In Metastatic NSCLC, Early Palliative Care Improves Survival as Well as QOL

CHICAGO—Early initiation of palliative care (PC) in the management of metastatic non–small-cell lung cancer (NSCLC) led to a longer survival time and better quality of life (QOL) than standard treatment, in a randomized phase 3 trial.

The study compared QOL and clinical outcomes for early PC versus standard oncology care in 150 patients with newly diagnosed metastatic NSCLC. 

“We found that compared with standard oncology care, integrated palliative care led to improvements in quality of life, lower rates of depression, less aggressive care at the end of life, greater documentation of resuscitation preferences, and, in addition, higher survival rates,” said Jennifer S. Temel, MD, of Massachusetts General Hospital, Boston, during her presentation at the annual meetting of the American Society of Clinical Oncology.

Patients were randomly assigned to receive early PC integrated with standard oncology care (n = 77), which included PC visits at least monthly from the time of enrollment, or standard care (n = 74), which included meeting with PC providers only when requested by the patient, family, or oncologist. PC was delivered according to established guidelines for symptom management, decision making, and assistance with coping.

There were no differences among the arms in patient demographics, baseline measures of QOL, or psychological distress, and no difference between the number of chemotherapy lines they received during the study period. Although the design was randomized, the study was not assessed in blinded fashion.

QOL was determined by measures of symptoms and psychological distress. The FACT-Lung instrument assessed lung cancer–specific symptoms (Lung Cancer Symptom Index) and functional/ physical well-being (Trial Outcome Index), whereas psychological distress was measured by the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ)-9. Change in FACT-Lung Trial Outcome Index was the primary end point.

The 12-week QOL assessment was completed by 78% in the PC group (13% had died) and by 64% in the standard care group (23% had died). At 12 weeks, 100% of the PC group had experienced a PC visit (by definition), which included four or more visits for 65% of patients. In the standard care group, 4% of the patients had two visits and 9% had one visit; no patient in this arm had more than two PC visits.

Early PC superior in multiple outcomes
“At 12 weeks, patients assigned to early PC experienced better QOL, as measured by the FACT-Lung and Trial Outcome Index,” Temel reported. The effect of early PC on psychological distress was also highly favorable, as these patients experienced lower rates of depression according to both the HADS (15.8% vs 38.3%; P = .01) and the PHQ-9 (3.5% vs 17%; P = .02). Interestingly, fewer patients randomized to PC received aggressive care at the end of life (33.3% vs 53.6%; P = .05), but despite this they lived significantly longer than the standard care arm (11.6 months vs 8.0 months; P = .02), Temel reported.

Aggressive care was defined as no use of hospice, use of hospice for 3 days or less, or chemotherapy administered within 14 days of death. Patients in the standard care arm averaged 4 days of hospice care, compared with 11 days for those in PC arm.

Patients treated in the PC arm were also more likely to have documented their resuscitation preferences (53% vs 28%; P = .05).

Temel suggested that the improvement in QOL and decreased rates of depression may be related to better symptom management and patients’ acceptance of their illness. Prolonged survival may be related to earlier recognition and management of medical issues, improved QOL and mood, the administration of less chemotherapy at the end of life and longer hospice admission.

The paper’s discussant, Raffit Hassan, MD, of the National Cancer Institute, lauded the investigators. “This is the first randomized study of early palliative care in newly diagnosed patients with advanced NSCLC,” he noted. “It shows that palliative care and active cancer therapy can go hand in hand, and that initiation of early palliative care at diagnosis improves QOL, psychological well-being, end-of-life care, and even overall survival.”

He said future research should have overall survival as the primary end point, and should include more diverse populations and more patients with poor performance status in order to better define PC benefits in this subset.