Effects of Early Integrated Palliative Care in Patients With Lung and GI Cancer: A Randomized Clinical Trial

Abstract

Purpose We evaluated the impact of early integrated palliative care (PC) in patients with newly diagnosed lung and GI cancer. Patients and Methods We randomly assigned patients with newly diagnosed incurable lung or noncolorectal GI cancer to receive either early integrated PC and oncology care (n = 175) or usual care (n = 175) between May 2011 and July 2015. Patients who were assigned to the intervention met with a PC clinician at least once per month until death, whereas those who received usual care consulted a PC clinician upon request. The primary end point was change in quality of life (QOL) from baseline to week 12, per scoring by the Functional Assessment of Cancer Therapy-General scale. Secondary end points included change in QOL from baseline to week 24, change in depression per the Patient Health Questionnaire-9, and differences in end-of-life communication. Results Intervention patients ( v usual care) reported greater improvement in QOL from baseline to week 24 (1.59 v -3.40; P = .010) but not week 12 (0.39 v -1.13; P = .339). Intervention patients also reported lower depression at week 24, controlling for baseline scores (adjusted mean difference, -1.17; 95% CI, -2.33 to -0.01; P = .048). Intervention effects varied by cancer type, such that intervention patients with lung cancer reported improvements in QOL and depression at 12 and 24 weeks, whereas usual care patients with lung cancer reported deterioration. Patients with GI cancers in both study groups reported improvements in QOL and mood by week 12. Intervention patients versus usual care patients were more likely to discuss their wishes with their oncologist if they were dying (30.2% v 14.5%; P = .004). Conclusion For patients with newly diagnosed incurable cancers, early integrated PC improved QOL and other salient outcomes, with differential effects by cancer type. Early integrated PC may be most effective if targeted to the specific needs of each patient population.

Figures

Fig 1.

Frequency and content of palliative care (PC) visits. (A) Number of PC visits by study group. Bars represent the percentage of PC visits for all study patients within 24 weeks. Four intervention patients withdrew from the study before their first scheduled PC visit. (B) Content areas of PC visits with intervention patients per PC clinician documentation. PC clinicians used a standardized template to electronically document the focus of their intervention visits after each encounter. Bars represent the proportion of PC visits that focused on each content area within 24 weeks. (C) Bars represent the proportion of visits that each symptom was addressed when PC noted symptoms as a visit focus. (D) Bars represent the proportion of visits that each topic was addressed when PC noted coping as a visit focus.

Fig 2.

Trajectories of quality of life (QOL) and depression symptoms over time by cancer cohort. (A) QOL in lung cancer. (B) QOL in GI cancer. (C) Depression symptoms in lung cancer. (D) Depression symptoms in GI cancer. FACT-G, Functional Assessment of Cancer Therapy-General scale; PHQ-9, Patient Health Questionnaire-9.

Fig. A1.

CONSORT diagram. ECOG PS, Eastern Cooperative Oncology Group performance status.