Wednesday, August 18, 2010
Game Changer: Early Palliative Care for Lung Cancer Patients Improves QOL AND Median Survival
Certainly, a smile came across my face when I first saw this. Even the most equipoised palliative care practitioner must have done the same (feel free to let us know if you didn't). The implications of this study, a randomized control trial of early palliative care in patients with stage IV non-small cell lung cancer published in the New England Journal of Medicine, will not be fully revealed for a while, but are likely to be important and long-lasting. The primary outcomes of the study stand on their own as important--it's yet more evidence that palliative care interventions improve quality of life and reduce psychological morbidity. The headlines from above derive from the secondary outcomes of the study--that palliative care may improve survival while reducing morbidity.
Before I write anything else about the study, I'll direct you to the editorial by Amy Kelley and Diane Meier.
The study was a single institution trial at Massachusetts General Hospital. Patients were randomized to receive either usual care or early palliative care integrated into oncologic care. The study intervention consisted of monthly outpatient palliative care visits (by a physician or nurse practitioner) until death with an average of four visits in the first 12 weeks. Control patients received usual care and only saw palliative care if requested by the oncologist with 14 percent of control patients receiving a palliative care evaluation. The two groups were similar in several demographic, prognostic, disease specific factors (including EGFR status of the cancer!), and QOL/mood measurements.
The primary outcome was a statistically significant reduction the Trial of Outcome Index (TOI) in the study group vs. the control group at 12 weeks. The TOI is a sum of the physical well-being and functional well-being subscales of the Functional Assessment of Cancer Therapy–Lung (FACT-L) and the the lung-cancer subscale (LCS) of the FACT-L scale evaluates seven symptoms specific to lung cancer. The study group also had a lower incidence of depression at 12 weeks but similar incidence of anxiety.
The secondary outcomes included utilization of health care near the end of life. The study was not powered to detect differences in utilization, however, there was a trend towards reduced chemotherapy utilization, hospitalization, emergency department visits, and an increase in hospice utilization and rate of death at home or an inpatient hospice facility.
And the one-liner that is garnering all the attention:
Despite receiving less aggressive end-of-life care, patients in the palliative care group had significantly longer survival than those in the standard care group (median survival, 11.6 vs. 8.9 months; P=0.02)This study strikes at the heart of two important misconceptions that may lead to underutilization of palliative care services:
- Primary providers (e.g. oncologists) who suggest that they "already do this" and that there is no benefit to additional services. I think the primary outcomes of the study are pretty airtight and consistent with past non-controlled studies that suggest benefit of palliative care interventions. Could oncologists provide these services and achieve the same outcomes? Hard to say since the intervention is bundled. Perhaps there are discrete parts of the intervention that an oncologist could deliver which would lead to the same outcomes, and certainly there is reason to believe that how oncologists do their job influences the outcomes studied. However, the lens through which palliative care physicians see patients is inherently different from the lens of the oncologist. While one might be able to borrow the other's lens momentarily, it's conceivable that due to the complexity of advanced medical illness, there's value in both being on hand regardless of how oncologists are trained or reimbursed.
- That palliative care equals "giving up." As the authors and editorialists state, the survival result needs to be replicated in further studies. There is evidence of lesser quality to suggest that other components of palliative care may lengthen life (for instance, hospice and morphine) so this secondary result should not be too surprising. The mechanism of this possible effect is quite unclear. Perhaps it's through excellent symptom control or perhaps through avoidance of toxic chemotherapy in an already failing organism. Regardless, it can be safely concluded from this study that the palliative care service at Mass General is NOT the grim reaper and may be quite the opposite, on the magnitude of Sorafenib for hepatocellular cancer. (*Fettig puts away his grim reaper costume and puts on his sorafenib cape, the new symbol of palliative care glory...well, I admit I don't work with the Mass General Palliative Care team, so cannot say that this study generalizes to my care, but I'm at least hopeful. Okay, I don't own and don't want a Sorafenib cape.*)
- This is primarily an outpatient intervention. Palliative care has grown up inside the walls of the hospital, but palliative care outpatient services are growing. Time to grow more.
- The intervention utilized The National Consensus Project for Quality Palliative Care, which should be reviewed regularly by all palliative care teams and used to drive quality improvement.
- I think it might be time to phase out the below diagram- perhaps it helps illustrate the difference between hospice in the US and palliative care, but may not represent the state of the art palliative care intervention as reflected in this study (better if provided early, often, and throughout the course of the disease).
