What Is the Role for Palliative Care in Patients With Advanced Solid-Tumor Malignancies?

Introduction and Scope of the Problem

Cancer has become one of the leading causes of premature death globally. The World Health Organization predicts that by 2040 there will be 27 million new cancer diagnoses annually. As the global burden of cancer continues to rise, so too do the number of cancer survivors living with the physical and emotional sequelae of cancer and its treatments. This represents a staggering burden of disease at both the individual patient and population levels, and it underscores the importance of ensuring that integrated palliative-oncological care is widely available for cancer patients.

Early integration of palliative care for patients with advanced cancer has been shown to improve patients’ quality of life and overall survival, compared with standard oncological care. Patients who receive integrated palliative-oncological care are also less likely to receive intensive, hospital-based care at the end of life, which has been associated with worse patient quality of life, decreased quality of care at the end of life, increased costs, and increased risk of psychiatric illness in bereaved caregivers. Consistent with this, early integration of palliative-oncological care has been shown to improve outcomes in caregivers, compared with standard oncology care. Based upon this evidence, the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) national guidelines recommend early, concurrent palliative care for all patients with advanced cancer who are receiving treatment for their disease. A summary of several key studies that evaluated the impact of integration of palliative care into oncology is provided in Table 35.1 .

Table 35.1

Studies Evaluating the Impact of Palliative Care Integration Into Oncological Care

Study	Study Design	Study Population	Intervention	Control ^a	Outcomes
Rabow, 2004	Case control	90 patients with advanced cancer, COPD, and CHF	Outpatient PC for patients with advanced disease (cancer and non-cancer–related diagnoses) n = 50	Usual care n = 40	PC patients had less dyspnea ( p = .01) and anxiety ( p = .05) and improved sleep quality ( p = .05) and spiritual well-being ( p = .007), but no change in pain ( p = .41), depression ( p = .28), quality of life ( p = .43), or satisfaction with care ( p = .26).
Casarett, 2008	Retrospective study—telephone interview of caregivers of veterans	524 caregivers of veterans who had received care at participating VA centers in their last month of life	Patients who had received PC during their last month of life n = 296	Patients who had no PC during their last month of life n = 228	PC patients had higher scores in almost all domains—symptoms, care at the time of death, spiritual support, access to benefits, and services.
Bakitas, 2009	RCT	322 patients with advanced cancers (stage III or IV lung, breast, GI, GU)	Case management, educational approach with monthly shared medical appointments	Usual care	PC patients had higher QoL ( p = .02), lower symptom intensity ( p = .06) and depressed mood ( p = .02), and no change in hospital, ICU utilization, or ED admissions.
Temel, 2010	RCT	151 patients with advanced lung cancer (stage IIIB, IV)	Early concurrent palliative care n = 77	Usual care n = 74	PC patients had improved QoL ( p = .03) and mood ( p = .01), less aggressive end-of-life care ( p = .05), and longer survival ( p = .02).
Clark, 2013	RCT	131 patients with advanced cancer scheduled for radiation	Structured 6-session multidisciplinary PC intervention followed by 10 brief phone counseling sessions n = 65	Usual care n = 66	PC patients had greater overall QoL ( p = .02), physical well-being ( p < .01), and functional well-being ( p < .01) at week 4. No statistically significant differences between groups at week 27 (after intervention’s phone sessions).
Zimmerman, 2014	Cluster RCT	461 patients with stage III or IV cancer (lung, GI, GU, GYN, or breast) with estimated prognosis of 6–24 months	Outpatient PC team with monthly follow-up and access to on-call, inpatient, and home services n = 228	Usual care n = 233	No significant trend toward improved QoL in PC group at 3 months. At 4 months, PC group had significantly improved QoL, symptom severity, and satisfaction with care.
Bakitas, 2015	RCT	207 patients with advanced-stage solid tumor or hematological malignancy with estimated prognosis of 6–24 months	Early access (within 30–60 days of diagnosis) to outpatient PC consultation, telehealth coaching, monthly PC follow-up n = 104	Delayed access: 3 months of UC then intervention n = 103	No significant differences in QoL, symptoms, mood, or resource use at EOL. Improved 1-year survival rates in early group (63% vs. 48%, p = .038); however no significant difference in overall survival ( p = .18).
Temel, 2017	RCT	350 patients with incurable cancer (lung or noncolorectal GI)	Early outpatient PC (within 8 weeks of diagnosis, met with PC team at least once monthly until death) n = 175	Usual care n = 175	PC group had improved QoL ( p = .01) and less depression ( p = .048) at 24 weeks and were more likely to discuss wishes with oncologist ( p = .004). Subgroup analysis by cancer type showed significant intervention effects in lung cancer cohort, not in GI cohort.
Vanbutsele, 2018	RCT	186 patients within 12 weeks of advanced cancer diagnosis (solid tumor) with prognosis of 12 months	Monthly PC consults and symptom assessments and integration of PC care with oncological care via PC nurse participation in multidisciplinary oncology meetings n = 92	Usual care n = 94	Significant improvement in PC patients’ reported QoL at 12 and 18 weeks, however no difference in mood or symptom severity.

