The Effect of Integrating Early Palliative Care Modalities on

Patients with Lung Cancer

Jessica L. Schwab
The Ohio State University

Abstract:
Objective: To determine if implementing palliative care on lung cancer
patients improves quality of life and eliminates aggressive end of life
care Methods: Obtaining a control and experimental group of 200
patients with NSCLC and observing if a palliative care clinic would
improve the quality of life, better the blood values and lessen the need
for pain medication Results: Implementing palliative care modalities
on patients with NSCLC improves the quality of life of patients and
reduces the need of aggressive end of life care. These patients also live
longer and tended to pass away in hospice or at their own home instead
of in an emergency room or inpatient unit.

Key Words: Palliative care, non-small cell lung cancer (NSCLC),

oncology, cancer, comprehensive medicine, hospice, end of life,
terminally ill
 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

Cancer remains the second leading cause of death to Americans; second only to heart
disease. Lung cancer stands as the deadliest and claimed approximately 157,000 lives in 2010
from the 222,000 new cases documented.1 Post surgical resection, the survival rate of late stage
non-small cell lung carcinoma patients (NSCLC) weavers around 10-20%.1 The needs of these
patients are very specific and unique; some not addressed head-on during consultation or
treatment. Palliative care, or treating the whole patient and not just the disease, holds an
important place in oncologic medicine. The World Health Organization (WHO) defines
palliative care as “…an approach that improves the quality of life of patients and their families
facing the problems associated with life-threatening illness, through prevention and relief of
suffering by means of early identification and impeccable assessment and treatment of pain and
other problems, physical, psychosocial, and spiritual”.2 Increased and early access of palliative
modalities during the treatment of cancer, specifically lung, have shown improvements in mood
and quality of life.3 To aid with the very specific needs of patients facing terminal illness, a
palliative care program was developed at the University of Texas M.D. Anderson Cancer
Center.4 This outpatient center recognized a problem in oncologic care; that patients at the
highest level of distress passed away in acute care settings instead of hospice.4 A team combined
with nurses and doctors welcomed outpatients into the center to discuss symptoms, end-of-life
wishes and the financial burdens of illness. These early consultations with patients helped to
lessen the aggressiveness of care towards the end-of-life and promoted comfort and well-being.4

Palliative care services should expand across the nation, and follow a model like the
outpatient clinic in Texas, to focus on the needs of cancer patients and their families. A
multidisciplinary approach to lung cancer care should be explained during the original
consultation between patient and doctor. Approximately 70-80% of lung cancer patients
experience significant physical and psychosocial symptoms that maximize in severity three
months before death.5 The need for widespread palliative care referral in the treatment of lung
cancer is imperative to improve the lives of patients and their families; and the whole oncologic
system overall. Based on statistics and known information, it would be hypothesized that
referring patients to palliative care clinics would increase their quality of life and reduce the need
for aggressive end of life care. These modalities, if implemented early enough during treatment,
could shift the way the deadliest of cancers is viewed by proving that life after diagnosis does not
have to be miserable; that there is hope.

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 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

By 2020, the WHO estimates that more than 15 million people will experience
cancer and 10 million will die each year, a 60% increase from what it is now.2 Optimal treatment
and early detection leads to high cure rates for cancers such as breast and lymphoma. Other
cancers, such as esophageal and lung, have poor survival rates. Treatment of lung cancer centers
around improving the quality and length of life; but sometimes they are not directly correlated.
As the population ages, the patients who are being diagnosed are increasingly older.2 These
patients come with a list of comorbidities which make the treatment of their cancers
multidisciplinary. Sometimes palliative care and hospice are used interchangeably, but
Higginson et al. explains that palliative care does not have to be specific to inpatients. A meta-
analysis utilizing palliative care modalities in oncology showed trends of less pain reported by
patients, decreased health care costs and a reduction in anxiety levels.2 Because the data was
taken across many different studies, one study could have a completely different result than
other. It is important to note that care is very specific and can differ from patient to patient but
overall trends should be recognized. Different data from trials such as the phase of illness,
functional scores and symptoms would allow for comparison and development of services
catered to specific needs.

Palliative care programs are evolving and existing programs need major growth to
accommodate their increased use.4 As referenced in the introduction, the M.D. Anderson Cancer
Center in Texas has created a Supportive Palliative Care Program. This program consists of a
mobile consultation team, acute unit and outpatient service. The mobile team visits the ICU and
ER as needed, and a counselor is always on call to address psychosocial needs. Admittance to the
acute unit is based on the presence of “severe physical or psychological stress”.4 A family
conference takes place two days after admission to offer social work advice and address
emotional needs. The average length of stay in the acute unit is less than normal hospitals and
70% of patients are discharged alive.4 An important statistic from the center is that median
survival after discharge is 21 days. Based on that statistic; the acute care center is visited by
patients very close to their passing. But, studies at the center have found a significant reduction
in pain, fatigue, anorexia and depression in these patients.4 Having a mobile palliative care team
and a palliative unit in hospitals throughout the country could have significant effects on the
realm of medicine. Working together with the oncology unit could create unity of care. At the
end of the day, a separate unit in a hospital completely devoted to palliative medicine could aid

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 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

in improved quality of life because the patients would be aware of their options. Instead of
having their final days in an emergency room, patients could be comfortable in an acute care unit
or at their own homes.