- Does this study represent the gold standard for a palliative care health services RCT? Likely. It's the inverse of an excellent chemotherapy trial where the primary outcome may relate to survival but where strong secondary QOL outcomes are examined.
- The methods in this study could be applied to many different patient populations, both oncologic and non-oncologic. "New diagnosis of Stage IV lung cancer" represents a trigger (I know some dislike that word, but it's the best I got). What other outpatient triggers could you envision? HIV with low CD4 count chronically and a recent admission for opportunistic infection? Childs class C cirrhosis with (choose your own other variable)? Non-small cell lung cancer is a neat and tidy place to start for this type of study- it's the most common diagnosis that I see (and I suspect many of you too), the prognosis is good enough that you can follow patients for several months but not for years. This makes the study and the intervention doable.
- Related to the last point, how can we work towards bundling this type of intervention back into primary care, have it reimbursed, and provide appropriate training for future clinicians so that they can do the bulk of this work? The Holy Grail. Your job is (relatively) safe.
(Also see post by Alex Smith at GeriPal)
Temel, J., Greer, J., Muzikansky, A., Gallagher, E., Admane, S., Jackson, V., Dahlin, C., Blinderman, C., Jacobsen, J., Pirl, W., Billings, J., & Lynch, T. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer New England Journal of Medicine, 363 (8), 733-742 DOI: 10.1056/NEJMoa1000678
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28 Responses to “Game Changer: Early Palliative Care for Lung Cancer Patients Improves QOL AND Median Survival”
August 19, 2010
Great write-up Lyle, I think you bring up some great points at the end. How we operationalize this information is extremely important. We all need to spend a little time being giddy, then writing a thank you letter to Dr. Jennifer Temel and her team (from NEJM site: Massachusetts General Hospital, 55 Fruit St., Yawkey 7B, Boston, MA 02114)
But then we have two major challenges:
1) how do we best communicate this message (see my post on sharing the message) in the short-term and long-term
2) how do we get 'The Holy Grail' you describe: "how can we work towards bundling this type of intervention back into primary care, have it reimbursed, and provide appropriate training for future clinicians so that they can do the bulk of this work?"
One interesting point was the palliative care team in the article only consisted of a doctor and an APRN. No mention of the other classic members of a palliative care team: social workers and chaplains. Does this mean for cost reasons they are cut out if any of this shapes policy? I don't know if that is the right answer but palliative care teams (not duos) are expensive to start up.
And one other thing: I love the fact they used the word palliative. If we could only get people to accept and understand the term palliative like the American public understands 'nutriceuticals', 'metabolism', and 'ChatRoulette' we would could be much more effective. This may be a good step towards that. Most of the news orgs are using 'palliative' as well. Great!
August 19, 2010
Lyle thanks for posting this. I'm traveling and using mostly a cellphone for internet so haven't been able to read the full paper yet, but, WOW, I'm smiling. That was my reaction to reading the abstract and your post.
I appreciate you pointing out that we should not spend too much time basking in the survival benefit. Or, to be clearer, it's important to foreground the improvements in HRQOL as much as survival, just as contemporary chemo trials for advanced/incurable cancers have begun routinely reporting HRQOL as an outcome, not just survival. Both are very very important to our patients, and, surveying the 'average' advanced cancer patient will reveal that most of them rate QOL as more important than survival. Although very few would argue with this win-win.
August 19, 2010
Great post Lyle. My email inbox was filled with people sending me this article only after about an hour after it came out. It is really great news for the work the pallliative care community has done to improve the lives of those living with cancer.
I also really liked your comment on the diagram showing when palliative care should be phased in to someone's care. This study makes a case that palliative care should be significantly involved from the time of diagnosis (at least for metastatic lung cancer). Next step is to prove this in other advanced illnesses.
August 19, 2010
While three cheers are certainly in order, I would be very cautious about saying that palliative care improves survival. Although randomized, the study was small and from a single institution. I love the results, but think we all need to be careful about over-interpreting single study results. When the next study shows no change in survival, which I fully expect, the fall for the field could be hard.
August 19, 2010
Thanks to all for comments-
Christian- Thanks for the push to spread this across the web. There was a recent controlled study
published in JPSM showing that a Life review can have an impact on similar QOL/psych outcomes as measured in this study--something for the sw/chaplain members to review.
