By Jessica Becker, Brandel France de Bravo, MPH, and Diana Zuckerman, PhD
Palliative care is often misunderstood as meaning a patient will not get “real treatment.” That is not accurate. In fact, patients who have palliative care often live longer as well as having a better quality of life.
A ground-breaking 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.1 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.
A different study, published in a medical journal in 2014 focused on patients with various serious diseases who were having trouble breathing. Half the patients received “breathlessness support services” for 6 weeks and the other half did not. The support services included palliative care, respiratory medicine, physiotherapy, and occupational therapy. Six months later, the patients who had received the support services had less trouble breathing and were more likely to still be alive. The services helped all patients breathe more easily but only improved survival for patients with COPD or non-cancerous lung disease, not for patients with cancer. 2
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.
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.
Many doctors do not feel comfortable discussing end-of-life issues or advance care planning. However, now that palliative care is often reimbursed by Medicare or private insurance, patients are more likely to consider it.
Patients should not have to choose between comfort and treatment
The study of lung cancer patients published in the New England Journal of Medicine deserves special attention because of its implications for many patients with fatal diseases.
The study patients did not have to choose between cancer treatment and palliative care. 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 reported a better 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.
The patients who were offered palliative care plus cancer treatment had fewer symptoms of depression. 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, the two other studies described in this article show 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.
- 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. ▲
- Higginson IJ, Bausewein C, Reilly CC, Gao W, Gysels M, Dzingina M, McCrone P, Booth S, Jolley CJ, Moxham J: An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respiratory Medicine Journal 2014. 979-87. href=”http://www.ncbi.nlm.nih.gov/pubmed/25465642?dopt=Abstract”>http://www.ncbi.nlm.nih.gov/pubmed/25465642?dopt=Abstract ▲
- J. Brian Cassel, Kathleen Kerr, Steven Pantilat, Thomas Smith, Donna McClish: Does Palliative Care Consultation Reduce ICU Length of Stay? Journal of Pain and Symptom Management 2011. 41, 191-192. http://www.jpsmjournal.com/article/S0885-3924%2810%2900752-9/fulltext ▲