Results from the first randomized clinical trial of its kind have revealed a surprising and welcome benefit of early palliative care for patients with advanced lung cancer—longer median survival. Although several researchers said that the finding needs to be confirmed in other trials of patients with other cancer types, they were cautiously optimistic that the trial results could influence oncologists’ perceptions and use of palliative care. The results were published online August 19, 2010, in the New England Journal of Medicine.
Patients in the trial who received palliative care early in the course of their cancer treatments also reported better of quality of life and were less likely to be depressed than those who did not automatically receive such care. But the finding that received the most attention was the improved survival, a noteworthy result for patients with this notoriously difficult-to-treat disease.
The extent of the survival improvement was just short of 3 months, which is equivalent to what is commonly seen with standard first-line chemotherapy, according to the research team led by Jennifer Temel, M.D., of Massachusetts General Hospital (MGH) and Harvard Medical School. While pleased with the results, Dr. Temel acknowledged in an interview that the findings have to be considered within the context of the study, which was conducted in a single large medical center with a strong palliative care program.
“Most big academic medical centers and larger community hospitals now have palliative care services. In larger hospitals, the rate [of such programs] is around 80 percent,” she said. “In smaller hospitals, they may not have access to these palliative care resources.”
In an accompanying editorial , Diane Meier, M.D., and Amy Kelley, M.D., of the Department of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine, acknowledged the trial’s limitations but argued that the findings stand to challenge the “prevailing notion of palliative care.” Until this point, palliative care has typically been seen “as the alternative to life-prolonging or curative care—what we do when there is nothing more that we can do—rather than as a simultaneously delivered adjunct to disease-focused treatment.”
The Design and the Results
More than 150 patients at MGH who were newly diagnosed with advanced non-small cell lung cancer (NSCLC) were enrolled in the trial and randomly assigned to receive standard care for the disease or standard care plus early palliative care services.
Within 3 weeks of enrolling in the trial, patients in the palliative care group met with a palliative care team. Such teams can include specially trained physicians and nurses, social workers, and clergy members, although in this trial, Dr. Temel noted, the team included only physicians and nurse practitioners. Patients then met monthly with the palliative care team and had additional consultations as needed. Patients in the standard care group or their clinicians could also request palliative care services.
The 2.7-month improvement in median survival came as somewhat of a surprise, said Dr. Temel, noting that overall survival was 11.6 months for patients in the palliative care group compared with just less than 9 months in the standard care group. But there is a strong rationale for why early palliative care can have a significant clinical impact.
“We gave [patients] the tools to make sound decisions about their medical care,” she said. When it comes to discussions and debates about palliative and hospice care, she continued, “instead of talking about ‘rationing’ care, we should be talking about better educating patients so they can make more appropriate decisions about their care.”
For example, the survival rates were better despite the fact that more patients in the standard care group received aggressive care at the end of life, which was defined as chemotherapy within 2 weeks of death or 3 days or less in hospice prior to death. However, Dr. Temel stressed that she believes the survival benefit is most likely a result of the improvements in quality of life and depression. Although patient decisions on end-of-life care “probably contributed” to the survival benefit, she said, “the survival benefit was seen early in time, so it could not all be accounted for by less aggressive end-of-life care.”
For Christian Sinclair, M.D., a staff clinician at Kansas City Hospice and Palliative Care, an outpatient facility in Kansas City, MO, the improved survival was also unexpected, but for a different reason. “Palliative care can be used early, at the time of diagnosis, but so often it’s used during symptom crises in the middle to late stages of advanced disease,” he said. “So I’m surprised just because I haven’t seen a lot of early palliative care.”
Because good palliative care “can diminish or alleviate a lot of the physical and psychological symptoms associated with cancer and its treatment, it might follow that survival can be improved,” said Ann O’Mara, PhD, RN, of NCI’s Division of Cancer Prevention , who oversees a large portfolio of NCI-funded palliative care research. Often, when patients enter hospice programs, she continued, their disease status will improve. “And there is a lot of overlap in the kinds of services provided in palliative care and hospice, particularly in terms of aggressive symptom management, so it’s not surprising that patients receiving palliative care would see similar improvements,” she said.
Although it’s unlikely that a single study will dramatically change how palliative care is used in oncology, Dr. O’Mara believes that similar studies will only help to increase the visibility and acceptance of palliative care. But that doesn’t change what the research team accomplished in this trial, she continued, particularly given the patient population. “I applaud [the researchers] for having chosen patients with advanced lung cancer,” she said, “because their symptom burden is quite severe.”
She acknowledged that the outcome may be different for patients treated at smaller community hospitals, many of which don’t have staff with the expertise to deliver comprehensive palliative care of the type used in the MGH trial. “It’s not just about delivering pain or nausea medication; it also requires managing family, financial, and psychosocial issues. Palliative care is very complex,” she explained.
There are a number of obstacles to wider adoption of palliative care, said Dr. Sinclair, but a big part of the problem still traces back to the clinic. “There’s a high level of cultural resistance to earlier palliative care,” he said. While he acknowledged that data showing the impact of palliative care on patient outcomes are limited, in his experience, he said, “there’s still the stigma that it’s primarily for late disease.
Dr. Temel and her colleagues are planning similar trials for patients with hard-to-treat cancers such as esophageal and pancreatic cancer. In the meantime, she hopes that the trial results will reinforce that palliative care and quality oncology care “are not an either/or proposition; they are not mutually exclusive. It’s feasible to provide both at same time, and it’s also beneficial for the patient.”