Palliative care offers symptom relief, comfort, and peaceful death to patients with advanced cancer. Historically, palliative care was provided to patients who were near death. Based on recent research, however, the American Society of Clinical Oncology now recommends combining palliative care with curative treatment early in the disease course. Nevertheless, an important question remains: How early in the disease trajectory should patients with advanced cancer begin receiving palliative care?
According to Marie A. Bakitas, DNSc, NP-C, FAAN, Associate Director, Center for Palliative and Supportive Care, University of Alabama at Birmingham, palliative care is not being offered to patients in a timely manner.
“Focusing the goals of cancer treatment on acquiring as much time as possible for a person by eradicating the underlying disease should be complemented by care and treatments that mitigate symptoms, treat the psychosocial and spiritual dimensions of a person, and maximize the quality of a person’s life. Palliative care is this complementary component of care, yet it is often introduced far too late in the illness trajectory,” Dr Bakitas told Value-Based Cancer Care.
To provide scientific evidence to clinicians and the general public that the early initiation of palliative care confers additional benefits in patients with cancer, Dr Bakitas and colleagues conducted ENABLE III, a phase 3 clinical trial in patients with advanced cancer (Bakitas MA, et al. J Clin Oncol. 2015;33:1438-1445).
Between October 2010 and March 2013, a total of 207 patients with advanced cancer from a National Cancer Institute cancer center, a Veterans Affairs Medical Center, and community outreach clinics were randomly assigned to 1 of 2 groups—early or delayed palliative care; 104 patients received palliative care 30 to 60 days after being informed of their advanced cancer diagnosis (early group), and 103 patients received palliative care 3 months later (delayed group).
Patients in both groups received 3 palliative care interventions, including inpatient palliative consultation, outpatient consultation by palliative care clinicians, and 6 weekly telephone coaching sessions by advanced practice nurses. The study outcomes assessed patient-reported quality of life (QOL), symptoms, and mood; 1-year survival and overall survival; and resource use and location of death.
The relative rates for resource use were similar between the 2 groups, including hospital days, intensive care unit days, emergency department visits, chemotherapy, and home death. Conversely, the 1-year survival rates were 63% in the early group versus 48% in the delayed group. The investigators expected that the improved survival rates in the early palliative care group would also coincide with improved QOL or mood.
The investigators, however, reported that there were no significant differences in QOL, symptom impact, and mood between the early palliative care group (QOL, P =.34; symptom impact, P = .09; mood, P = .33) and the delayed group (QOL, P = .73; symptom impact, P = .30; mood, P = .82). They attributed these differences in the survival rates and QOL to several factors, including a reduced study sample size and power.
Dr Bakitas further emphasized the importance of initiating palliative care early in the disease process. “First and foremost, a culture shift is needed whereby clinicians and the general public understand that palliative care is not just about end of life. It is a type of supportive care and an extra layer of support that can be received at the same time as other medical treatments aimed at cure,” she said.
“Currently, palliative care is often introduced very late when a person is near death and, therefore, patients and families rarely are able to experience the full range of palliative care services,” she said.
“Furthermore, this means palliative care is often mistakenly associated only with end of life. Second, reimbursement mechanisms need to incentivize this care to be offered regardless of prognosis (Medicare currently limits palliative care via hospice only to patients with a 6 month or less prognosis). Third, increased clinician education is needed to train both specialists and general practitioners in palliative care,” Dr Bakitas added.
Overall, the investigators concluded that although early palliative care improved survival in patients with advanced cancer, more research is needed to determine the optimal timing, essential elements, and personnel to deliver the high-quality palliative care.
