Impact of palliative care on quality of life in advanced cancer: A meta-analysis of randomised controlled trials

Using Oncology Treatment Pathway Data to Evaluate Serious Illness Communication, Care Utilization, and End-of-Life Care for Patients With Cancer

PURPOSE

Oncology treatment pathways provide decision support and encourage guideline adherence. Pathway data combined with electronic health record (EHR) data can identify patient populations with poor prognoses, low serious illness conversation (SIC) rates, and high acute care utilization that may benefit from targeted interventions.

PATIENTS AND METHODS

We conducted a retrospective cohort analysis among adults with cancer treated at seven affiliated sites of the Dana-Farber Cancer Institute (DFCI) who had navigations within 21 treatment pathways between July 29, 2019, and March 8, 2023. DFCI clinicians previously identified pathway nodes with an estimated survival less than 1 year, termed poor prognosis (PP) nodes. We combined pathway data with EHR data to calculate the median overall survival (OS) and proportion of patients with SICs, acute care utilization (hospitalizations and emergency department visits), and outpatient palliative care 6 months after treatment node navigation for all, PP, and nonpoor prognosis (nPP) nodes. SICs were identified using the EHR advanced care planning (ACP) tab.

RESULTS

There were 15,261 navigations for 10,203 patients (median age 66 years, 55% female, 85% White). The median OS was 13.8 months for all nodes, 7.8 months for PP nodes, and 21.0 months for nPP nodes. The ACP section of the EHR rate 6 months after navigation was 19.6% for PP nodes versus 11.0% for nPP nodes. There was substantial intragroup variability in OS and SIC rates among all nodes. SICs were recorded in the ACP tab for only 34.3% of decedents. Patients who navigated to PP nodes had higher levels of acute care utilization and palliative care encounters.

CONCLUSION

Treatment pathway data enabled identification of patient populations with poor prognoses, low SIC rates, and high acute care utilization.

Influence of palliative care policy on place of death for people with different cancer types: a nationwide' register study

This study investigated the impact of a national palliative care policy introduced in 2013. The hypothesis was that end-of-life and palliative care policy shape healthcare services, which in turn influence service utilisation and ultimately place of death for people dying from cancer. The aim was to identify longitudinal trends in place of death for people with cancer in Sweden. A population-level longitudinal trend in place of death study was performed, based on register data of all adults aged 18 or above with a cancer diagnosis as underlying cause of death in Sweden between 2013-2019. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. In addition to a more descriptive overview of place of death (hospital, home, nursing home, and other places), linear regression models were used to analyse trends in place of death and associated socio-demographic factors, and healthcare services and utilisation. Dying in hospital was most common (48.7%), followed by nursing home (25.6%) and own home (23.5%), and differed according to sex, age, marital status, type of cancer, healthcare regions, and utilising specialised palliative care services at death or not. From 2013 to 2019 the total number of home deaths increased from 21.8% to 24.7%, whereas hospital deaths decreased from 49.2% to 47.1%. For people residing in their own home, there was a downward trend for dying in hospital, while no trend was detected for people residing in nursing homes. The identified trend had cross-regional variations and inconsistencies. In conclusion, the hypothesis was not confirmed. The results point to inequity in palliative cancer care, and need for national governance strategies and improved integration of palliative care in national healthcare structures.

Awareness, information sources, and beliefs regarding palliative care in the general population in Japan: a nationwide cross-sectional survey (INFORM study 2023)

BACKGROUND

The diversification of information sources and changes in social structures necessitates updates on the state of public awareness of palliative care. Therefore, we clarified the status and determinants of awareness, information sources, and beliefs, regarding palliative care in Japan.

METHODS

This nationwide cross-sectional survey included 10 000 participants aged ≥20 years enrolled through random sampling using a two-stage stratification in 2023. We used a mailed self-administered questionnaire (INFORM Study 2023). The questionnaire items were selected (partially modified) from the Health Information National Trends Survey (USA) to ensure comparability, included palliative care awareness, information sources, and beliefs. Weighted logistic regression was conducted to explore the determinants of awareness.

