in the aisles. The question is, will it rise to that level of interest? I would like to believe this will be a game changer, but I’m not sure that it is…These are very difficult conversations to have with a patient still in active treatment.”⁸

Simultaneous care model 

In March 2012, ASCO published a provisional clinical opinion paper based on a review of seven published, randomised controlled trials of palliative care, including the Temel paper.⁹

This review concluded that:

• Patients with metastatic NSCLC should be offered concurrent palliative care and standard oncological care at initial diagnosis 
• A survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, but substantial evidence indicates that better patient and caregiver outcomes are achieved
• Early involvement of palliative care leads to more appropriate referral to and use of hospice, and reduces futile intensive care
• No trials to date have demonstrated harm to patients and caregivers, or excessive costs, associated with the integration of palliative care into standard oncology care.  

It was the panel’s expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high-symptom burden. 

Strategies to optimise concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes, (eg. quality of life, survival, healthcare services utilisation and costs), and on society, should be an area of intense research. 

Research from the UK and Canada has shown that palliative care services reduce the healthcare costs of patients who are dying. The financial savings are due to a reduction in hospital admissions, length of stay, re-admissions, admissions to intensive care units (ICU), and inappropriate investigations and treatments. 

In addition, palliative care services improve the chances of the patient dying in the setting they prefer.¹⁰

Metastatic cancer is a devastating diagnosis. Clinicians need to find a way to offer open and honest information, while at the same time, maintaining hope. When fostering hope, it is crucial not to give misleading information about the possibility of a cure or further treatment ‘down the line’. 

The clinician/patient relationship is ultimately based on mutual trust, honesty and understanding. Irrespective of our motives, we must never act in a way that will undermine a patient’s trust.

“…perhaps the most surprising finding was that the average survival rates for patients in the early palliative care intervention group were prolonged by 2.7 months” (click to enlarge)

The issue is best summarised by Kelley and Meier in a New England Journal of Medicine editorial that accompanied the original paper by Temel et al: 

“The study represents an important step in confirming the beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specific therapies beginning at the time of diagnosis. 

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 recognises 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. Perhaps unsurprisingly, reducing patients’ misery may help them to live longer. 

“We now have the means and the knowledge to make palliative care an essential and routine component of evidence-based, high-quality care for the management of serious illness.”¹¹

References 

1. Cancer Trends Progress Report – 2011/2012 Update. National Cancer Institute, National Institutes of Health and Human Services [online] 2012; [cited Oct 1, 2013] Available from http://progressreport.cancer.gov 
2. Abernethy A, Aziz MM, Basch E et al. A strategy to advance the base in palliative medicine: Formation of a palliative care research co-operative group. J Palliat Med 2010; 13: 1407-1413 
3. Kumar P, Casarett D, Corcoran A et al. Utilisation of supportive and palliative care services among oncology outpatients at one academic cancer centre: Determinants of use and barriers to access. J Palliat Med 2012; 15(8): 923-930
4. World Health Organisation. WHO definition of palliative care [online]; [cited Oct 3, 2013]. Available from http://www.who.int/cancer/palliative/definition/en/
5. National Comprehensive Cancer Network. NCCN Guidelines: Palliative care. Version 2, 2013; [cited 2013 Oct 03]. Available from: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp
6. Temel J, Greer JA, Muzikansky A et al. Early palliative care for patients with metastatic non-small-cell lung cancer. NEJM 2010; 363: 733-742
7. Cherny NI, Catane R. Palliative medicine and modern cancer care. In: Hanks G, Cherny NI, Christakis NA et al, editors. Oxford textbook of palliative medicine (4th ed). Oxford: Oxford University Press, 2010: 111-124
8. Kelly KB. Early palliative care lengthens survival for lung cancer patients. American Medical News. [online] 2010; [cited 2013 Oct 4] Available from: http://www.amednews.com/article/200100906/profession/309069940/6/
9. Smith TJ, Temin S, Alesi ER et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012; 30(8): 880-887
10. Canadian Hospice Palliative Care Association. Cost effectiveness of palliative care: A review of the literature. Ottawa, ON: The way forward initiative: An integrated palliative approach to care. 2012; [cited 2013 Oct 03]. Available from: http://www.hpcintegration.ca/media/36290/TWF-Economics-report-Eng-final-webmar7.pdf 
11. Kelley AS, Meier DE. Palliative care – a shifting paradigm. NEJM 2010; 363:781-782