Early palliative care lengthens survival for lung cancer patients

Palliative care not only helps patients with terminal illnesses have less painful deaths but also can increase survival times when it is integrated soon after diagnosis.

That is the finding of a study of 151 Boston-area patients with lung cancer in the Aug. 19 New England Journal of Medicine. The 74 patients who received standard oncologic care at Massachusetts General Hospital for metastatic non-small-cell lung cancer had a median survival time of nine months, compared with nearly a year for the 77 patients who received standard care and visited the hospital's outpatient palliative care service within three months of diagnosis. The patients getting palliative care lived longer despite spending more time in hospice care and receiving less chemotherapy.

Palliative care specialists helped patients understand their disease, clarify treatment goals, make medical decisions and manage symptoms, including pain, dyspnea, fatigue, mood swings and gastrointestinal distress. The patients who received early palliative care saw the specialists an average of four times, achieved better pain symptom management, and were less depressed and anxious than patients getting standard care.

"One of the most important messages of this study is demonstrating to clinicians that state-of-the-art cancer care and palliative care are not mutually exclusive," said lead author Jennifer S. Temel, MD, a thoracic surgeon at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School in Boston. "It's not only feasible to do both, but beneficial. Hopefully, clinicians will see that and talk to patients about that."

Palliative care may have lengthened survival times by helping terminally ill patients avoid preventable hospitalizations and fruitless chemotherapy, said Diane E. Meier, MD, director of the Center to Advance Palliative Care, a New York nonprofit that helps hospitals develop palliative care programs. She co-wrote a NEJM editorial commenting on the study.

"It's urgent that we move our capacity to provide this kind of care for terminally ill patients way upstream," said Dr. Meier, also director of the Hertzberg Palliative Care Institute at Mount Sinai School of Medicine in New York. "The palliative care we provide has to be available from the point well before patients are in the hospital, and that's at the point of diagnosis."

Whether oncologists take the findings to heart remains to be seen, said Len Lichtenfeld, MD, deputy chief medical officer at the national office of the American Cancer Society.

"If this was a report on a new drug for non-small-cell lung cancer, people would be cheering in the aisles," said Dr. Lichtenfeld, a retired oncologist and primary care physician. "The question is: Will it rise to that level of interest? I would like to believe this will be the game changer, but I'm not sure that it is. ... These are very difficult conversations to have with a patient still in active treatment."

The study comes at a time of increasing interest in the model of concurrent care -- delivering a simultaneous combination of palliative care and treatment for the underlying disease -- to patients diagnosed with terminal illnesses. Traditionally, palliative and hospice care have been offered to patients only after disease-fighting efforts have failed.

The new health reform law calls on the Dept. of Health and Human Services secretary to conduct a three-year, budget-neutral demonstration project of concurrent care for Medicare patients at 15 hospice-care sites.

Since 2004, Aetna has allowed its members diagnosed with terminal illnesses to receive concurrent care, more than tripling the number of patients who receive hospice. These patients spent 82% fewer days in the hospital compared with patients who declined hospice care, said Randall Krakauer, MD, Aetna's national medical director for Medicare.

There are emotional and logistical impediments to oncologists' making better use of palliative care services to help patients, said Mark Kris, MD, chief of the thoracic oncology service at Memorial Sloan-Kettering Cancer Center in New York.

"Many physicians may be very uncomfortable bringing this up on the day they meet someone if they have a serious illness like lung cancer," said Dr. Kris, chair of the American Society of Clinical Oncology's Cancer Communications Committee.

"People are doing everything possible to instill hope. Even bringing up the words 'palliative care' can seem to patients and families like it means you're not hopeful and you've already given up."

Finding physicians with expertise in the relatively new specialty of palliative care can be a challenge, Dr. Kris said. Outpatient palliative care services are uncommon. Patients with lung cancer may have trouble fitting palliative care visits into schedules packed with chemotherapy, radiation and imaging studies.

More patients are receiving hospice and palliative care. Nearly 1.5 million patients received hospice care in 2008, up from 950,000 in 2003, according to the National Hospice and Palliative Care Organization, which represents hospice and palliative care programs. More than 80% of hospitals of 300 beds or more now offer palliative care programs, according to the Center to Advance Palliative Care.

Experts said further research is needed to see if concurrent care also can increase survival times among patients with other kinds of terminal illnesses. About a quarter of terminally ill patients have cancer.