RESULTS

Of the 3452 participants that responded (response rate: 35.3%), 65.2% had palliative care awareness. The weighted logistic regression analysis revealed that respondents less likely to have any palliative care awareness were younger, were male, had limited education history, had lower household income, and were non-Internet users. Of these, sex had the clear association (adjusted odds ratio for female vs. male: 3.20 [95% CI: 2.66-3.85]). Across all age groups, healthcare professionals (58.5%) and the Internet (30.5%) were the most trusted source of information. Younger participants frequently received information online. Most participants believed that palliative care was beneficial, although 82.0% associated it with death.

CONCLUSIONS

The Japanese population had a relatively high palliative care awareness, with the majority trusting information from healthcare professionals rather than the Internet. Further efforts are warranted to address barriers to receiving trustworthy palliative care information.

Effectiveness of Timely Implementation of Palliative Care on the Well-Being of Patients With Chronic Heart Failure: A Randomized Case-Control Study

Objectives: To date, there is a lack of consensus on the timely implementation of palliative care (PC) in patients with chronic heart failure (HF). We aimed to investigate the impact of primary PC intervention on chronic HF patients with different classes of cardiac function, and to determine a proper time point for the implementation of primary PC intervention. Methods: A consecutive series of 180 chronic HF patients with the New York Heart Association (NYHA) Cardiac function ranging from I to III were enrolled in this study. Patients with the same cardiac function class, they were randomized and equally assigned to the usual care (UC) group or to the PC intervention group. At the end of 24-week treatment, quality-of-life (QoL) measurements were evaluated. Left ventricular ejection fraction and N-terminal pro-B-type natriuretic peptide were measured for each group at baseline and the final follow-up, respectively. Results: Through the 6-month follow-up, patients randomized to the PC intervention group presented significantly better QoL and cardiac function as compared with patients randomized to the UC group alone. Subgroup analysis showed that for patients with NYHA class II or III, significantly improved cardiac function and QoL were observed in the PC intervention group as compared with the control group. As for patients with class I, no significant difference was found between the 2 groups. Conclusions: Palliative program can effectively improve the QoL and cardiac function of patients with chronic HF. Moreover, we provided evidence on timely referral of patients to PC intervention, which could be beneficial for patients with NYHA class II.

Early palliative care and overall survival in patients with metastatic upper gastrointestinal cancers (EPIC): a multicentre, open-label, randomised controlled phase 3 trial

Background

Early palliative care (EPC) leads to an improvement in quality of life and an unexpected survival benefit compared with oncological care for patients with metastatic lung cancer. The Early Palliative Integrated Care (EPIC) is aimed at examining whether EPC can improve overall survival in patients with metastatic upper gastrointestinal cancer.

Methods

We performed a multicentre, open-label, randomised phase-3 trial. Eligible patients were ≥18 years, had metastatic upper gastrointestinal cancer and a performance status of 0-2. Patients from 19 French centres were randomly assigned between 10/10/2016 and 17/12/2021 to receive EPC plus oncological care or standard oncological care (SOC) alone. EPC was provided by palliative care physicians and included five EPC visits scheduled every month, starting within 3 weeks after randomisation. The primary endpoint was overall survival, analysed by intention-to-treat. This study was registered at ClinicalTrials.gov (NCT02853474).

Findings

470 patients were randomised: 233 and 237 patients in the EPC and SOC groups, respectively. In the EPC group, 216/233 patients (92.7%) underwent ≥1EPC visit, with 159 EPC visits per protocol (68.2%). The median follow-up duration was 46 months. We did not observe any overall survival difference between the EPC (median = 7.0 months [95% confidence interval, 6.1-8.8]) and SOC groups (8.6 months [6.8-9.8]) (stratified hazard ratio = 1.04 [0.86-1.26], p = 0.68). No significant heterogeneity was found in primary tumour locations, performance status groups, sex, age groups, and inclusion periods.

Interpretation

Our findings suggested that receiving EPC did not improve the benefit of oncological care with regard to overall survival in patients with metastatic upper gastrointestinal cancer.

Funding

Programme Hospitalier de Recherche Clinique, Ligue Contre le Cancer, Conseil Régional du Nord-Pas-de-Calais.

