Palliative care increases survival in randomized clinical trial!


Two weeks ago we let readers know about an article in The New Yorker about end-of-life decision-making. In this week’s issue of the New England Journal of Medicine, there is a report showing that palliative care can extend survival (albeit by only 2-3 months) in lung cancer patients with end-stage disease.

Obviously, it would have been even better from a prostate cancer point of view if the new study had shown a survival benefit in patients with end-stage prostate cancer. However, this is the first time that any study has actually documented a survival benefit associated with palliative care in end-stage cancer. From that point of view, this article is highly relevant to the prostate cancer community as well as to other segments of the cancer community.

The full text of the article by Temel et al. is available on line on the New England Journal of Medicine web site, as is an accompanying editorial by Kelly and Meier.

Because the full test of the article and the editorial are both available on  line, we have provided only a limited set of comments about the study and its findings. We recommend the original materials to interested readers.

Temel et al. randomized 151 patients with newly diagnosed, metastatic non–small-cell lung cancer to either early palliative care integrated with standard oncologic care or standard oncologic care alone. Their primary goal was to assess the quality of life and the mood of these patients over the next 12 weeks. However, they also, subsequently, collected data on the end-of-life care of these patients from their electronic medical records.

Their study showed the following results:

  • 27/151 patients died within the first 12 weeks of the study.
  • 107/124 surviving patients (86 percent) completed mood and quality of life assessments at study entry and at 12 weeks of follow-up.
  • Patients assigned to early palliative care had a significantly better quality of life than did patients assigned to standard care.
  • Significantly fewer patients in the palliative care group than in the standard care group had depressive symptoms (16 vs. 38 percent).
  • Significantly fewer patients in the early palliative care group received aggressive end-of-life care than did those in the standard care group (33 vs. 54 percent).
  • Median overall survival was significantly longer among patients receiving early palliative care (11.6 vs. 8.9 months).

The authors conclude that, “Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.”

This study should provide a wake-up call to the medical and the patient advocacy community about the importance of palliative care in the management of late stage disease (and late-stage cancer in particular). It is not always appropriate to make every effort to extend Grandpa or Grandma’s life by using every possible intervention known to man. Indeed, this may actually shorten the patient’s life, and reduce the quality of that life at the same time. There are, however, limitations to this study (for example, it was not a double-blind study; the patients, their families, and the clinical teams clearly knew which patients were in which arm of the trial). These limitations must be fully acknowledged and recognized.

Why did the patients who received palliative care from the get-go live longer? We don’t know. In their editorial, Kelly and Meier speculate that possible reasons include the effective treatment of depression, improved management of symptoms, and a reduction in the need for hospitalization. But the study was never designed to address this question.

Patients need to understand the options and be allowed to make decisions in their own best interests. There is also a similar obligation on caregivers and clinicians to help to make decisions in the best interests of the patient of he or she is unable to make those decisions him- or herself. For the first time, this study clearly shows that the best decision may well be to “do less” to gain more. The median survival benefit demonstrated in this study is comparable to that shown by many forms of late-stage drug therapy in patients with late-stage cancer (prostate cancer included).

4 Responses

  1. Too good to be true. While this study might have been done by good people in good faith, how long until Kaiser, Aetna and the rapacious employers and politicians cynically, severely limit or eliminate access to the oncological components of the palliative care? Doesn’t “palliative” translate to “camel’s nose”?

  2. END OF LIFE COUNSELING NOT IN THE HEALTH CARE REFORM LAW

    Hi Tracy. I’m responding to your first response to this article, published at August 19, 2010 at 2:37 pm. I know about this issue because I followed it closely and have some related news documents. (I’m hardly alone in following at least some of the furore; you probably saw it too.)

    Probably, using your words, the lead “rapacious” and “cynical” (I’ll add ignorant) politician was Sarah Palin. She used the inaccurate and demogogic phrase “death panels” to describe end-of-life counseling that made it as far as the bill approved by the House in that dramatic vote. The fire she lit was fanned by other irresponsible elements in the media.

    Unfortunately, end-of-life counseling was left out of the Senate bill, and that led to its being left out of the law.

    I can provide additional detail and leads if you would like them.

    I still have difficulty in controling anger at Ms. Palin for her monstrous role in blocking end-of-life counseling.

  3. Tracy,

    Bear in mind that in this study, chemotherapy utilization in the group that received the palliative care intervention was less than the group that did not receive the palliative care intervention routinely. In spite of that, the palliative care patients lived longer.

    The field of palliative care aims to ensure that patients receive therapies that match their goals of care. In many cases, but not all, chemotherapy is consistent with the patient’s goals.

    Palliative care is NOT a substitute for receiving appropriate oncologic care of cancer. The two should go hand in hand and they meet different ends. Most chemotherapies for advanced lung cancer provide only limited survival benefit. Unfortunately in 2010 and for the foreseeable future, patients with metastatic lung cancer will eventually die regardless of therapies provided. Rather than being the camel’s nose, palliative care should represent the standard of care for those patients as time goes by. Many, many patients will still elect to receive chemotherapy in addition to palliative care, and this is appropriate. However, patients who receive excellent palliative care may be more likely to decide not to receive chemotherapy, and that’s OK, too.

    Lyle

  4. Certainly it’s possible that insurers could reflexively seize this sort of finding to deny charges for end of life care. That would be tragic for many. Its also hopefully unnecessary. Gawande pointed out in his New Yorker article, in when insurance company study, offering patients palliative care and continuation of chemotherapy resulted in much less chemotherapy per patients’ requests. Unfortunately, this is not the norm in hospice care.

    Also, there will be considerable “big pharma” push to keep chemotherapy health coverage, whatever happens with palliative care. I’m as worried about pharma twisting public health policy as the health insurance companies.

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