Palliative Care Referrals Needed Earlier
Presented at ASCO 2017 by Angelique Wong, MD, Assistant Professor, Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, a prospective survey of 200 patients with advanced cancer revealed that many patients would have preferred to receive referral to outpatient supportive and palliative care services earlier in the course of their disease.
Median time of referral was 8.5 months before death, and 72% of patients said this referral was “just in time,” whereas 21% said the referral was “late/much too late.” Only 7% reported that their referral was “early” or “too early.” When questioned about the preferred timing of their referral to supportive and palliative care, 39% of patients replied “at the time of diagnosis,” whereas 17% preferred that their referral take place at the start of first-line chemotherapy.
Palliative Care Improves Patient Experience After Stem-Cell Transplantation
Study results presented by Areej El-Jawahri, MD, Director, Bone Marrow Transplant Survivorship Program, and Associate Director, Massachusetts General Hospital Cancer Center Survivorship Program, Boston, revealed that inpatient palliative care during hematopoietic stem-cell transplantation (HSCT) hospitalization improves psychological distress at 6 months post-HSCT.
Although HSCT is potentially curative for patients with hematologic malignancies, it comes with a significant symptom burden.
“The patient experience during a 3- to 4-week hospitalization is predictive of post-HSCT quality of life and psychological outcomes. And depression and posttraumatic stress disorder (PTSD) is prevalent in this patient population,” said Ms MacIntyre.
The study randomized 160 patients with hematologic malignancies to inpatient integrated palliative and transplant care, or transplant care alone. The palliative care intervention focused mostly on building rapport with patients, teaching coping strategies, and alleviating symptoms such as pain, nausea, and constipation. At 6 months post-HSCT, Dr El-Jawahri and colleagues observed a significant improvement in depression symptoms and PTSD among patients in the intervention group.
Dr El-Jawahri and colleagues discovered that this brief inpatient intervention also sustained the improvement in patients’ depression and PTSD symptoms posttransplantation, underlining the importance of improving the HSCT experience as a means to reduce long-term psychological distress.
A multisite, randomized, controlled trial is planned to definitively demonstrate the efficacy of this care model for patients hospitalized for HSCT, and to further understand how palliative care impacts short- and long-term HSCT outcomes.
Lorazepam Lessens Agitation and Delirium at the End of Life
A double-blind, randomized, controlled clinical trial from David Hui, MD, MSc, Associate Professor, Department of Palliative Care and Rehabilitation Medicine, Division of Cancer Medicine, The University of Texas M.D. Anderson Cancer Center, and colleagues evaluated lorazepam as an adjuvant to haloperidol for agitated delirium at the end of life, and found that the use of this combination was associated with a rapid, sustained, and clinically significant reduction in agitation compared with haloperidol alone.
Delirium is diagnosed in >90% of patients with cancer before death. It is highly distressing to patients, caregivers, and healthcare professionals, and can pose serious safety risks, but the use of neuroleptics and benzodiazepines in delirium is highly controversial, and to date, only 2 clinical trials have examined treatment strategies for delirium in the palliative care setting.
The study included patients with cancer who had been admitted to an acute palliative care unit and had mixed or hyperactive delirium despite regular haloperidol use. Patients were randomized to haloperidol plus lorazepam, or haloperidol and placebo. This is the first randomized trial of delirium that directly compares benzodiazepines with placebo.
Patients in the lorazepam arm had significantly less agitation than those in the placebo arm.
“Since caregivers and nurses were blinded, scores were based purely on observation. Patients on lorazepam displayed less agitation overall, and were perceived to be more comfortable. Perhaps this can be integrated into the hospice setting to better patients’ end-of-life experiences,” Ms MacIntyre noted.
This was an important trial to help understand the needs of inpatients, and it demonstrated a clear benefit of adding benzodiazepines to the standard of care, she added. The trial also showed that it is possible to conduct a study of patients in the end-of-life setting, as patients in the study had a median survival of approximately 70 hours.
Patient Self-Reporting of Symptoms Improves Outcomes
Finally, a clinical trial presented at ASCO 2017 by Ethan Basch, MD, MSc, Director, Cancer Outcomes Research Program, University of North Carolina at Chapel Hill School of Medicine, assessed patient-reported outcomes for symptom monitoring during routine cancer treatment.
Symptoms are common in advanced cancer. They interfere with daily activities and frequently lead to emergency department and hospital visits.
“Symptom management is a cornerstone of oncology practice, and that is where we as nurses shine. We are the ones who manage a lot of these symptoms,” said Ms MacIntyre.
Previous research has revealed that clinicians are unaware of up to 50% of the symptoms experienced by patients. However, systematic symptom monitoring closes this gap. Patients are willing and able to self-report, and clinicians trust patient-reported information.
The standard approach to symptom monitoring involves a reactive approach to treatment. But in this study, Dr Basch and colleagues hypothesized that proactive symptom monitoring during chemotherapy would improve symptom management and lead to better clinical outcomes.
Patients were randomized to the intervention arm, in which they electronically self-reported 12 common symptoms before and between visits, or to the control arm, consisting of standard symptom monitoring. Patients in the intervention arm received weekly reminders to self-report via e-mail, and if they reported a symptom grade 3 or worse, a nurse would contact them. When it came time for the patient to see the oncologist, a complete report had already been prepared, inclusive of all of the symptoms the patient experienced during the monitoring period.
A total of 766 patients were enrolled between September 2007 and January 2011. After a median follow-up of 7 years, Dr Basch and colleagues found that patients self-reported 73% of the time they were prompted to do so, and nurses took action in response to alerts 77% of the time.
Compared with patients receiving standard care, 31% more of those in the self-reporting arm experienced significant benefits in quality of life, and 7% fewer patients visited the emergency department, with durable effects throughout the study. In addition, median survival was 5 months longer among patients in the self-reporting arm than in the control arm (31.2 months vs 26.0 months, respectively). These results are being explored further in a national trial.
“Technology has definitely evolved since this study was conducted in 2007, so, looking forward, more innovative approaches to technology might help us to even further improve patient symptoms. It is something to consider in improving overall survival, decreasing ER [emergency room] visits, and improving symptom management,” said Ms MacIntyre.