PRACTICE CHANGER
Recommend a palliative care consultation at the time of diagnosis. Early palliative care can improve quality of life, decrease depressive symptoms, and prolong life in patients with metastatic cancer.1
STRENGTH OF RECOMMENDATION
B: Based on a single well-done randomized controlled trial (RCT).
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733-742.
ILLUSTRATIVE CASE
A 73-year-old patient you’ve known for your entire career comes in for follow-up after a recent hospitalization, during which he was diagnosed with metastatic non–small-cell lung cancer. “I know things don’t look good,” he says. “I don’t want to die a miserable, painful death. But I’m not going to just roll over and die without fighting this.” What can you do to improve his quality of life while he undergoes cancer treatment?
Palliative care focuses on the prevention and treatment of pain and other debilitating effects of serious illness, with a goal of improving quality of life for patients and their families. Unlike hospice care, which requires a prognosis of less than 6 months of life to qualify for Medicare reimbursement,2 eligibility for palliative care is not dependent on prognosis. Indeed, palliative care can occur at the same time as curative or life-prolonging treatment. Palliative care programs include psychosocial and spiritual care for patient and family; management of symptoms such as pain, fatigue, shortness of breath, depression, constipation, and nausea; support for complex decisions, such as discussions of goals, do not resuscitate (DNR) orders, and requests for treatment; and coordination of care across various health care settings.3
Palliative care lowers health care spending
One study found that palliative care consultation was associated with an average savings of $1700 per admission for patients who were discharged, and $4900, on average, for every patient who died in the hospital.4 Another study demonstrated an association between states with a higher percentage of hospitals with palliative care services and fewer Medicare hospital deaths; fewer admissions to, and days in, intensive care units in the last 6 months of life; and lower total Medicare spending per enrollee.5
A 2008 systematic review of the effectiveness of palliative care revealed that there were methodological limitations in all the existing studies of palliative care, and called for higher quality studies.6 The RCT detailed here is a first step toward filling the gap in palliative care research.
STUDY SUMMARY: Intervention group lived longer and felt better
Temel et al enrolled 151 ambulatory patients with biopsy-proven non–small-cell lung cancer. The average age of the enrollees was 64 years, and slightly more than half (51.6%) were female. All had been diagnosed with metastatic cancer within 8 weeks of enrollment in the study.
The patients were randomized to receive either an early referral to the palliative care team along with standard oncology care or standard oncology care alone. Race, marital status, smoking history, presence of brain metastases, and initial cancer therapy—radiation, chemotherapy, or a combination—were similar for both groups.
The study ran for 12 weeks. Those in the intervention group had an initial meeting with a member of the palliative care team, which consisted of board-certified palliative care physicians and advanced practice nurses. Follow-up meetings with the team were scheduled at least monthly, and more frequently if requested by the patient or recommended by either the palliative care team or the oncology team—with an average of 4 meetings over the course of the study. Palliative care team members worked with patients to assess physical and emotional symptoms, coordinate care, and determine and document goals of treatment.
The primary outcome was the change in quality of life (QOL) from baseline to 12 weeks after the initial meeting with the palliative care team. QOL was measured with the Functional Assessment of Cancer Therapy-Lung (FACT-L) tool; scores range from 0 to 136, with higher scores indicating a higher QOL. The researchers used 3 subscales of the FACT-L—physical well-being, functional well-being, and a lung-cancer subscale (LCS) based on questions about 7 symptoms—to create a Trial Outcome Index (TOI), the main outcome measure. The TOI, which is the sum of the subscales, has a range of 0 to 84, with higher scores indicating higher QOL.
Secondary outcome measures were mood, use of health care services, and survival. The researchers assessed mood with 2 tools: the Patient Health Questionnaire-9 (PHQ-9) and the Hospital Anxiety and Depression Scale (HADS). The PHQ-9 is a 9-question survey that uses criteria from the Diagnostic and Statistical Manual of Psychiatric Disorders, 4th edition (DSM-IV) to diagnose depression. HADS is a 14-question survey with subscales for depression (HADS-D) and anxiety (HADS-A).