Integrating palliative care early in the treatment of patients with advanced lung cancer not only improved their mood and quality of life, it also extended their lives. In the August 19 New England Journal of Medicine, Massachusetts General Hospital (MGH) investigators report that patients with metastatic non-small-cell lung cancer (NSCLC) who received early palliative care along with standard treatment lived more than two months longer than patients receiving standard care only. Metastatic NSCLC is difficult to treat, and patients typically are expected to survive less than one year.
"For me as an oncologist, results like this are incredibly exciting," says Jennifer Temel, MD, of the MGH Cancer Center, the paper's lead author. "We showed that adding the services of a care team focused on quality of life and not altering patients' cancer treatments could both enhance and extend life in patients with an incurable cancer diagnosis. These findings are very promising, and we are already taking steps to examine the impact of early palliative care in other situations."
"One of the most common misconceptions about palliative care is that it indicates treatment has failed -- that it means giving up," says Vicki Jackson, MD, MPH, acting chief of the MGH Palliative Care Service and a co-author of the NEJM study. "In this study the addition of palliative care early in the course of illness extended the survival of patients with incurable lung cancer. These patients not only lived longer, they also experienced improved quality of life and were better able to enjoy the time they had remaining."
Palliative care teams consist of physicians, nurses, social workers and chaplains specially trained to help patients facing serious illness cope with the psychological and spiritual aspects of their disease, as well as managing symptoms such as pain, nausea and shortness of breath. Cancer patients traditionally have been enrolled in palliative care late in the course of their illness, often when they are hospitalized and symptoms have become debilitating. A 2007 study by members of the MGH team found it feasible to integrate palliative care into the treatment of patients newly diagnosed with metastatic NSCLC, the leading cause of cancer death in the U.S. The current study was designed to evaluate the impact of early, continuing palliative care on patients' lives.
Study participants -- all of whom had recently been diagnosed with metastatic NSCLC -- were randomly assigned to receive either standard oncology care or early palliative care integrated with standard care. Those in the latter group met with members of the palliative care team within three weeks of study enrollment and then at least monthly throughout the course of their illness. Additional sessions could be scheduled as needed. The visits included assessing and treating symptoms, establishing goals of care, providing psychosocial support and coordinating care with other services. Participants receiving standard care who wished to access palliative services were free to do so at any point during the study.
Members of both groups completed standard questionnaires assessing mood and quality of life when they enrolled in the study and 12 weeks later. The research team collected data on the services and treatments participants received -- including hospital admission, hospice services, chemotherapy and other medications -- as well as whether patients' resuscitation preferences were documented in the medical record. A total of 151 patients enrolled -- 77 assigned to the palliative care group, and 74 to standard care -- during the three-year study period.
Responses to the quality-of-life questionnaire showed significant improvement from enrollment to 12-week assessment in the palliative care group but worsening quality of life in the standard care group. Depression symptoms in the palliative care group were about half those reported in the standard care group at 12 weeks, although the rates of new antidepressant prescriptions among both groups was similar. While more than half the palliative care participants had documented resuscitation preferences, essential to ensuring that patients' goals and end-of-life wishes are respected, fewer than 30 percent of standard care participants had documented preferences.
More than half the standard care participants received what the study protocol defined as aggressive end-of-life care -- chemotherapy within 14 days of death, a time when it is usually considered futile, and either no or late referral to hospice care -- compared with only a third of the palliative care group. Despite the lack of such aggressive end-of-life care, patients in the palliative care group lived an average of 11.6 months, while survival for standard care patients was less than 9 months.
Temel says, "Traditionally, cancer care has focused on treating the disease itself, but now we realize we must also focus on managing patient's symptoms and distress related to their diagnosis. We hypothesize that the increased survival was due to improved mood and quality of life, to early and more comprehensive management of symptoms and complications, and possibly to more appropriate end-of-life care. Similar studies in patients with other types of cancers and in other care settings will help us better understand the impact palliative care can have on the well-being and health of all patients with cancer." Temel is an assistant professor of Medicine, and Jackson an instructor in Medicine at Harvard Medical School.
The study was supported by grants from the American Society of Clinical Oncology, the Joanne Hill Monahan Cancer Fund and Golf Fights Cancer. Senior author of the NEJM article is Thomas Lynch, MD, formerly chief of MGH Hematology/Oncology and now director of the Yale Cancer Center. Additional co-authors are Emily Gallagher, RN, MGH Cancer Center; Constance Dahlin, APN, Craig Blinderman, MD, Juliet Jacobsen, MD, and Andrew Billings, MD, MGH Palliative Care; Joseph Greer, PhD, and William Pirl, MD, MPH, MGH Psychiatry; Alona Muzikansky, MGH Biostatistics; and Sonal Admane, MBBS, MPH, State University of New York, Buffalo.
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