The Validity of Patient-Reported Outcome Measures of Quality of Life in Palliative Care: A Systematic Review

Importance: A recent systematic review and meta-analysis found that palliative care was not associated with improvement in quality of life (QOL) in terminal noncancer illness. Among potential reasons for a null effect, it is unclear if patient-reported outcome measures (PROMs) measuring QOL were derived or validated among populations with advanced life-limiting illness (ALLI). Objective: To systematically review the derivation and validation of QOL PROMs from a recent meta-analysis of randomized controlled trials (RCT) of palliative care interventions in people with terminal noncancer illness. Evidence Review: EMBASE, MEDLINE, and PsycINFO were searched from inception to January 8, 2023 for primary validation studies of QOL PROMs in populations with ALLI, defined as adults with a progressive terminal condition and an estimated median survival of less than or equal to one year. The primary outcome was the proportion of PROMs that were derived or validated in ≥1 ALLI population. Findings: Twenty-one unique studies of derivation (n = 13) and validation (n = 11, 3 studies evaluated both) provided data on 9657 participants (mean age 63 years, 50% female) across 15 unique QOL PROMs and subscales. Among studies of validation, 9 were in people with cancer (n = 2289, n = 5 PROMs), 1 in neurodegenerative disease (n = 23, n = 1 PROM), and 1 with mixed diseases (n = 248, n = 1 PROM). Across 15 QOL PROMs and subscales, 47% (n = 7) were derived or validated in an ALLI population. The majority of these seven PROMs were exclusively derived or validated among people with cancer (57%, n = 4). QOL PROMs such as Quality of Life at End of Life, EuroQoL-5 Dimension 5-level, and 36-item Short Form Survey demonstrated validity in more than one terminal noncancer illness. Conclusions: Most QOL PROMs that measured the effect of palliative care on QOL in RCTs were neither derived nor validated in an ALLI population. These findings raise questions about the inferences that palliative care does not improve QOL among people with terminal noncancer illness.

Psychometric Properties of the Chinese Version of the Functional Assessment of Chronic Illness Therapy - Palliative Care (FACIT-Pal) in Patients With Advanced Cancer

CONTEXT

The Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) has been widely used in assessing the quality of life (QOL) of patients with life-limiting illness. However, the Chinese version of the FACIT-Pal has not been psychometrically validated yet.

OBJECTIVES

The purpose of this study was to psychometrically validate the FACIT-Pal in Chinese patients with advanced cancer.

METHODS

160 patients with advanced cancer in mainland China participated in this cross-sectional study. The scalability of the instrument was determined by the item-total correlations and the reliability was tested by examining the Cronbach's alpha coefficients. The construct and concurrent validity of the FACIT-Pal were also examined.

RESULTS

The item-total correlation coefficients ranged from 0.25 to 0.72 (P < .01). Cronbach's alpha coefficient of the Chinese version of the FACIT-Pal was 0.94, ranging from 0.78 to 0.89 for subscales. Confirmatory factor analysis (CFA) results provided support for the measurement structure of the 26-item Functional Assessment of Cancer Therapy-General (FACT-G). Exploratory factor analysis (EFA) of the 19-item palliative care subscale identified five factors accounting for 62.21% of the total variance. Total/subscale scores of the FACIT-Pal were positively correlated with that of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being 12 Item Scale (FACIT-Sp-12) (r = 0.338-0.811, P < .01), as well as with the Karnofsky Performance Scale (KPS) scores (r = 0.163-0.273, P < .05), except for the correlation between social/family well-being subscale score and KPS score.

CONCLUSION

The Chinese version of the FACIT-Pal demonstrates desirable psychometric properties for evaluating QOL in Chinese patients with advanced cancer.

Development of care quality indicators for palliative care in China: A modified Delphi method study

Objective

While there are limited studies addressing palliative care quality in China, the availability of an effective set of care quality indicators is scarce. This study aimed to develop a comprehensive set of quality indicators for palliative care in China.

Methods

Conducting a systematic literature search across databases and guideline websites from inception to October 2020, combined with qualitative interviews, we established a preliminary pool of indicators. Subsequently, two rounds of Delphi expert consultation surveys were administered to 19 multidisciplinary experts (specializing in clinical nursing/medicine, nursing/medicine management, and health care administration, as well as those engaged in teaching and research) from 12 provinces in Mainland China (three each from North, East, and South China, and four from Central China) via email from March to June 2021. The analytic hierarchy process was employed to determine indicator weights.