With every diagnosed cancer comes differing side effects (both physical and emotional)
and lung cancer is no different. In a study completed by Deodhar et al., patients reported that
fatigue, pain and appetite loss were the most distressing physical symptoms.5 The study was
limited to fifty stage IV NSCLC patients. A palliative care team was assembled at a hospital in
India with a research goal of determining symptom relief, if any, after six months. Nurses, a
palliative care physician, social workers and a clinical psychologist were included in the
outpatient department. Patients were examined three times a week, and if hospital admittance
occurred during the study, they were examined everyday.5 After-hours service (a telephone line
connecting three doctors) was always available to the patients. Providing a direct line of
communication is vital to establish credibility of care. The telephone number stood as a direct
link between patient and doctor; which could be a great way to increase communication in the
field of oncology in the future. Doctors followed a protocol which included assessment of
nursing needs, psychosocial needs, goals of care and home-based palliative care.5 Included in
each visit was an assessment by a nurse, a checklist of current problems and drug
compliance/needs. Utilizing checklists in palliative care is an important tool because it can aid in
further research. By having a timeline of symptoms experienced by lung cancer patients, doctors
can start to plan palliative care modalities earlier in treatments.

The study reported a “low symptom burden” across the board.5 Pain, tiredness and
anxiety improved after the initial follow-ups. Shortness of breath decreased after an average of
five visits with the palliative care team. Quality of life assessments were given and there seemed
to be a progressive decrease in most symptoms. Nausea and vomiting had slight increases as
treatment went on.5 The study was concluded as a success and a step in the right direction for the
treatment of lung cancer. Integration of palliative care modalities are now recommended by the
American Society of Clinical Oncology for metastatic and advanced cancers. Disease recurrence
is common in lung cancer so aggressive action should be taken even before metastasis occurs.1

There were several limitations in the Deodhar et al. study. Although recruiting patients
from surrounding cities can increase the field of interest, patients did not want to make the drive

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 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

to the facility for follow-up visits, especially when their health declined.5 Many patients in the
study reported chemotherapy-induced fatigue. If recruitment would have been more local the
attendance could have been improved. Another thought is to include more hospitals and
outpatient palliative care centers so patients can have the option to travel somewhere more
convenient. The authors mentioned that recruitment was difficult because of the lack of
knowledge of palliative care modalities in oncology.5 If palliative care modalities are mentioned
in consultation, patients could have the tools and knowledge to aid in their own course of
treatment.

Another study was completed on patients with metastatic NSCLC in 2009 at the
Massachusetts General Hospital in Boston. Eligible patients were randomized into a palliative
care and standard oncologic care group or a group that offered the standard care alone. The first
group met with a board-certified palliative care physician early on in treatment. These patients
received individual psychosocial care and assisted more with the decision making in their
treatment than did the standard group.3 Data was collected from the electronic medical records
and included but was not limited to medication prescriptions, hospital admissions, emergency
room visits and location of death.3 The patients assigned early palliative care had significantly
higher scores on quality of life assessments at the end of the twelve-week study. The presence of
depression was lower in the first group, but both groups did have an increase in the use of anti-
depressant drugs.3 Fewer patients in the standard care group had resuscitation preferences
documented in their medical record. Because the palliative care group received extensive
amounts of information about end of life care, one could hypothesize that they were more well
read on the subject and thus received an option to decide on resuscitation preferences. The later
remains a very important, yet delicate, conversation in palliative medicine. If talked about earlier
in treatment (or even the original consultation) patients may be more comfortable with their
realm of options.

Despite receiving less aggressive end of life care, the palliative care group had a two
month longer survival rate compared to the standard group.3 This study was specific to metastatic
patients but could be replicated for patients with early stage lung cancer. A two month longer
survival rate is statistically significant, especially because the presence of metastasis often carries
a gloomy outlook for patients. Timely introduction of palliative care can reduce costs by

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 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

reducing the amount of hospital care and aggressive treatment towards the final days of life. The
study showed that palliative care is clinically meaningful and deserves to be researched further.
The findings need to be replicated for different patients (with different stages of disease) but
shows great promise for alleviating distress in patients with metastatic NSCLC.

The above study was followed and studied after its initial completion. Patients that had
poor illness understanding, the standard group, overestimated their prognosis and were more
likely to choose aggressive care.6 Even with ample information, twenty patients believed their
metastasis was curable. More research needs to be done to improve illness understanding of
patients with advanced lung cancer. Facilitating discussions between caregiver and patient can
aide in this understanding. Providing clinical and psychosocial information and support can
enable patients to make informed treatment decisions. By having a palliative care consultation
early during illness, patients can have realistic goals and expectations for the remainder of their
lives.