David- Enthusiasm tempered, and indeed, it would not be a surprise for future trials to suggest no change in survival. I would anticipate mixed results depending on the intervention itself, the population of patients, when in the course of illness the intervention took place, etc. Furthermore, if you envision a population of patients where potentially burdensome therapies are available which routinely prolong life for months (for instance, prolonged mechanical ventilation/tracheostomy, etc for advanced pulmonary disease), then one might expect that excellent palliative care might even reduce median survival (but do much better at identifying goals of care/preferences and avoiding unwanted procedures).
Here's how I'm attempting to put this into perspective: At this time, it's vitally important (as Drew says and I'm sure you agree) to keep our eyes on the primary outcomes of HRQOL that should remain our field's main focus. If we do perchance come across a trial where survival is worse in the palliative care group, this shouldn't invalidate the intervention as long as the HRQOL outcomes are robust--we'd just need to come up with a good explanation for the reduction in survival and know that this might be a "risk." (Just as you wouldn't throw out a chemotherapeutic agent that confers survival benefit but doesn't improve QOL.)
Presumably, any negative future studies wouldn't make a splash in the headlines. (An example from the recent past would be the Lautrette ICU study in NEJM a few years ago.) Even if the next 10 trials don't replicate, hopefully attitudes will have shifted, even if slightly. (You know how fixed attitudes can become!)
August 20, 2010
I share Dr. Weissman's concern re the need to be cautious about saying that palliative care improves survival. I do worry that we will be tempted to use the study to promote the idea. The media seem to be focussing on that particular aspect of the study and Dr. Cooney's comment that Palliative Care helped her through really aggressive chemotherapy may also provide false hope. Having said all that I am really excited about finally having an RCT on the subject.
August 20, 2010
I appreciate Lyle's balanced presentation of the study.
I have been troubled by the way that organizations that many of us belong to and admire--NHPCO, AAHPM, CAPC, etc.--are promoting and interpreting this study (the recent 8/20 media update by CAPC is slightly better, but remains focused on survival).
All of these organizations have been focusing on the fact that patients in the study who received palliative care lived a bit (2.7 months) longer than patients who did not. While I understand that the hospice and palliative care communities have long suffered from the stigmatized perception that they welcome (or, even, hasten) death, and that this study seems to provide a rebuttal to such a perception, I believe the way the study is being embraced and promoted is misleading. Moreover, it may even be harmful.
(1) The study compared patients receiving standard oncological care vs. patients receiving standard oncologic care and palliative care (concurrently). As such, the study says little about hospice insofar as most hospice patients most stop oncology interventions to begin receiving hospice care. And, while this provides some evidence to support concurrent care, it surely does not mean that patients who elect hospice as it is currently delivered will live longer. It is, therefore, troubling that NHPCO's press release reads: "Research Shows Patients May Live Longer with Hospice and Palliative Care."
(2) The study itself was not designed to measure a primary outcome of time to death. Rather, the study was designed to measure a primary outcome of quality of life, using two validated instruments. And, the study showed an improved quality of life for patients receiving concurrent palliative care over patients receiving standard care (moderate improvement on one scale, significant improvement on the second). That patients receiving concurrent palliative care had improved quality of life is very good news for palliative care and for patients. Indeed, it is the primary goal of palliative care. However, this improved quality of life is being far outshadowed by the emphasis being placed on time to death.
(3) Finally, the emphasis on time to death perpetuates exactly the belief that hospice and palliative care have been working to change for decades: that what is important is how long you live rather than how well you live. If we begin promoting hospice and palliative care under the premise that such care extends life, we tacitly accept that extension of life is the primary goal of healthcare. And, we tacitly send that message to our colleagues, patients, and the public at large.
This is an important study with encouraging results. The way it is being promoted, however, (1) misrepresents the study design and results and (2) supports the premise that length of life--rather than quality of life--is what is most important.
August 20, 2010
What will the oncology community say? I am looking forward to reading the letters to the editor in the next issues of NEJM. I do not really understand the ins and outs of the data which supports the authors conclusion of improved survival, but I suspect much of the peer review will center on this conclusion and not give much importance to the improved HRQOL measures. And here we are falling right in step with that, by putting our own spin on the survival benefit.
I say that as one who has spent the last 24 hours or so, basking in the glow. I appreciate the wisdom of your comments here on Pallimed. I think my response going forward will be "Gee, that survival benefit is great, but did you see that robust result for HRQOL." That is the goal for us as practitioners and, as Drew points out, what is most important for patients. Otherwise we implicitly endorse the premise that interventions to improve survival have more value than those which improve QOL, as Timothy points out. Data that demonstrates improved survival is more important to us than data that shows we have achieved (in an RCT!) that which is most important to us as a specialty and to our patients.
