Early Palliative Care for Patients With Metastatic Non-Small-Cell Lung Cancer
Temel JS, Greer JA, Muzikansky A, et al.
N Engl J Med. 2010;363:733-742
Lung cancer is the single most fatal malignancy in the United States and most other countries. Most patients with lung cancer are not cured, so it is important to ensure that the final stages of their lives are optimally managed and they are offered appropriate care with a minimum of suffering. Palliative care aims to provide these benefits, but for whatever reasons, its use has been low. Temel and colleagues performed a randomized controlled trial of early palliative care in addition to standard care to determine the efficacy of palliative care in patients with metastatic non-small cell lung cancer. They enrolled 151 patients, all of whom received standard oncologic care, and half of whom were randomly assigned to receive early palliative care in addition to standard care.
Palliative care consisted of initial and monthly meetings with a palliative care clinician who "assessed physical and psychosocial symptoms, established goals of care, assisted with decision making regarding treatment, and coordinated care on the basis of the individual needs of the patient." The primary outcome was the change in quality of life 12 weeks after enrollment using 3 complementary scales. Secondary outcomes were duration of survival, healthcare utilization, and other relevant measures.
By each of the 3 quality-of-life outcomes, the intervention group had scores that were statistically better than those of the control group. They had less depression, used fewer healthcare services, and their median survival was 2.7 months longer (P < .05).The study showed that palliative care added to usual care can play an important role in improving end-of-life outcomes in patients with metastatic lung cancer. Unexpectedly, survival was also prolonged.
This is the first prospectively designed scientific study to convincingly show measurable improvements attributable to traditional palliative care in terminal illness. It was methodologically sound, and the outcomes were consistently positive. Although the quality-of-life indexes showed statistically significant improvements, they were not large and only just at the threshold of clinical relevance. The mechanism of the beneficial effect of early palliative care is unknown. Previous studies in patients with lung cancer have shown that a poor quality of life and depression are associated with worse outcomes.[14,15,16] The present results seem to be the other side of the same coin: the avoidance of those factors improves outcomes, as has also been previously found in those with breast cancer. Also noteworthy is that the prolongation of survival, a mean of 2.7 months, is similar to that obtained by many chemotherapy programs, yet does not entail the unpleasant side effects of lung cancer chemotherapy, nor its high cost.
It needs to be stated that palliative care is not synonymous with hospice care or curative therapy. It is, however, compatible with both of those modalities. Typically, when palliative care is brought into a patient's management, it is as a late and somewhat desperate modality. This is unfortunate. It seems likely that its success in the present study is that it was employed early, as soon as the diagnosis of metastatic cancer was made; and continued simultaneously with conventional oncologic therapy. It is underutilized, and one hopes the present study will encourage its early and more widespread use to assuage the end-of-life distress of those with cancer.
The accompanying editorial makes useful suggestions about which components of the palliative care program provided the most benefit, and explores whether similar results could be obtained with other malignancies.
Obviously, too, the study needs to be replicated at sites where most cancer is seen and treated, namely community hospitals. One weakness of the present report is that the study was performed at a single institution -- and one of the best academic institutions in the world, at that.
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