Early palliative care for advanced lung cancer increases survival

September 19, 2019

Early palliative care is associated with better survival in patients with advanced lung cancer, according to a study by VA Portland Health Care System and Oregon Health and Science University researchers.

Lead author Dr. Donald Sullivan, with the VA Portland Health Care System Center to Improve Veteran Involvement in Care (CIVIC) and the Oregon Health and Science University Division of Pulmonary and Critical Care Medicine, explains that this research is the first time in a real-world clinical setting that palliative care has been linked to increased survival in lung cancer patients.

"This therapy that is already known to offer improved symptom burden, quality of life, and support also works like other cancer therapies to improve survival," he says.

The results will appear Sept. 19, 2019, in JAMA Oncology.

The goal of palliative care is to improve the quality of life and mood of a patient with a life-limiting illness. It focuses on providing a patient with relief from physical symptoms of a disease--such as pain and stress--rather than trying to cure or modify the disease. Treatment includes a variety of practices, such as using medication to reduce pain, treating nausea caused by chemotherapy, and counseling to deal with psychological distress and depression that often accompany a serious illness.

While palliative care can provide relief and comfort to patients with diseases such as advanced lung cancer, it is often underutilized or provided too late to offer any meaningful benefit.

According to the researchers, both patients and clinicians often associate palliative care only with poor prognosis at the very end of life. It is often confused with hospice. Palliative care can be appropriate for anyone with a complex illness. Hospice care provides a variety of end-of-life care that includes handling legal and ethical matters concerning death in addition to symptom relief. Many people think of palliative care as "giving up" because it is seen as something done only when nothing else works, or when life-prolonging therapies are no longer advised.

Many even believe that palliative care can have negative effects. Some oncologists have expressed concern that palliative care destroys patients' hope. Results of past research on the effects of palliative care on survival have been mixed. However, the Portland researchers write that their new results "help dispel the belief that early palliative care among patients with lung cancer is associated with shortened survival."

The study shows that palliative care may actually increase survival when provided shortly after a lung cancer diagnosis. It is most effective when included in the initial disease treatment rather than as part of the dying process, say the researchers. They conclude that palliative care should be considered a complementary approach in patients with advanced lung cancer, given alongside treatment to fight the cancer.

Sullivan explains that, while more research is needed to define the most beneficial elements of palliative care for survival, the result could lead to changes in how Veterans with lung cancer are treated in VA.

"I think research like this gets more clinicians and patients thinking about the importance of palliative care," he says, "and I believe more Veterans with advanced cancer will receive this care along with other cancer therapies."

To learn how palliative care affects survival, the researchers looked at data on 23,154 patients with advanced lung cancer who received care through the Veterans Health Administration. Of those, 57% received palliative care. The team found that patients who received palliative care between 31 and 365 days after their diagnosis lived longer than patients who did not receive palliative care at all.

According to Sullivan, outpatient palliative care seemed to be a significant driver of the finding, meaning that "palliative care offered in outpatient settings rather than the intensive care unit is going to be an important component of this type of care."

Patients receiving palliative care more than a year after lung cancer diagnosis had no difference in survival compared with those not receiving such care. Patients who received palliative care between 0 and 30 days after diagnosis had decreased survival rates.

The researchers suggest that patients who receive palliative care very soon after diagnosis are likely more seriously ill, perhaps beyond the point at which any treatment would prolong life. Palliative care is intended, in those circumstances, to ease the dying process rather than improve survival. The results show that many of these patients died shortly after their diagnosis, meaning patients had little time to experience palliative care.

The results suggest that the timing of palliative care is important. The researchers recommend moving palliative care earlier in the lung cancer treatment process to take advantage of its benefits. Sullivan explains that currently, palliative care is typically offered when all other treatments fail at the very end of life rather than integrated intro treatment earlier on. However, professional societies are beginning to offer guidelines that focus on early integration. Recent American Society of Clinical Oncology guidelines suggest palliative care be delivered within eight weeks of diagnosis.

Changing the current culture will take time, says Sullivan. More emphasis also may need to be placed on primary care providers such as oncologists and pulmonologists, he explains, because of a shortage in palliative care specialists.

The researchers offer several explanations as to why early palliative care may prolong life. Patients who receive early palliative care are more likely to benefit from its multidisciplinary, patient-centered approach, which may help increase survival. By enhancing patients' understanding of their illness and promoting shared decision-making, palliative care may also decrease overly aggressive end-of-life care, which can often do more harm than good.

Furthermore, negative symptoms, mood, and quality of life have been linked to decreased survival among patients with cancer in other studies. By relieving these burdens, palliative care may improve patients' outlook and therefore their survival odds.

The study found an additional benefit of early palliative care beyond increased survival. Early palliative care was linked to reduced odds of death in an acute health care setting (meaning a hospital ward or intensive care unit). Surveys have shown that terminally ill patients would prefer to die at home rather than in the hospital. So while palliative care will not increase survival for all patients, it can still improve their quality of life and help them die on their own terms.

Sullivan and his colleagues are already at work building on the research. The finding are being disseminated to other clinicians in VA. The research team has several other studies underway examining the impact of palliative care within VA and ways to improve value and quality in lung cancer care. While the work is focused on lung cancer, Sullivan says that "I have no reason to believe these findings could not be generalizable to patients with other serious conditions."
The study was funded by VA Health Services Research and Development and the National Cancer Institute of the National Institutes of Health.

Veterans Affairs Research Communications

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