Maybe Pallimed could get cited again by offering comment about the responses above. Just saying
(-:
August 21, 2010
The reaction to this article confirms the value of being part of online communities: I got a flash emal from HPNA the night before telling us to look for breaking news, then I got emails from CAPC, NHPCO, Getpalliativecare.org, saw the posts on Twitter, Pallimed and Geripal. I subsequently forwarded links to the NEJM article to the HPNA APN sig and my Facebook page. Lots of ensuing dialogue which will hopefully spread out to the public and broader online community.
August 22, 2010
Lyle - Thanks again for the great write up. Christian - Thanks for the comments as well as the social media "How to" for everyone.
This article is definitely getting everyone's attention, and also is helping the HPM community to realize how powerful media and health care social media can be. Last Wednesday's #HPM tweetchat was the busiest and most excited one yet! (Wednesdays @ 6 pm PST, 8 pm Central, if others are interested in seeing what it's all about)
While I agree we should be cautious about promoting the survival benefit in metastatic NSCLC until we have more studies, I would not be surprised if early palliative care is shown to prolong life in many diseases. We just need more research to figure that out. While our focus is on promoting quality of life for as long as a person has, I can't help but think that increasing whole-person, interdisciplinary support, decreasing physical stress by controlling symptoms, and helping patients understand and match their treatments to their goals of care seems like something that could improve survival.
@jayaramanjyothi Thanks for your comments as well! Good to "see" you on Pallimed! I wanted to respond to your comment on hope. I am not concerned that Dr. Cooney's comments provide "false hope". Instead, think it is important for the public (and our physician colleagues) to consider the possibility that early palliative care may help people complete their therapies to prolong life or to cure when possible. How many patients stop taking medications or treatments because the physical and emotional burden is too high, because it has made life with treatment intolerable?
If a palliative care team is involved early, I believe that fewer people would stop their therapies because of the symptomatic burden of their treatments. They may stop earlier for other reasons, like clarification of treatment preferences, but I don't consider advocating for patients' goals of care a bad thing. It would be a fascinating study!
We need to shift the paradigm, and that's what I love about the NEJM article and all the press. It's making people consider the possibilities. Even though we are concerned about touting the life prolongation data, you can't consider the survival benefit piece without thinking about palliative care and what palliative care entails, and hmmm... why shouldn't my patients (my husband, my sister, my child, I)have it earlier/now? Which brings the focus back to our primary goal, enhancing the quality of life for our patients, our families, and ourselves.
August 22, 2010
End-of-Life Care is a hot button issue with strongly held opinions on all sides - we surely learned that from the "Death Panel" brouhaha. We can't be too careful in how the message of palliative care is crafted. As Drew says, "we should not spend too much time basking in the survival benefit."
August 23, 2010
I'm an oncologist, and though it's probably like everyone considering themselves a better than average driver, I do consider myself to also have a palliative emphasis and am among the leading referrers to hospice in our area (though this is probably in part based on my subspecialty in lung cancer).
I was at the ASCO presentation at which Dr. Temel presented these data, and I've covered it in a discussion with another colleague on a website I run for cancer patients:
http://cancergrace.org/cancer-treatments/2010/07/30/is-palliative-care-giving-up/
(We have both also worked with Dr. Temel during our non-overlapping periods of training in Boston).
I think the lung cancer community, and probably the oncology community in general, welcome these data, though I'll admit that they are hard to interpret and do have limitations. It requires at least a little hand-waving to develop a biologically plausible explanation for the survival benefit. It's not really possible to glean what the interventions actually were. And I'm disappointed that both arms had such an incredibly short interval between referral to hospice and death.
The last issue reminds me that we're talking about a clinical population from Mass General, a place where cancer patients from all over New England and beyond go to receive the best, and sometimes just the most, cancer care. This is not a group of patients who travel there for the easy commute and cheap parking to get to the neighborhood oncologist. Consequently, I am not at all sure that the results can be generalized to a broader population that isn't so self-selected that make it very polarized. This is a very aggressively minded treatment population, more than just about any clinical population outside of Memorial Sloan-Kettering or MD Anderson.
This isn't meant to diminish the provocative nature of these data. I just think that it isn't feasible to use the data from a 150 patient, single center trial to conclude that these findings truly represent what a large multi-institutional study would demonstrate.
