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Early Palliative Care

"Palliative Care in Patients with Metastatic Non–Small-Cell Lung Cancer".The New England Journal of Medicine. 2010.PubMed•Full text•PDF

1 Clinical Question
2 Bottom Line
3 Major Points
4 Guidelines
5 Design
6 Population
6.1 Inclusion Criteria
6.2 Exclusion Criteria
6.3 Baseline Characteristics
7 Interventions
8 Outcomes
8.1 Primary Outcome
8.2 Secondary Outcomes
9 Criticisms
10 Funding
11 Further Reading

Clinical Question

Does early integration of palliative care with standard oncologic care improve quality of life, mood, survival, and end-of-life care among patients with newly diagnosed metastatic non–small-cell lung cancer?

Bottom Line

Early palliative care led to significant improvements in both quality of life and mood among patients with metastatic non–small-cell lung cancer. Compared to patients receiving standard oncologic care, those receiving early palliative care had less aggressive care at the end of life and longer survival.

Major Points

Metastatic non–small-cell lung cancer is a debilitating disease which results in high symptom burden and poor quality of life, with a survival prognosis less than one year. This study demonstrates the beneficial impact of introducing palliative care early in the disease continuum, significantly improving patient quality of life, mood, and survival.

Guidelines

This trial's results encourage early integration of palliative care in the management of patients with metastatic non–small-cell lung cancer, altering previous models which introduced palliative care late in the course of the disease.

Design

Nonblinded, randomized, controlled trial with two groups:
1. Early palliative care integrated with standard oncologic care.
2. Standard oncologic care alone.

Population

Adult patients with newly diagnosed metastatic non–small-cell lung cancer enrolled within 8 weeks after diagnosis.

Inclusion Criteria
- Pathologically confirmed metastatic non–small-cell lung cancer
- Performance status 0, 1, or 2
- Able to read and respond to questions in English

Exclusion Criteria
- Already receiving palliative care
- Unable to provide informed consent

Baseline Characteristics
No significant differences in demographic characteristics or known prognostic factors between the two groups. Baseline quality of life and mood symptoms were also well-matched.

Interventions

1. Early palliative care group: initial visit within 3 weeks after enrollment and at least monthly outpatient visits thereafter.
2. Standard care group: standard oncologic care without scheduled palliative care visits unless requested.

Outcomes

Primary Outcome
- Change in quality of life from baseline to 12 weeks, measured by the Functional Assessment of Cancer Therapy–Lung (FACT-L) scale.

Secondary Outcomes
- Mood, assessed by the Hospital Anxiety and Depression Scale and the Patient Health Questionnaire 9.
- Survival, aggressive end-of-life care, and documentation of resuscitation preferences.

Criticisms

- Single-site study limiting generalizability
- Lack of diversity in the patient population
- Potential influences of non-specific care aspects
- Open-label design

Funding

Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts from the Joanne Hill Monahan Cancer Fund and Golf Fights Cancer.