Early palliative care may improve survival in advanced cancer

1. In a randomized controlled trial of over 200 patients with advanced cancer, early palliative care (PC) intervention was associated with improved 1-year survival rate compared to delayed PC referral.

Evidence Rating Level: 2 (Good)

Study Rundown: Current recommendations endorse the use of early palliative care (PC) in the course of treatment for patients with advanced or very symptomatic cancer. However, the optimal timing of PC intervention remains unclear. Thus, the purpose of this randomized controlled trial was to evaluate the effect of early versus delayed PC intervention on survival and patient-reported outcomes. The trial randomized over 200 patients with advanced-stage cancer to receive standardized outpatient PC consultation within 30 to 60 days of cancer diagnosis (early group) or 3 months post-diagnosis (delayed group). At the conclusion of this trial, the early PC intervention arm was associated with an increase in 1-year survival rate compared to the delayed PC intervention group. There was no significant difference in patient-reported quality-of-life, symptom impact, or mood outcomes, although the trend favored early PC intervention. There was no significant difference in health care resource use between the groups. The results of this trial support the use of early PC referral in patients with advanced cancer or high symptomatic burden. However, the trial was underpowered to detect any differences which would suggest potential mechanism of early PC intervention (i.e. less aggressive treatment options). Furthermore, all patients enrolled in this trial were from the Northeastern United States, which may limit generalizability to other populations. Additional large randomized trials are needed to clarify this association.

Click to read the study in JCO

Relevant Reading: Project ENABLE: a palliative care demonstration project for advanced cancer patients in three settings.

In-Depth [randomized controlled trial]: ENABLE (Educate, Nurture, Advise, Before Life Ends) III was a multicenter, randomized controlled trial from the United States comparing the use of early (within 30 to 60 days of diagnosis) versus delayed (after 3 months) PC intervention following diagnosis of advanced cancer. The inclusion criteria were patients with advanced stage solid tumor or hematologic malignancy with a prognosis of 6-24 months. PC intervention included in-person outpatient PC consultation with a certified clinician as well as 6, weekly telephone coaching sessions. Study outcomes included overall and 1-year survival, patient-reported quality-of-life and mood as assessed by previously validated scoring scales (FACIT-Pal and CES-D scores, respectively), and health care resource use. At the conclusion of the trial, the 1-year survival rate was significantly increased in the early versus the delayed PC group (63% versus 48%; p = 0.038). There was no difference in overall survival between the two groups (18.3 versus 11.8 months; p = 0.18). There was no statistical difference in patient reported quality-of-life score (FACIT-Pal score: 129.9 versus 127.2; p = 0.09) or mood (CES-D score: 11.2 versus 10.8; p = 0.33) between early and delayed PC intervention. There was no significant difference in hospital or ICU admission or frequency of emergency department visits between the two groups.

Image: PD

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