In 2010, the world of lung cancer, and cancer in general, was abuzz with an intervention that improved quality of life and mood, and extended survival in patients with metastatic NSCLC. It was not a new chemotherapy or molecular biological agent. It was “early palliative care.” The original New England Journal of Medicine article several months ago were covered by both Dr. West (here) and Dr. Ramchandran (here). A group from Massachusetts General Hospital (Harvard system), led by Jennifer Temel, conducted the study.
What exactly is “early palliative care”? What exactly was happening in those visits? Could it be replicated? I’m a palliative care doctor, and I’ve been trying to figure this out myself.
In a separate article earlier this year, Jennifer Temel (a thoracic oncologist) and her colleagues took a closer look at what was happening in those visits. In general, they noted that palliative care consultation teams provide support through a number of ways, including symptom management, decision-making, education regarding illness, coping (for both patients and families), and planning ahead. In their article “Components of Early Outpatient Palliative Care Consultation in Patients with Metastatic Nonsmall Cell Lung Cancer”, they found that out of all the services that palliative care consultation provides, there were three particular areas that were emphasized in these outpatient visits: symptom management, patient and family coping, and understanding of illness. They also found that for those patients who reported a lower quality of life, the palliative care clinicians spent more time on symptom management during their visits. The clinicians did not know about any of the scores the patients reported.
On the surface, this makes some sense, particularly in thinking about improved quality of life and mood. The outcome of longer survival with palliative care is not as simple to explain. Indulge me here, as I go through a thought experiment with each of these content areas–symptom management, coping, and illness understanding—and seeing how they could lead to increased survival.
Imagine having pain under better control: one would be more mobile and more functional. One can imagine that if a patient was having a lot of troublesome symptoms, these may be a barrier to continuing a particular therapy. For example, if a patient was receiving chemotherapy but was so miserable from symptoms they wanted to stop—maybe not even side effects directly of the chemotherapy, but other symptoms (pain, fatigue, etc.). Aggressive symptom management may then enable a patient to continue their therapy.
In considering patient and family coping, I can imagine that if coping could be strengthened, this may lead to lower stress. There have been some studies on metastatic breast cancer patients in support groups and some survival benefit associated (as compared to similar patients not in a support group).
Illness understanding is an intriguing content area to contemplate. Why would understanding the illness better lead to longer survival? Perhaps patients may make decisions more deliberately if they have a resource like palliative care to assist them in the decision-making process.
Overall, the visits weren’t all about death and dying, a common misconception of palliative care. The bottom line? Early palliative care is still a black box, but one that has been opened! Stay tuned…