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Care for lung cancer pain, suffering linked to improved survival

OHSU study of 23,000 VA patients finds timing of palliative care is pivotal
Donald Sullivan, wearing white doctor's coat, standing in a glass hallway
Dr. Donald Sullivan believes that palliative care shouldn't be utilized only for end-of-life-care, and his research supports this. “Given the quality of life benefit and the potential to improve survival, I think it makes sense that people get this as early as possible.” (OHSU/Kristyna Wentz-Graff)

Palliative care is intended to bring physical, emotional and spiritual support to help people cope with serious illness. A new study focused on individuals with lung cancer makes the case that palliative care also can help people live longer.

Palliative care teams work to relieve pain and symptoms such as fatigue, anxiety, shortness of breath, nausea and depression. It is well established that palliative care improves quality of life. But findings on survival have been mixed, possibly because some patients receive palliative care too late in the course of their illness for it to have an impact.

“Palliative care shouldn’t be something that you withhold from people until the very end of their life,” says Donald Sullivan, M.D., M.A, M.C.R., senior author of the new study. “Given the quality of life benefit and the potential to improve survival, I think it makes sense that people get this as early as possible.” Sullivan is an associate professor of medicine (pulmonary and critical care medicine) in the OHSU School of Medicine and core investigator at the Center to Improve Veteran Involvement in Care at the Veterans Affairs Portland Health Care System.

His research team studied the experience of a national population of more than 23,000 patients with advanced stage lung cancer treated in the Veterans Health Administration. They found that timing was indeed pivotal: palliative care given 31 to 365 days after diagnosis was strongly associated with increased survival. Among those receiving palliative care during this time window, the risk of dying was about half that of those not given palliative care. The authors used statistical modeling to account for differences between the patients who did and did not receive palliative care, including age, severity of cancer and presence of other illnesses.

More immediate palliative care delivery – done within 30 days of diagnosis – was associated with decreased survival. Sullivan and colleagues say the likely reason is that the patients who received palliative care this soon after diagnosis tended to be more seriously ill and were being cared for as hospital inpatients. The palliative care in such cases would be more like hospice and intended to ease the dying process, Sullivan says.

Those less seriously ill at diagnosis, who tended to receive palliative care outside of a hospital, would have had more time to benefit from its multidisciplinary, patient-centered approach, Sullivan says.

The means by which palliative care could act to improve survival remain unknown. It could be connected to reduced symptom burden and improved mood and quality of life. Palliative care also can promote shared decision making and that might decrease overly aggressive cancer treatment, which can be associated with more harm than benefit for some patients, Sullivan and co-authors say. They published their findings today in JAMA Oncology.

Palliative care is appropriate at any stage in a serious illness, for patients young or old. It fits alongside standard medical care. Palliative care, unlike hospice, does not depend on a clinician’s estimate of life expectancy and patients do not have to give up curative medication or treatment to receive palliative care. But many people who are seriously ill miss the benefits of palliative care because clinicians wait too long or never make a referral.

Fewer than 1 in 5 patients with advanced lung cancer received a palliative care consultation in one study of a hospital network with dedicated palliative care services. In a survey of physicians taking care of people with lung cancer, nearly half of them said they referred less than a quarter of their patients to palliative care. Low-referring physicians expressed concerns that bringing up palliative care would alarm patients and families.

“We need to get away from the myth that addressing palliative care needs with a patient is giving up hope,” Sullivan says.

In the VA population analyzed by Sullivan’s group, 57% received palliative care. “While there are opportunities for improvement, the VA has one of the best, well-developed integrated palliative care systems in the country,” he says.

While misconceptions about palliative care remain a barrier to broader access, another barrier is the supply of trained palliative care specialists, especially outside of large cities. One way forward, Sullivan says, is for health systems to provide palliative care training to nonspecialists such as primary care physicians and nurse practitioners.

“The number of palliative care specialists needed is so much higher than the number who are going to be available,” he says.

Funding for the research was provided by the National Cancer Institute (award number K07CA190706), the Health Services Research & Development Center to Improve Veteran Involvement in Care (CIN 302 13-404) at the VA Portland Health Care System and the Department of Veterans Affairs, and the VA Informatics and Computing Infrastructure (VA HSR RES 13-457). Support for VA/CMS Data was provided by the Department of Veterans Affairs, VA Health Services Research and Development Service, VA Information Resource Center (Project: Dr. Sullivan-01).


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