Integrated outpatient palliative care for patients with advanced cancer: A systematic review and meta-analysis

Abstract

Background: Despite increasing emphasis on integration of palliative care with disease-directed care for advanced cancer, the nature of this integration and its effects on patient and caregiver outcomes are not well-understood. Aim: We evaluated the effects of integrated outpatient palliative and oncology care for advanced cancer on patient and caregiver outcomes. Design: Following a standard protocol (PROSPERO: CRD42017057541), investigators independently screened reports to identify randomized controlled trials or quasi-experimental studies that evaluated the effect of integrated outpatient palliative and oncology care interventions on quality of life, survival, and healthcare utilization among adults with advanced cancer. Data were synthesized using random-effects meta-analyses, supplemented with qualitative methods when necessary. Data sources: English-language peer-reviewed publications in PubMed, CINAHL, and Cochrane Central through November 2016. We subsequently updated our PubMed search through July 2018. Results: Eight randomized-controlled and two cluster-randomized trials were included. Most patients had multiple advanced cancers, with median time from diagnosis or recurrence to enrollment ranging from 8 to 12 weeks. All interventions included a multidisciplinary team, were classified as “moderately integrated,” and addressed physical and psychological symptoms. In a meta-analysis, short-term quality of life improved, symptom burden improved, and all-cause mortality decreased. Qualitative analyses revealed no association between integration elements, palliative care intervention elements, and intervention impact. Utilization and caregiver outcomes were often not reported. Conclusions: Moderately integrated palliative and oncology outpatient interventions had positive effects on short-term quality of life, symptom burden, and survival. Evidence for effects on healthcare utilization and caregiver outcomes remains sparse.

Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model

“…A seamless integration of cancer and palliative care throughout the disease trajectory was supported. To our knowledge, this is a unique organization of a fully integrated cancer clinic [48].…”

“…Stand-alone palliative care clinics and cancer clinics embedding a palliative care consultant or palliative care team, are two common models of outpatient palliative care services [48,50]. Temel et al presented in 2010 an outpatient cancer palliative care model where patients with newly diagnosed metastatic lung cancer in addition to regular cancer care were offered regular meetings with palliative care physicians and nurses [7].…”

Summarizing the Evidence Base for Palliative Oncology Care: A Critical Evaluation of the Meta-analyses

“…Hypothesis-driven research and high-quality RCTs have provided a growing evidence base for palliative oncology care. The 4 meta-analyses that were considered in this review [4][5][6][7] provide evidence that palliative care successfully improves both physical and psychological quality of life for patients with serious illnesses, including cancer. Two of the meta-analyses that focused specifically on outpatient palliative oncology care provided congruent accounts that implicate palliative care with a small, but noteworthy, benefit for survival duration.…”

“…Finally, Fulton et al 7 published their meta-analysis of outpatient palliative oncology care RCTs which replicated the findings of Hoerger et al This study considered 9 RCTs and thus 1 additional study that was not analyzed in the Hoerger et al article because the palliative care clinician did not provide care using an interdisciplinary team in accordance with the clinical practice guidelines set by the National Consensus Project for Quality Palliative Care. Importantly, Fulton et al, using a different research methodology and analytic approach, reiterated the findings of an outpatient palliative oncology care survival benefit first noted by Hoerger et al Interestingly, the study did use hazard ratios to examine survival differences, and although we criticized this approach previously, it is noteworthy that they replicated the survival advantage even when using an approach that was statistically conservative.…”

“…After considering the 4 meta-analyses on palliative oncology care, [4][5][6][7] the benefits for patient quality of life and survival are clear. Moving forward, disseminating these research findings will be critical to improve the lives of cancer patients and, more generally, public health.…”