I do think the points about not vaulting overall survival over HRQOL endpoints is very appropriate, and the benefits in these variables are not hard to explain and themselves should be enough to recommend early palliative care. And there is certainly a risk that focusing too much on overall survival could undermine the message that QOL is a critical factor.
Finally, a central limitation is that most practicing oncologists don't have access to a dedicated palliative care team like the one at MGH, though I imagine that most readers here are working to change that.
August 24, 2010
May I suggest that our incurably enthusiastic commentators please re-read Dr Kirk’s post? It is embarrassing to see individuals ostensibly charged with fellowship education neglect the very basics of data interpretation - again please see comments of Dr Kirk. The NEJM data are extremely valuable, but NOT by the virtue of the incidental findings.
August 24, 2010
Great comments here.
In principle, agree with the comments by Drs. Kirk and West as well as anonymous.
More pragmatically, there is the journalistic/public relations/marketing issue in an on-line 24-hour news cycle. It is difficult to grab bandwidth and to keep it long enough and deep enough to compete with more sensational, more superficial, or more "hard-sciencey" healthcare news. Death, I find, is pretty hard data.
Also, there is the issue that physicians are people too; I swear. They do irrational, people-things like go out of their way to avoid death and deathy things. palliative care has a Pavlovian association with things deathy.
In my early experience, I am amazed that at 3 large teaching institutions, in 3 regions of the country, doctors are apparently, universally, deathly afraid of death. Considering what we deal with as our stock-in-trade, I am unimpressed and frustrated in seeing patients who are diagnosed with new conditions, or have pivotal, new findings, that every doctor would agree, over coffee, makes for a dismal prognosis. But bringing up making a palliative care consultation/referral is like pouring cold water over the team in rounds, and is generally out of bounds as a consultant. Making early, and to mind mind responsible, palliative care consultations/referrals is avoided like the plague, even for getting help in having the indicated, but dreaded "Talk," any other dispo is sought and easily accepted, and so even the "Talk" is not even had, but rather is systematically avoided. This stuff anthropological, sociological and psychological; it is not rational, dispassionate or clinical.
My point is that some types of medical decision-making more than others are not just made on the data, or strictly on what would be best for the patient, but rather entail meaning, context (e.g., coffee talk vs rounds), attribution, conjecture and even, yes, emotion on the part of decision-makers.
So in this real-world milieu (taking physicians where we find them, rather than where we'd like them to be, with respect to this stuff), without irresponsibly misrepresenting findings, we are obliged to grab attention when the opportunities present themselves, and attempt to make in-roads in the thinking (and maybe even in those unacknowledged, and even denied, feelings that seem to drive some key decisions ) of physicians, by bringing to the fore anomalies to the prevailing paradigm when they arise.
August 24, 2010
A panel discussed this article in NPR today, on the Dianne Rehm show.
August 24, 2010
New Studies in Palliative Care
Diane Rehm Show
Tuesday, August 24, 2010 - 10:06 a.m.
http://thedianerehmshow.org/shows/2010-08-24/new-studies-palliative-care
August 25, 2010
hello from north kansas city!
reminder: well-done study from 4 years ago or so showing corrected survival for medicare recipients ever on hospice for 4 cancer dx. and CHF all longer than medicare recipients who were never on hospice. QOL and resource utilization better also. so the effect is probably consistent across types of palliative care, and i sure hope the value effect is more important than the survival effect! (Connor JPSM 2007)
comment: of course earlier is better....... but, most of the effect is likely in meeting patients goals and preventing harm and burden and cost at the time of crisis near the end. it takes some time to build the trust and relationships that allow the effect, but the potency in real time is near the end, and what hospice and palliative care really do best is end of life care. the conversation of palliation can and should start early but us being very involved and doing what we do best and help most with is the very best care for dying people.
thanks lyle and christian and drew and all of you; it does feel good.
clay anderson
hospice and palliative care and medical oncologist :-)
kansas city, mo
August 27, 2010
Many great comments and they are all appreciated.
See Drew's excellent separate post which addresses many of the concerns brought up in the comments to this post.
