Palliative care and pain management for people with late stage lung cancer

By Jessica Becker and Brandel France de Bravo, MPH


A study published in the highly respected New England Journal of Medicine shows that palliative care, which helps manage symptoms and control pain, is a very effective addition to standard cancer treatment for people with metastatic non-small-cell lung cancer.[end  Temel J, Greer J, Muzikansky A, Gallagher E, Admane S, Jackson V, Dahlin C, Blinderman C, Jacobsen J, Pirl W, Billings J, Lynch T: Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Caner. New England Journal of Medicine 2010; 363:733-742.] The patients who had palliative care, which was offered as soon as they were diagnosed, suffered less depression, were less likely to receive aggressive end-of-life care, and lived longer.

Non-small-cell lung cancer is the most common form of lung cancer, and metastatic lung cancer means that the cancer was caught very late (Stage 4) and has spread beyond the lungs and lymph nodes to other organs like the brain, bones, or heart. When lung cancer spreads like this, it is inoperable and incurable. Various treatments have been found to prolong life by months and in some cases years, but these treatments have many unpleasant/serious side effects, involve hours of chemotherapy or radiation treatment on a regular basis, and do not necessarily provide relief from the many debilitating and painful symptoms of late-stage lung cancer.


What is palliative care?

Palliative care focuses on helping relieve the patient’s pain, offering psychological support to the patient and family, and providing the patient and family with information they may need to adapt to life with a serious illness and make relevant decisions. This kind of care enables patients with late-stage cancer and other debilitating diseases to live as comfortably as possible during the time they have left and spend meaningful time with their families.

During the 2009 debates on health care reform, some people mistakenly equated end-of-life palliative care with ending people’s lives through so-called “death panels.”  However, this new research is an example of how palliative care can improve the quality of life and even prolong life for patients who are very ill.

Doctors are not trained to discuss end-of-life issues or advance care planning, nor are they currently reimbursed for time spent on such discussions with patients. Most insurance plans will not pay for palliative care, or will only pay for it for a very limited time, unless the patient has decided to discontinue treatment.  As a result, many patients do not know about palliative care or are not willing or financially able to consider it.


What if patients didn’t have to choose between comfort and treatment?

In the New England Journal of Medicine study by Dr. Jennifer Temel and her colleagues at various universities, patients did not have to choose between cancer treatment and palliative care the way patients in the real world usually have to. Half of the 151 patients with non-small-cell lung cancer at Massachusetts General Hospital were randomly assigned to get cancer treatment and the other half were given palliative care in addition to cancer treatment. The patients that were assigned to receive cancer treatment and palliative care experienced an increase in their quality of life (measured by patient’s scores on three different quality-of-life gauges) while patients receiving cancer treatment alone experienced a decrease in their quality of life.

Along with having a better quality of life, the patients that were assigned to the group receiving palliative care plus cancer treatment had fewer symptoms of depression. Among the patients receiving palliative care and treatment, only 16% showed symptoms of depression while 38% of patients getting only standard cancer treatment had symptoms of depression.

More patients in the group assigned only to standard cancer treatments received aggressive end-of-life care, including chemotherapy, compared to patients who received palliative care plus cancer treatment.  Aggressive end-of-life care was defined as chemotherapy during the last two weeks of life; no hospice care; or hospice care for only the last few days of life. Hospice care is a form of palliative care for those who are terminally ill and near death, and can be provided at home or in a hospice. Aggressive end-of-life care can be very expensive. Even when health insurance covers a significant portion of the medical expenses, it can be very costly for a patient and the patient’s family.

Although the patients receiving palliative care plus standard treatment were less likely to continue with aggressive treatment, they lived about 2 months longer than the patients receiving only standard cancer treatment alone. In addition to showing that patients live longer and better when given palliative care, the study suggests that treatment that helps the whole patient and doesn’t just focus on fighting the cancer may also be more cost-effective.

The researchers explain their findings in several ways:

  • The improvements in quality of life, such as fewer symptoms of depression, may have helped patients live longer;
  • By pursuing less aggressive treatment, the patients enrolled in palliative care may have benefited from fewer toxic side effects which may have increased their will to live;
  • Palliative care patients got earlier referral to hospice programs, and preparing for death in a supportive environment may have helped prolong life.

While this specific study only focused on the use of palliative care in conjunction with standard cancer treatment for patients with metastatic non-small-cell lung cancer, there is reason to hope that patients with other kinds of metastatic cancer or other terminal diseases might also benefit from palliative care plus standard treatment.  This deserves further study.