This is for our readers who treat cancer patients.
Expanding the evidence that palliative care has measurable clinical benefits in cancer patients, a new randomized study has found that patients who receive palliative care starting soon after the cancer diagnosis have a reduced risk for death at one year compared with patients whose palliative care is delayed by three months.
Although palliative care has been shown to offer benefit, it “is often given weeks or even hours before death,” observed Marie Bakitas, DNSc, CRNP, the associate director of the University of Alabama, Birmingham’s Center for Palliative and Supportive Care. According to Dr. Bakitas, who presented the randomized trial results at the 2014 annual meeting of the American Society of Clinical Oncology (ASCO), this practice will continue in the absence of evidence-based guidance delineating how palliative care should be administered to achieve optimal benefit.
This study was designed to answer the question of when palliative care is best initiated. In this trial, which is the third in a series of multicenter studies called ENABLE (Educate, Nurture, Advise Before Life Ends), newly diagnosed patients with advanced cancer were randomized to receive palliative care starting immediately or three months later (abstract 9512). Other aspects of cancer management were the same. In addition to survival, other primary end points included validated measures of quality of life, symptom impact and mood.
The palliative care protocol consisted of an initial in-person consult, followed by six structured telephone calls by specially trained advanced practice nurses, during which the nurses assisted with symptom management, problem solving and advanced care planning. Along with palliative care, most patients in both arms received chemotherapy or other treatments to control their disease. Baseline characteristics, including measures of quality of life and symptoms, were generally comparable, with the exception of education, which was significantly lower in the delayed-care arm.
Median survival was substantially longer in the immediate palliative care group (18.3 vs. 11.8 months), although this difference did not reach statistical significance (P=0.17). There was, however, a highly significant difference in survival at one year, producing a hazard ratio (HR) of 0.72 in favor of immediate versus delayed palliative care (P=0.003).
“The potential explanations for this difference include enhanced medical care, reduced aggressive care, longer access to hospice care and the biological impact from an improvement in quality of life,” Dr. Bakitas reported. She said that additional data analyses are being launched to better define the mechanism(s) by which the survival advantage was achieved.
There were no measurable differences in other primary end points, such as the number of hospital days, over the course of follow-up, but Dr. Bakitas noted that the delay in palliative care in routine practice typically is far longer than the three months evaluated in this study.
In fact, Dr. Bakitas suggested that patients in both arms appeared to have better palliative care than typically found. For example, “only 7% of patients were receiving chemotherapy within two weeks of death, which is low,” Dr. Bakitas observed.
There already is good evidence that providing palliative care, concurrent with standard oncology care, has meaningful benefits in patients with advanced cancer, but this study suggests that early initiation is preferable. The data imply that centers that deliver cancer care should have an organized and standardized approach to initiating early concurrent palliative care that employs evidence-based principles of optimal management.
Asked to comment on the research, Arif H. Kamal, MD, the director of quality and outcomes at Duke Cancer Institute, in Durham, N.C., said that “palliative medicine is increasingly embracing a discipline-wide responsibility to grow the evidence base
imultaneous to growing its clinical services.” Dr. Kamal suggested that this and other studies that “critically examine how, when and to whom service is provisioned, are needed to move the field forward and further define what entails high-quality palliative care.”