Jack- I'm not sure how much hand-waving is involved in coming up with a plausible explanation for the survival benefit result. Several have been mentioned already here and elsewhere, but I'll highlight a few other possibilities. One possibility is that the PC wing was subject to a Hawthorne Effect whereby patients did better merely through greater observation and attention (regardless of palliative care expertise). Additionally, however, this observation combined with palliative care expertise might have led to improved health safety. Complications such as medication toxicity might have been reduced through earlier identification of the problem (eg opioid neurotoxicity) and through minimization of delirium inducing combinations (would be interesting to know if the improved psych outcomes in the PC group also resulted in reduced use of benzodiazapines on average, for instance). Furthermore, is it possible that through greater focus on symptoms, oncologic emergencies such as cord compression and hypercalcemia were identified and managed sooner? Merely hypotheses.
I agree with the disappointment over how late hospice referrals are in both groups and understand that the study location has much to do with that.
Clay- thanks for bringing up this study.
August 29, 2010
On a personal note . . . the question about "don't / can't oncologists provide palliative care?" Answer: well, some could, but many can not. Case in point, my sister's oncologist, who could not manage my sister's pain with anything other than Tylox. Fortunately, my sister was referred to a Palliative Care physician and her pain was well managed with Methadone. Unfortunately, the Palliative Care physician was never able to convince my sister and brother in law of the need for hospice, and the oncologist persisted in "trying one more" chemo med, even as everyone could see that nothing was working. Her oncologist, like many oncologists, was unable to say to them, "It's time to stop chemo and call hospice." Maybe, just maybe, if Palliative Care had been part of her care from the very beginning, there would have been a better outcome and more resolution.
Judy Goldthorp, RN CHPN
August 29, 2010
I feel that people are avoiding stating outright that "overuse of chemotherapy could be contributing to the difference in survival between the Pall Care and non-Pall Care groups". I was insulted that Kelly and Meier's Editorial in the NEJM did not suggest this as a possible explanation for the survival discrepancy. Especially as this article comes on the heels of Atul Gawande's description of Sara Monopoli (ironically, also with metastatic NSCLC) dying 3 days BEFORE initiating a FOURTH line chemotherapy agent. Obviously, the 4th line chemo did not kill Sara, but perhaps discussions of goals of care performed by a nonbiased party (i.e. Pall Care and not oncologists, [far more accurate is 'differently-biased party']) lead to a decreased use of toxic therapies at the end of life leading to increased survival. Does anyone else agree with this sentiment (1. the suggested mechanism, 2. the fact that no one is suggesting it) ?
Additional comments: I'm guessing we would all be surprised to see the 2.7 month survival advantage fully corroborated in future studies, but if not we're all happy that it made it into the books this time. Also, most of us wish we could see more details on how the 2 groups differed in treatments they received until death, and an analysis of the differing costs between groups.
Regarding Oncologists and EOL care (mentioned in ppl's comments) I would like to highlight the following 2 articles that provide very interesting insights and I think dovetail with one another (both are qualitative studies = easy read):
1)A Qualitative Study of Oncologists’ Approaches to EOL Care - J Pall Med, 2008, p893-906. [PMID: 18715182]
2)How oncology fellows discuss transitions in goals of care; a snapshot of approaches used prior to training - J Pall Care, 2010. p395-400. [PMID: 20307195]
AND a one page editorial that succinctly & poignantly captures the above articles by coining the terms: "Type I" and "Type II" Oncologists:
3)Oncologists and EOL Care - J Pall Med, 2008. p813. [PMID: 18715165]
[1st time Commenter; PGY-2 in Int Med in NYC, considering Pall Care. Appreciate above comments especially Dr. Kirk, dspacl, & Dr. West.]
August 29, 2010
I feel that people are avoiding stating outright that "overuse of chemotherapy could be contributing to the difference in survival between the Pall Care and non-Pall Care groups". I was insulted that Kelly and Meier's Editorial in the NEJM did not suggest this as a possible explanation for the survival discrepancy. Especially as this article comes on the heels of Atul Gawande's description of Sara Monopoli (ironically, also with metastatic NSCLC) dying 3 days BEFORE initiating a FOURTH line chemotherapy agent. Obviously, the 4th line chemo did not kill Sara, but perhaps discussions of goals of care performed by a nonbiased party (i.e. Pall Care and not oncologists, [far more accurate is 'differently-biased party']) lead to a decreased use of toxic therapies at the end of life leading to increased survival. Does anyone else agree with this sentiment (1. the suggested mechanism, 2. the fact that no one is suggesting it) ?
Additional comments: I'm guessing we would all be surprised to see the 2.7 month survival advantage fully corroborated in future studies, but if not we're all happy that it made it into the books this one time. Also, most of us wish we could see more details on how the 2 groups differed in the cancer treatment they received until death (directly related to above comment) and an analysis of the differing costs between groups.
