Exceptional

F1000 Factor 9.0

Early palliative care for patients with metastatic non-small-cell lung cancer

Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD,Jacobsen J, Pirl WF, Billings JA, Lynch TJ

N Engl J Med, 2010, 363: 8: 733-742

Selected byHeidi Klepin

Evaluated 27 Aug 2010

Comments

This landmark article demonstrates that integration of early palliative care with standard oncologic practice shortly after diagnosis may improve quality of life, mood, and overall survival for adults with advanced non-small-cell lung cancer (NSCLC). If validated, these findings could support a paradigm shift in the care of adults with metastatic NSCLC and possibly patients with other tumor types characterized by short survival and high symptom burden. this study should prompt discussion of integrating palliative care services early in treatment for advanced lung cancer as a standard of care. this has implications for resource allocation and enhancing palliative care training of future oncologists.

In this study, 151 patients (Eastern Cooperative Oncology Group [ECOG] score 0-2) were randomized in an unblinded fashion to either standard oncologic care or early palliative care, integrated as part of the multidisciplinary treatment for patients with newly diagnosed advanced NSCLC. the intervention consisted of meetings with a palliative care team within 3 weeks of enrolment and at least monthly thereafter in the outpatient setting until death. Patients on the control arm were able to receive palliative care services if requested by the patient or physician.the primary outcome of the study was the change in quality of life from baseline to 12 weeks measured by the Functional Assessment Cancer Therapy (FACT) Lung Scale. Secondary outcomes included depression, use of health services including anti-cancer therapy, medications,hospice, hospital admission, emergency department visits, and overall survival. Patients were classified as having received ‘a(chǎn)ggressive end-of-life care' if they met any of the following criteria: chemotherapy within 14 days before death, no hospice care, or admission to hospice 3 days or less before death. All analyses were intention to treat. Results confirmed the expected outcome: early palliative care improved quality of life scores and decreased depressive symptoms (16% vs. 38%). Fewer patients in the palliative care group received ‘a(chǎn)ggressive end-of-life care' (33% vs. 54%).Most interestingly, the median overall survival was longer among patients receiving earlier palliative care (11.6 months vs. 8.9 months, p=0.02).Proposed hypotheses for improved overall survival include indirect benefits of decreased depression, decreased hospitalizations due to improved symptom control or, possibly, decreased toxicity from minimizing futile ‘a(chǎn)ggressive end-of-life care'. this study suggests that early palliative care can improve quality of life and symptoms, while having a positive impact on overall survival. the survival difference is similar in magnitude to that seen in practice-changing treatment trials for metastatic lung cancer. Strengths of the study include the randomized study design and use of multiple relevant outcomes including survival. A limitation of this study is that it is based in a single institution and should be validated at other sites to establish generalizability. In addition, the unblinded design and lack of attention control may have influenced outcomes, particularly selfreport assessments. However, these results should promote consideration of a shift in paradigm to incorporate palliative care early, as part of standard oncologic management, which may improve outcomes for many older patients. Please click here for the free full text to the article.

Competing interests:No potential interests relevant to this article were reported.

Evaluated 27 Aug 2010