Timing of Palliative Care Linked to Better Lung Cancer Survival

Patients with advanced lung cancer who received palliative care earlier lived longer than those who did not receive palliative care, according to the results of a study of patients at the Veterans Affairs health care system. Recently reported in JAMA Oncology, the study findings emphasize the importance of initiating palliative care early on.

“I think the tendency has been to refer only at a point when a person is dying rather than intervene earlier, where you might really see that benefit,” David Friedland, MD, medical oncologist, University of Pittsburgh Medical Center’s Hillman Cancer Center in Pennsylvania, told CancerNetwork. Having worked closely with palliative care doctors, Friedland has been told before that patients who are referred for palliative services do better when they are referred earlier, as proven by the findings of the study.

The retrospective, population-based cohort study included 23,154 patients who received an advanced lung cancer diagnosis (stage IIIB or stage IV) between January 1, 2007 and December 31, 2013 and were treated at the Veterans Affairs health care system. The timing of palliative care was stratified into three groups: 0 to 30 days, 31 to 365 days, and more than 365 days after diagnosis.

Patients in the study were an average of 68 years of age and nearly all (98%) were men. Also, 89% of patients had stage IV tumors and 69% had non–small cell lung cancer. After diagnosis, chemotherapy treatment lasted for a median of 37 days (interquartile range [IQR], 19-63 days) and radiotherapy lasted for a median of 33 days (IQR, 14-62 days). Among the 23,154 patients, a total of 13,109 patients (57%) received palliative care.

The study revealed that overall patients who received palliative care had a 19% decreased likelihood of survival (adjusted hazard ratio [aHR]=1.19; 95% CI, 1.15-1.23). However, for patients who received palliative care between 31 and 365 days after diagnosis, a survival benefit was seen (aHR=0.47; 95% CI, 0.45-0.49). Furthermore, when only patients who received care at facilities that were high users of palliative care were included, the survival benefit was even more pronounced (aHR=0.42; 95%CI, 0.40-0.45).

As for the other groups, patients who received palliative care within 30 days had worse survival than patients who did not receive palliative care (aHR=2.13; 95% CI, 1.97-2.30). Patients who received palliative care beyond 365 days had no difference in survival compared with patients who did not receive palliative care (aHR=1.00; 95% CI, 0.94-1.07).

For the patients who received palliative care within 30 days, Friedland said those patients were likely dying, and that's why the outcomes were “so poor” for that group. When asked about the patients who received palliative care beyond 365 days, he said those patients may be “very heavily” pretreated and at a point where they’re dying, where any intervention probably won’t improve their outcome.

In addition, receipt of palliative care was linked to place of death. Patients who received palliative care had a lower risk of dying in an acute care setting compared with patients who did not receive palliative care (adjusted odds ratio=0.57; 95% CI, 0.52-0.64).

However, because the study cohort is primarily men, the findings may not be generalizable to all advanced lung cancer patients. 

“Years ago,” Friedland said, “the lung cancer population was mostly men, but there are a lot of women now.” As a result, he said, “This [study] may not translate perfectly to a regular clinical setting out in the world.”