Regarding Oncologists and EOL care (mentioned in ppl's comments) I would like to highlight the following 2 articles that provide very interesting insights and I think dovetail with one another (both are qualitative studies = easy read):
1)A Qualitative Study of Oncologists’ Approaches to EOL Care - J Pall Med, 2008, p893-906. [PMID: 18715182]
2)How oncology fellows discuss transitions in goals of care; a snapshot of approaches used prior to training - J Pall Care, 2010. p395-400. [PMID: 20307195]
AND a one page editorial that succinctly & poignantly captures the above articles by coining the terms: "Type I" and "Type II" Oncologists:
3)Oncologists and EOL Care - J Pall Med, 2008. p813. [PMID: 18715165]
[1st time Commenter; PGY-2 in Int Med in NYC, considering Pall Care. Appreciate above comments especially Dr. Kirk, dspacl, & Dr. West.]
August 29, 2010
I feel that people are avoiding stating outright that "overuse of chemotherapy could be contributing to the difference in survival between the Pall Care and non-Pall Care groups". I was insulted that Kelly and Meier's Editorial in the NEJM did not suggest this as a possible explanation for the survival discrepancy. Especially as this article comes on the heels of Atul Gawande's description of Sara Monopoli (ironically, also with metastatic NSCLC) dying 3 days BEFORE initiating a FOURTH line chemotherapy agent. Obviously, the 4th line chemo did not kill Sara, but perhaps discussions of goals of care performed by a nonbiased party (i.e. Pall Care and not oncologists, [far more accurate is 'differently-biased party']) lead to a decreased use of toxic therapies at the end of life leading to increased survival. Does anyone else agree with this sentiment (1. the suggested mechanism, 2. the fact that no one is suggesting it) ?
Additional comments: I'm guessing we would all be surprised to see the 2.7 month survival advantage fully corroborated in future studies, but if not we're all happy that it made it into the books this one time. Also, most of us wish we could see more details on how the 2 groups differed in the cancer treatment they received until death (directly related to above comment) and an analysis of the differing costs between groups.
Regarding Oncologists and EOL care (mentioned in ppl's comments) I would like to highlight the following 2 articles that provide very interesting insights and I think dovetail with one another (both are qualitative studies = easy read):
1)A Qualitative Study of Oncologists’ Approaches to EOL Care - J Pall Med, 2008, p893-906. [PMID: 18715182]
2)How oncology fellows discuss transitions in goals of care; a snapshot of approaches used prior to training - J Pall Care, 2010. p395-400. [PMID: 20307195]
AND a one page editorial that succinctly & poignantly captures the above articles by coining the terms: "Type I" and "Type II" Oncologists:
3)Oncologists and EOL Care - J Pall Med, 2008. p813. [PMID: 18715165]
[1st time Commenter; PGY-2 in Int Med in NYC, considering Pall Care. Appreciate above comments especially Dr. Kirk, dspacl, & Dr. West.]
August 29, 2010
I feel that people are avoiding stating outright that "overuse of chemotherapy could be contributing to the difference in survival between the Pall Care and non-Pall Care groups". I was insulted that Kelly and Meier's Editorial in the NEJM did not suggest this as a possible explanation for the survival discrepancy. Especially as this article comes on the heels of Atul Gawande's description of Sara Monopoli (ironically, also with metastatic NSCLC) dying 3 days BEFORE initiating a FOURTH line chemotherapy agent. Obviously, the 4th line chemo did not kill Sara, but perhaps discussions of goals of care performed by a nonbiased party (i.e. Pall Care and not oncologists, [far more accurate is 'differently-biased party']) lead to a decreased use of toxic therapies at the end of life leading to increased survival. Does anyone else agree with this sentiment (1. the suggested mechanism, 2. the fact that no one is suggesting it) ?
Additional comments: I'm guessing we would all be surprised to see the 2.7 month survival advantage fully corroborated in future studies, but if not we're all happy that it made it into the books this one time. Also, most of us wish we could see more details on how the 2 groups differed in all treatments received until death, and an analysis of the differing costs between groups.
[1st time Commenter; PGY-2 in Int Med in NYC; considering Pall Care. Appreciate above comments especially Dr. Kirk, dspacl, & Dr. West.]
August 29, 2010
Welcome aboard BergMD!
Thanks for the cites.
I think that there is general assent to the deleterious affect of chemo in this picture, and that it is part of the assumption/hypothesis set. Take another look at Lyle's original post, particularly bullet point #2.
