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Study Suggests Timing of Palliative Care for VA Patients with Advanced Lung Cancer is Associated with Survival


BACKGROUND:
Palliative care reduces patients’ physical symptom burden and improves their mood and quality of life; however, rather than combining standard oncology care with palliative care, many clinicians delay palliative care until patients have decided to suspend life-prolonging treatments. As a result, palliative care is often underutilized – or delivered too late to provide meaningful benefit. This retrospective cohort study sought to determine whether the early use of palliative care – received soon after diagnosis – is associated with improved survival, if referral did not occur as part of the dying process. Investigators identified 23,154 VA patients diagnosed with advanced-stage lung cancer from 2007-2013, with follow-up until January 2017. Overall, 13,109 Veterans (57%) received palliative care, and there was a 41% relative increase in the use of palliative care from 2007 to 2013. The primary outcome was the association between palliative care and survival, and place of death (acute versus non-acute setting) also was examined.

FINDINGS:

  • Palliative care was associated with survival among patients with advanced lung cancer; however, the timing of palliative care receipt was an important component of this benefit. Palliative care received 31 to 365 days after cancer diagnosis was associated with increased survival, while palliative care received within 30 days of diagnosis was associated with decreased survival. Most of the patients who received palliative care within 30 days of diagnosis only survived a few weeks after diagnosis, suggesting palliative care referral occurred to ease the dying process.
  • When received within 30 days of diagnosis, only 24% of the initial palliative care encounters occurred in an outpatient setting. When received 31 to 365 days after a cancer diagnosis, 45% of the initial encounters occurred in an outpatient setting.
  • Palliative care also was associated with a reduced risk of dying in an acute care setting compared to Veterans who did not receive palliative care.
  • and rates of MAT and naloxone prescribing were lowest, among those ages 55+.

IMPLICATIONS:

  • Given the benefits, palliative care should be considered a complementary approach in patients with advanced lung cancer, and it should be integrated with disease-modifying therapies earlier in the treatment plan.

LIMITATIONS:

  • This retrospective, cohort study is subject to unmeasured, residual confounding. For example, oncologists who refer patients earlier to palliative care also may be more likely to focus on quality end-of-life care that could improve survival in unpredictable ways.
  • There is no standardized definition of a palliative care encounter, thus investigators examined treatment with a palliative care “approach.”
  • Patients who were offered but refused palliative care were not captured.

AUTHOR/FUNDING INFORMATION:
This study was partly supported by HSR&D’s Center to Improve Veteran Involvement in Care (CIVIC), Portland, OR, where Dr. Sullivan is an investigator.


PubMed Logo Sullivan D, Chan B, Lapidus J, et al. Association of Early Palliative Care Use with Survival and Place of Death among Patients with Advanced Lung Cancer Receiving Care in the Veterans Health Administration. JAMA Oncology. September 19, 2019;epub ahead of print.

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What are HSR&D Publication Briefs?

HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.