Volume 23, Number 4: April 2022
Under My Microscope
IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
By Dr. Tania Pastrana
IAHPC Research Advisor
Randomized Trial of a Palliative Care Intervention to Improve End-of-Life Care Discussions in Patients with Metastatic Breast Cancer
Greer JA, Moy B, El-Jawahri A, Jackson VA, Kamdar M, Jacobsen J, Lindvall C, Shin JA, Rinaldi S, Carlson HA, Sousa A, Gallagher ER, Li Z, Moran S, Ruddy M, Anand M V, Carp JE, Temel JS. (2022). J Natl Compr Canc Netw 2022; 20(2): 136-143. DOI: 10.6004/jnccn.2021.7040
The recently launched “Lancet Breast Cancer Commission: Tackling a global health, gender, and equity challenge” points out the challenge of breast cancer and associated disparities.1 Breast cancer has the highest incidence of cancer globally and, despite significant improvements in the diagnosis and treatment, 685,000 deaths were reported in 2020.2 However, there is a gap in clinical research and practice with respect to the provision of palliative care for long disease trajectories of patients with metastatic breast cancer.
The study, led by Joseph Greer and Jennifer Temel, aims to determine the effect of a structured palliative care intervention on documentation of end-of-life (EoL) care preferences (primary outcome) and in patient-reported measures of prognostic awareness, quality of life, anxiety, depression, and hospice utilization. The 120 patients with metastatic breast cancer enrolled were within eight weeks of any clinical indicators signifying poor prognosis. They were randomized in two parallel arms (usual care for 59; intervention for 61). The intervention consisted of five structured visits (the first was within the first four weeks of enrolment, and subsequent visits were done once every four weeks).
The authors found a statistically significant higher rate of EoL care discussions documented for the intervention group, including a higher completion rate of a “Medical Orders for Life-Sustaining Treatment” form. The group was also three times more likely to report discussing their end-of-life care wishes with their doctor, and four times more likely to receive hospice services than patients undergoing the usual care. No effect was found in quality of life, depression, or anxiety.
This study shows the benefits of early palliative care adapted to the needs of patients with longer disease trajectories. As the authors state, “this study represents an important step forward in enhancing access to essential supportive care services in a timely manner and for improving the quality of EoL care.”
Camila Zimmermann and Jean Mathews suggest the presentation of early palliative care as a metaphorical “umbrella to have at hand in case of rain.”3
References
- Coles CE, Anderson BO, Cameron D, Cardoso F, Horton et al. The Lancet Breast Cancer Commission: tackling a global health, gender, and equity challenge. Lancet 2022:399(10330): 1101-1103. DOI: 10.1016/S0140-6736(22)00184-2
- World Health Organization. Fact sheet. Breast cancer. March 26, 2021.
- Zimmermann C, Mathews J. Palliative Care Is the Umbrella, Not the Rain—A Metaphor to Guide Conversations in Advanced Cancer. JAMA Oncology 2022. DOI: 10.1001/jamaoncol.2021.8210
Background: Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population.
Patients and methods: Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization.
Results: The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21-7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10-14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms.
Conclusions: This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories.
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Media Watch: Advice on Conducting Research
The articles below are selected from recent issues of Barry R. Ashpole’s weekly report Media Watch.
Developing a More Tailored Approach to Patient and Public Involvement with Children and Families in Pediatric Clinical Research: Lessons learned
Therapeutic Innovation & Regulatory Science | Online – 19 February 2022 – The pediatric research community needs to address how to meaningfully involve children and families if they are to succeed in designing clinical research that suits the needs of pediatric patients and their families. This paper describes how an international community working under the umbrella International Children’s Advisory Network and European Young Person’s Advisory Group Network has involved children and families in the design and delivery of pediatric clinical research. It offers practical solutions through various case studies assessed against seven patient engagement quality criteria within the Patient Engagement Quality Guidance tool.
Patient and Physician Perspectives on Engaging in Palliative and Healthcare Trials: A qualitative descriptive study
BMC Palliative Care | Online – 14 October 2021 – This study identified challenges related to conducting and participating in research as perceived by primary care physicians, patients, and caregivers/proxies. Through this new understanding of the relationship between the patient, proxy, caregiver, and physician perspectives, this study provides a better understanding of how researchers could work with physicians to build participant trust in research by providing a “warm handoff” during recruitment. Additionally, findings highlight the need for researchers to address physician’s challenges, namely in ensuring adequate time and/or incentives are provided for physician inclusion in research trials. In particular, nearly all physicians in this study identified time as a major challenge in participating in research, a finding widely supported by previous research.
Successful Strategies and Areas of Improvement: Lessons earned from design and conduction of a randomized placebo-controlled trial in palliative care
Life | Online – 15 November 2021 – Clinical trials in palliative care (PC) are challenging to design and conduct. Burden on patients should be minimized, while gatekeeping by professionals and next-of kin needs to be avoided. Clinical deterioration due to disease progression affects attrition unrelated to intervention, and different care settings complicate comparisons and reduce the generalizability of the results. This review provides advice for planning to perform clinical trials in PC based on the authors’ experiences from performing the Palliative-D study and by a thorough literature review on this topic. The authors discuss challenges in research based on lessons learned from the ‘Palliative-D' trial regarding successful strategies as well as areas for improvement.
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Related:
- Barriers to Recruitment into Emergency Department-Initiated Palliative Care: A sub-study of a multi-site, randomized controlled trial
- Development of Guidelines to Reduce, Handle and Report Missing Data in Palliative Care Trials: A multi-stakeholder modified nominal group technique
- Administrative Data for Palliative Care Research: Friend or foe?
- Undertaking Research Using Online Nominal Group Technique: Lessons from an international study
Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.