Integration of Palliative and Oncology Care in patients with lung and other thoracic cancer: referral criteria and clinical care pathways

Abstract

Background. Recent evidences showed that early integration of palliative care in oncology have a positive impact on patients’ quality of life, quality of care and costs. However there is no consensus on outpatient referral criteria. Based on the experience of the collaboration between the Palliative care Outpatient Clinic (POC) and the Thoracic Medical Oncology outpatient Clinic (TMOC) of the Fondazione IRCCS Istituto Nazionale dei Tumori of Milan, the aim of this study was to identify timing and factors associated to POC referral by the oncologist, and to describe the subsequent clinical care pathway of these patients. Material (patients) and methods. This observational retrospective study included all patients with lung cancer seen for the first time at TMOC between Jan. 01, 2014 and Dec. 31, 2014. Patients were followed-up till death or till Dec. 31, 2015. Clinical and demographic patients’ data were collected from the electronic patient records form. Univariate and multivariate Cox regression models were used to evaluate the association between time to POC referral and performance status, disease stage and presence of symptoms at inclusion. Results are reported as percentages, interquartile range (IQR), hazard ratios (HRs) and 95% confidence intervals (95%CI). Results. 229 patients were eligible for the study. 98 of them (43%; 95% IC 36%-49%) were referred to the POC with a median time interval of referral of 30 days (IQR 4-188 days). 80/98 patients continued to receive anticancer therapy and palliative care simultaneously. Univariable analysis showed that HR of being referred to POC is significantly higher for patients with worse performance status (HR = 4.5), more advanced disease stage (HR = 3.1), and presence of pain (HR = 4.9), dyspnea (HR = 2.5) and cough (HR = 2.2). The multivariable model confirmed independent prognostic value for ECOG PS, disease stage and pain. On Dec. 31, 2015, 25/98 patients were still alive, 65/98 had died and 8 patients were lost at follow up. Among patients who died, 19 (29%) were admitted to the hospital in the last 30 days of life, 56 (86%) did not receive chemotherapy in the last 30 days of life, 40 (61%) died with hospice or home care service. Conclusions. Our results suggest to consider symptom burden, ECOG PS, disease stage among the screening criteria for referral to palliative care in patients with lung cancer.