Results

Both rounds of expert consultation yielded a 100% positive coefficient, with expert authority coefficient values of 0.91 and 0.93, respectively. Kendall coefficient of concordance values for the two rounds were 0.148 and 0.253 (P < 0.001), indicating consensus among experts. Consequently, 71 quality indicators deemed important in the Chinese palliative care setting were identified, comprising 22 structure indicators, 35 process indicators, and 14 outcome indicators.

Conclusions

This study established an evidence-based set of quality indicators, addressing previously unmet needs and providing a novel approach to assessing and monitoring palliative care quality. Furthermore, ongoing refinement and integration with the evolving social context are warranted.

Understanding how shared decision-making approaches and patient aids influence patients with advanced cancer when deciding on palliative treatments and care: A realist review

BACKGROUND

Patients with advanced incurable cancer face difficult decisions about palliative treatment options towards their end of life. However, they are often not provided with the appropriate information and support that is needed to make informed decisions. This review aimed to identify contexts and mechanisms associated with communication tools, patient decision-aids and shared decision-making (SDM) approaches that influence patient outcomes.

METHODS

We used a realist review method to search for published studies of patients (adults > 18) with advanced cancer who were expected to make a decision about palliative treatment and/or supportive care in consultation with healthcare practitioners. We appraised and synthesised literature describing the contexts of (when and how) decision aids and SDM approaches are used, and how these contexts interact with mechanisms (resources and reasoning) which impact patient outcomes. Stakeholders including academics, palliative healthcare professionals (HCPs) and people with lived experience of supporting people with advanced incurable cancer contributed to identifying explanatory accounts. These accounts were documented, analysed and consolidated to contribute to the development of a programme theory.

RESULTS

From the 33 included papers, we consolidated findings into 20 explanatory accounts to develop a programme theory that explains key contexts and mechanisms that influence patient and SDM. Contexts include underlying patients' and HCPs' attitudes and approaches. These need to be understood in relation to key mechanisms, including presenting information in multiple formats and providing adequate time and opportunities to prepare for and revisit decisions. Contexts influenced mechanisms which then influence the levels of patient decisional satisfaction, conflict and regret.

CONCLUSIONS

Our programme theory highlights mechanisms that are important in supporting shared treatment decisions for advanced noncurative cancer. The findings are informative for developing and evaluating interventions to improve understanding and involvement in SDM for patients with advanced incurable cancer.

PATIENT AND PUBLIC CONTRIBUTION

We included patient and public involvement (PPI) representatives in four stakeholder meetings. PPI helped to define the scope of the review, identify their unique experiences and perspectives, synthesise their perspectives with our review findings, make decisions about which theories we included in our programme theory and develop recommendations for policy and practice and future research.

Supportive care needs and health-related quality of life in cancer patients receiving palliative care

Objective

Cancer patients receiving palliative care experience a variety of impairments in their quality of life (QoL), and have corresponding supportive care needs (SCNs). The aim of this study was to analyze the relationship between SCNs, satisfaction with QoL dimensions, and the perceived importance of these dimensions.

Method

A sample of 152 cancer patients receiving palliative care were included in this cross-sectional study. Eight dimensions of QoL were defined and assessed concerning SCNs, satisfaction, and subjective importance using a new assessment instrument with five-point scales (range 1-5) for each dimension.

Results

Among the eight specific domains examined, the greatest SCNs were observed for absence of pain (M = 3.18; SD = 1.29). The patients were least satisfied with their physical functioning (M = 2.60; SD = 0.84), and the dimension social relationships (M = 4.14; SD = 0.72) received the highest perceived importance ratings. The eight dimensions' SCNs scores were significantly correlated with each other (r between 0.29 and 0.79); the lowest correlations were found for social relationships. The correlations between the satisfaction scores and the SCNs differed from dimension to dimension, with coefficients between -0.32 (absence of pain) and - 0.57 (sleep quality).

Conclusion

The results show that detriments in QoL do not automatically indicate high levels of SCNs in those dimensions. Health care providers should consider both factors, QoL (as measured with QoL questionnaires) and subjectively expressed SCNs, to optimize their patients' care regimens.