On another vaguely related point, I believe that the funny business (error message saying something to the effect that the "post is too large to process") that's gone on when I click the "publish your comment button" is happening to others, too, leading them also to repost repeatedly with edited and shorted posts. Perhaps we need to call the comment Blogger interface repairperson.
March 27, 2011
Welcome aboard BergMD!
Thanks for the cites.
I think that there is general assent to the deleterious affect of chemo in this picture, and that it is part of the assumption/hypothesis set. Take another look at Lyle's original post, particularly bullet point #2.
On another vaguely related point, I believe that the funny business (error message saying something to the effect that the "post is too large to process") that's gone on when I click the "publish your comment button" is happening to others, too, leading them also to repost repeatedly with edited and shorted posts. Perhaps we need to call the comment Blogger interface repairperson.
March 27, 2011
I appreciate Lyle's balanced presentation of the study.
I have been troubled by the way that organizations that many of us belong to and admire--NHPCO, AAHPM, CAPC, etc.--are promoting and interpreting this study (the recent 8/20 media update by CAPC is slightly better, but remains focused on survival).
All of these organizations have been focusing on the fact that patients in the study who received palliative care lived a bit (2.7 months) longer than patients who did not. While I understand that the hospice and palliative care communities have long suffered from the stigmatized perception that they welcome (or, even, hasten) death, and that this study seems to provide a rebuttal to such a perception, I believe the way the study is being embraced and promoted is misleading. Moreover, it may even be harmful.
(1) The study compared patients receiving standard oncological care vs. patients receiving standard oncologic care and palliative care (concurrently). As such, the study says little about hospice insofar as most hospice patients most stop oncology interventions to begin receiving hospice care. And, while this provides some evidence to support concurrent care, it surely does not mean that patients who elect hospice as it is currently delivered will live longer. It is, therefore, troubling that NHPCO's press release reads: "Research Shows Patients May Live Longer with Hospice and Palliative Care."
(2) The study itself was not designed to measure a primary outcome of time to death. Rather, the study was designed to measure a primary outcome of quality of life, using two validated instruments. And, the study showed an improved quality of life for patients receiving concurrent palliative care over patients receiving standard care (moderate improvement on one scale, significant improvement on the second). That patients receiving concurrent palliative care had improved quality of life is very good news for palliative care and for patients. Indeed, it is the primary goal of palliative care. However, this improved quality of life is being far outshadowed by the emphasis being placed on time to death.
(3) Finally, the emphasis on time to death perpetuates exactly the belief that hospice and palliative care have been working to change for decades: that what is important is how long you live rather than how well you live. If we begin promoting hospice and palliative care under the premise that such care extends life, we tacitly accept that extension of life is the primary goal of healthcare. And, we tacitly send that message to our colleagues, patients, and the public at large.
This is an important study with encouraging results. The way it is being promoted, however, (1) misrepresents the study design and results and (2) supports the premise that length of life--rather than quality of life--is what is most important.
March 27, 2011
While three cheers are certainly in order, I would be very cautious about saying that palliative care improves survival. Although randomized, the study was small and from a single institution. I love the results, but think we all need to be careful about over-interpreting single study results. When the next study shows no change in survival, which I fully expect, the fall for the field could be hard.
March 27, 2011
Great write-up Lyle, I think you bring up some great points at the end. How we operationalize this information is extremely important. We all need to spend a little time being giddy, then writing a thank you letter to Dr. Jennifer Temel and her team (from NEJM site: Massachusetts General Hospital, 55 Fruit St., Yawkey 7B, Boston, MA 02114)
But then we have two major challenges:
1) how do we best communicate this message (see my post on sharing the message) in the short-term and long-term
2) how do we get 'The Holy Grail' you describe: "how can we work towards bundling this type of intervention back into primary care, have it reimbursed, and provide appropriate training for future clinicians so that they can do the bulk of this work?"
One interesting point was the palliative care team in the article only consisted of a doctor and an APRN. No mention of the other classic members of a palliative care team: social workers and chaplains. Does this mean for cost reasons they are cut out if any of this shapes policy? I don't know if that is the right answer but palliative care teams (not duos) are expensive to start up.
And one other thing: I love the fact they used the word palliative. If we could only get people to accept and understand the term palliative like the American public understands 'nutriceuticals', 'metabolism', and 'ChatRoulette' we would could be much more effective. This may be a good step towards that. Most of the news orgs are using 'palliative' as well. Great!
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