Impact of early palliative care according to baseline symptom severity: Secondary analysis of a cluster‐randomized controlled trial in patients with advanced cancer

Abstract

Background Early palliative care (EPC) improves the quality of life but may not be feasible for all patients with advanced cancer. Symptom screening has been suggested to triage patients for EPC, but scant evidence exists for this practice. Methods We conducted a subgroup analysis of a cluster‐randomized controlled trial of EPC vs. standard oncology care according to patients' baseline symptom scores (high [>23] vs. low [≤23] Edmonton Symptom Assessment System Distress Score [ESAS SDS]). A linear mixed‐effects model was used to account for correlation within clusters, adjusting for the baseline outcome score and all covariates in the original trial. Results Among the 461 participants, baseline symptom scores were high in 229 patients (127 intervention, 102 control) and low in 232 (101 intervention and 131 control). Among those with high baseline symptoms, there was improved quality of life in the EPC arm compared to controls at 4 months (adjusted difference in primary outcome of FACIT‐Sp change score [95% CI], 8.7 [2.8 to 14.5], p = 0.01; adjusted difference in QUAL‐E, 4.2 [0.9–7.5], p = 0.02); there was also improved satisfaction with care (6.9 [3.8–9.9], p = 0.001) and clinician‐patient interactions (−1.7 [−3.4 to −0.1], p = 0.04), but no significant difference in ESAS SDS (−5.6 [−12.7 to 1.4], p = 0.11). In the low baseline symptom group, there were no significant differences between arms for any outcomes. Conclusion EPC improved quality of life, satisfaction with care, and clinician‐patient interactions only in those with high baseline symptoms. Symptom severity may be an appropriate criterion to trigger early referrals to palliative care.

Timely Palliative Care: Personalizing the Process of Referral

“…Of note, patients did not need to have supportive care needs to qualify for a palliative care referral in these trials. However, a recent secondary analysis of the Zimmermann trial found that patients with higher symptom burden at baseline were more likely to derive a benefit from the palliative care intervention [ 29 ].…”

“…Similar to the concept of targeted therapy, oncologists may only offer treatment for selected patients with “targetable mutations” instead of treating all patients. This approach provides a more rational use of resources, minimizes unnecessary exposure to those who may be less likely to benefit, and maximizes the impact on patients offered the intervention [ 29 ].…”

A Retrospective, Single-Center Analysis of Specialized Palliative Care Services for Patients with Advanced Small-Cell Lung Cancer

“…Although the definition of “early PC” has not been established, many trials on early integration used the timeframe of two to three months for their investigations [ 17 , 19 , 21 , 32 , 33 , 34 , 35 ]. Nevertheless, a recent analysis found that patients with a higher symptom burden profited more from the PC interventions [ 36 ]. Due to a lack of resources, it becomes less possible to provide early access to SPC for all cancer patients with advanced disease [ 37 ].…”

“…The concept of “timely” PC focuses on referral based on needs [ 9 ] and the delivery of services at the optimal time and setting [ 38 ]. Recent models for timely and adequate PC suggest offering “targeted PC” only to patients with PC needs instead of treating all patients, providing a more rational use of resources [ 36 ]. According to these suggestions, we also evaluated more disease-specific referral points for our patients with SCLC.…”

Palliative care models for patients living with advanced cancer: a narrative review for the emergency department clinician

“…Following this study in 2012, the American Society of Clinical Oncology (ASCO) recommended that palliative care be integrated into oncology services early in the disease course and concurrently with other lifeprolonging therapies [33]. Subsequently, multiple studies have confirmed the benefits of outpatient palliative care showing decreased depression [34] and improved quality of life [18,[34][35][36], symptom burden [35][36][37], satisfaction with care [37][38][39][40], communication about end-of-life care preferences [34], survival [35,36,41], and healthcare utilization [37,42].…”