CHF , Congestive heart failure; COPD , chronic obstructive pulmonary disease; ED , emergency department; EOL , end of life; ESAS , Edmonton System Assessment Scale; GI , gastrointestinal; GU , genitourinary; GYN , gynecological; ICU , intensive care unit; PC , palliative care; QoL , quality of life; RCT , randomized controlled trial; SC , simultaneous care; UC , usual care; VA , Veterans Affairs.

a Of note, it is typical for usual/standard care groups to provide palliative care consultations upon request.

Over the past two decades, there has been rapid growth in the number of hospitals in the United States that have palliative care services available. In 2018, approximately 72% of hospitals with 50 or more beds had a palliative care service, compared to just 7% in 2001. In larger hospitals with over 300 beds, 94% had inpatient palliative care services in 2018. In contrast, access to outpatient palliative care remains relatively scarce, underutilized, and concentrated at National Cancer Institute (NCI)–designated cancer centers. In 2018, 95% of NCI-designated centers had outpatient palliative care clinics, compared with only 40% of non-NCI–designated cancer centers. While this represents an increase in access to outpatient palliative care overall, from 59% of NCI-designated cancer centers and 22% of non-NCI cancer centers in 2009, the majority of palliative care services available today remain inpatient based.

Unfortunately, the need for palliative care far outweighs the current availability of specialty providers. It is therefore crucial that oncologists and other clinicians caring for cancer patients are able to provide fundamental palliative care skills (primary palliative care), such as assessing physical and psychological symptoms and discussing advance care plans, while recognizing when it is appropriate to engage clinicians with specialty training in palliative care.

Palliative Care Needs and Screening

Indications for palliative care for patients with advanced cancer can generally be organized into five key domains:

1.
Disease/Prognosis: advanced disease, prognosis of less than 1 year, or progression despite receipt of second-line systemic therapy
2.
Poor Performance Status: Eastern Cooperative Oncology Group (ECOG) performance status score ≥3 or Karnofsky Performance Scale (KPS) score ≤50
3.
Symptom Severity: significant symptom burden from disease, treatment, or serious comorbidities
4.
Psychosocial Distress
5.
Advance Care Planning

Advanced Disease

A diagnosis of advanced cancer is one of the most common referrals for palliative care. Early palliative care referral is now recommended for all cancer patients within 8 weeks of receiving an advanced cancer diagnosis, as defined by one or more of the following: distant metastases, late-stage disease, and a life-limiting prognosis of 6 to 24 months. Although accurate prognostication is a challenge, the use of the “surprise question” may help clinicians identify patients who need further assessment by palliative care. Specifically, if a clinician answers “no” to the question “would you be surprised if the patient died within 12 months?” they should consider referral to palliative care. This simple question has a sensitivity of 67.0% for predicting mortality within 6 to 18 months and a specificity of 80.2%.

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