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Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer

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Patients with metastatic non-small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease. We randomly assigned patients with newly diagnosed metastatic non-small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records. Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02). 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. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)
Mean Change in Quality-of-Life Scores from Baseline to 12 Weeks in the Two Study Groups. Quality of life was assessed with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale, on which scores range from 0 to 136, with higher scores indicating a better quality of life; the lung-cancer subscale (LCS) of the FACT-L scale, on which scores range from 0 to 28, with higher scores indicating fewer symptoms; and the Trial Outcome Index (TOI), which is the sum of the scores on the LCS and the physical well-being and functional well-being subscales of the FACT-L scale (scores range from 0 to 84, with higher scores indicating a better quality of life). With study group as the independent variable, two-sided independent-samples Student's t-tests showed a trend toward a significant between-group difference in the mean (±SD) change in scores from baseline to week 12 on the FACT-L scale (−0.4±13.8 in the standard care group vs. 4.2±13.8 in the palliative care group; difference between groups, 4.6; 95% confidence interval [CI], −0.8 to 9.9; P = 0.09) (Panel A), no significant betweengroup difference in the mean change in scores on the LCS (0.3±4.0 and 0.8±3.6 in the two groups, respectively; difference between groups, 0.5; 95% CI, −1.0 to 2.0; P = 0.50) (Panel B), and a significant between-group difference in the mean change in scores on the TOI (−2.3±11.4 vs. 2.3±11.2; difference between groups, 4.6; 95% CI, 0.2 to 8.9; P = 0.04) (Panel C). Data are from the 47 patients in the standard care group and the 60 patients in the palliative care group who completed the 12-week assessments. I bars indicate 95% confidence intervals.
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Twelve-Week Outcomes of Assessments of Mood. Depressive symptoms were assessed with the use of the Hospital Anxiety and Depression Scale (HADS), which consists of two subscales, one for symptoms of anxiety (HADS-A) and one for symptoms of depression (HADS-D) (subscale scores range from 0, indicating no distress, to 21, indicating maximum distress; a score higher than 7 on either HADS subscale is considered to be clinically significant) and with the use of the Patient Health Questionnaire 9 (PHQ-9). The PHQ-9 is a nine-item measure that evaluates symptoms of major depressive disorder according to the criteria of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). A major depressive syndrome was diagnosed if a patient reported at least five of the nine symptoms of depression on the PHQ-9, with one of the five symptoms being either anhedonia or depressed mood. Symptoms had to be present for more than half the time, except for the symptom of suicidal thoughts, which was included in the diagnosis if it was present at any time. The percentages of patients with mood symptoms, assessed on the basis of each of these measures, in the group assigned to standard treatment and the group assigned to early palliative care, respectively, are as follows: HADS-D, 38% (18 of 47 patients) versus 16% (9 of 57), P = 0.01; HADS-A, 30% (14 of 47 patients) and 25% (14 of 57), respectively; P = 0.66; and PHQ-9, 17% (8 of 47 patients) versus 4% (2 of 57); P = 0.04. The analyses were performed with the use of a two-sided Fisher's exact test.
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