A longitudinal study was continued from the original trial started in Boston. The data
from that trial was expanded further, and hypothesis were drawn based upon age and gender.
Palliative care improves mood and quality of life differently between male and female, as well as
younger compared to older patients.7 Older adults with cancer tend to report lower pain, less
emotional distress and fewer psychological issues. The research surrounding the supportive care
of young versus older patients is lacking in the field of oncology. In the future, this topic should
be expanded upon to further individualize treatments. Women in the study reported higher rates
of anxiety and a lower quality of life.7 Future areas of research need to expand upon the needs of
the geriatric population and so that palliative care can be tailored accordingly. Also, the needs of
specific genders should be introduced into comprehensive oncologic care. With thoughtful
planning and communication, the quality of life of lung cancer patients can increase. Options
discussing possible improvements for care will be highlighted throughout the remainder of the
essay.

An experiment to test the hypothesis, that palliative care would overall benefit the lives
of patients with lung cancer, would consist of a control group and an experimental group. The
screening process would consist of in-person consults with late stage (III or IV) non-small cell
lung cancer. Because metastasis is common in late stage lung cancer, patients would not be

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 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

turned away if they presented with systemic disease spread. The presence of metastasis is a
variable, though, and would be followed and closely documented throughout the study. This
experiment would take place at a large regional hospital with a large influx of patients (ie The
James). 200 late stage NSCLC patients would be chosen for the experiment. Unfortunately, this
disease can occur anytime during adult life, so patients of all ages would be accepted. It would
be beneficial to accrue data from patients of many ages to identify how palliative care needs
change throughout the different life stages. The study would not be blinded in any way (the
patient and caregiver will be aware of what group the later was in). 100 patients would be
randomly assigned to the control group which involves the “normal” care the patient would
receive. This could involve chemotherapy, hormone treatment, radiation therapy and
experimental drug trials. If the patient presented with acute care needs, they would be to report to
an emergency room. Of course, inpatient services would be available and hospice could be
recommended. Where this experiment could support the hypothesis resides in the quality of life
reports from the experimental group.

Patients randomized to the experimental group would also receive their normal care. It
would not be morally, or medically, acceptable to prevent patients from receiving care that could
save their lives. However, they would be referred to an outpatient palliative care clinic.
Depending on the location of the study, the clinic could be off site or inside of the hospital. If, for
instance the study is at The James, patients would meet with palliative care doctors and nurses.
These patients would have access to complementary care services like aromatherapy and
acupuncture which have been used for years to reduce pain. Palliative care doctors are licensed
to prescribe opioids and medication that can reduce the pain of cancer. This group would also
have access to an acute care clinic much like the one from M.D. Anderson in Texas. The clinic is
specific to patients with end of life needs. These patients would also have access to financial aid
counselors and psychological counselors. To quantify this study, patients from both groups will
be given quality of life assessments. Blood values (including eosinophils, an inflammation
marker) and the patient’s need for pain medication would be documented. The data would be
collected every week for twelve weeks and the study would conclude after the later.

If the hypothesis was correct, the experimental group would have a longer
average life expectancy. These patients would have higher scores on their quality of life

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 The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

assessments and would not request or utilize pain medications as much (because the
complimentary care would lessen the pain felt). A failed hypothesis would show no difference
between the two groups or the control group would show higher quality of life. It would be
expected that the experimental group would need less aggressive end of care because their
assigned care team would explain all possible options. These patients would be referred to
hospice sooner, and thus could receive even more supportive care. Early implementation of
palliative care, and building specialized clinics across the nation, could change the realm of
medicine. Lung cancer patients require a unique team of caregivers and palliative care could be
just what they need. The literature review and proposed study explained the need for palliative
care in NSCLC patient treatments. More research needs to be performed (on all types of cancers)
but the need is obviously there.

Experiment Results
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Need for pain medication Deaths in hospital Overall deaths

Control Experimental

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The Effect of Integrating Early Palliative Care Modalities on Patients with Lung Cancer

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Outcomes for Cancer Patients and Their Families? The Cancer Journal. 2010;16(5):423-
435. doi:10.1097/ppo.0b013e3181f684e5.

3. Temel JS, Green JA, Muzikansky A, Gallagher E, Admana S, Jackson V. Early Palliative
Care for Patients with Metastatic Non-Small Cell Lung Cancer. New England Journal of
Medicine. August 2010:733-742. doi:10.1056/NEJMoa10000678.

4. Bruera E, Hui D. Conceptual Models for Integrating Palliative Care at Cancer Centers.
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5. Deodhar JK, Noronha V, Muckaden MA, Atreya S, Joshi A, Tandon SP, Ghoshal A,
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Metastatic Non–Small-Cell Lung Cancer: Results of a Randomized Study of Early
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Palliative Care in Metastatic Non-Small Cell Lung Cancer. The Oncologist.
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