Early Palliative Care For Patients Research Articles

Early palliative care and its impact on end of life care.

The impacts of early palliative care for patients with advanced cancer are well described. This has led to endorsement of early palliative care, alongside cancer treatment, by leading cancer organisations. The aim of this review is to consider how best to adopt and integrate the learning from studies of early palliative care into an effective, sustainable service that is offered as part of routine cancer care. 'Timely', 'targeted' and 'precision' approaches have been proposed to ensure that limited palliative care resources are available to those who are most likely to benefit. Triage and referral based on individual patients' needs has been shown to be both efficient and effective. Standardised referral criteria and the use of tools to assess complexity may support equitable service development. A specialist multidisciplinary approach is a common factor underpinning successful integration between palliative care and oncology but does not negate the importance patient-centred considerations such as advance care planning, which can be facilitated by non-specialist teams. The challenge is no longer whether early palliative care should be provided, but how. Evidence-based strategies about how best to implement early palliative care are needed to inform appropriate resourcing, funding, and delivery.

Telehealth vs In-Person Early Palliative Care for Patients With Advanced Lung Cancer

Numerous studies show that early palliative care improves quality of life and other key outcomes in patients with advanced cancer and their caregivers, although most lack access to this evidence-based model of care. To evaluate whether delivering early palliative care via secure video vs in-person visits has an equivalent effect on quality of life in patients with advanced non-small cell lung cancer (NSCLC). Randomized, multisite, comparative effectiveness trial from June 14, 2018, to May 4, 2023, at 22 US cancer centers among 1250 patients within 12 weeks of diagnosis of advanced NSCLC and 548 caregivers. Participants were randomized to meet with a specialty-trained palliative care clinician every 4 weeks either via video visit or in person in the outpatient clinic from the time of enrollment and throughout the course of disease. The video visit group had an initial in-person visit to establish rapport, followed by subsequent virtual visits. Equivalence of the effect of video visit vs in-person early palliative care on quality of life at week 24 per the Functional Assessment of Cancer Therapy-Lung questionnaire (equivalence margin of ±4 points; score range: 0-136, with higher scores indicating better quality of life). Participants completed study questionnaires at enrollment and at weeks 12, 24, 36, and 48. By 24 weeks, participants (mean age, 65.5 years; 54.0% women; 82.7% White) had a mean of 4.7 (video) and 4.9 (in-person) early palliative care encounters. Patient-reported quality-of-life scores were equivalent between groups (video mean, 99.7 vs in-person mean, 97.7; difference, 2.0 [90% CI, 0.1-3.9]; P = .04 for equivalence). Rate of caregiver participation in visits was lower for video vs in-person early palliative care (36.6% vs 49.7%; P < .001). Study groups did not differ in caregiver quality of life, patient coping, or patient and caregiver satisfaction with care, mood symptoms, or prognostic perceptions. The delivery of early palliative care virtually vs in person demonstrated equivalent effects on quality of life in patients with advanced NSCLC, underscoring the considerable potential for improving access to this evidence-based care model through telehealth delivery. ClinicalTrials.gov Identifier: NCT03375489.

Clinician perspectives on delivering primary and specialty palliative care in community oncology practices.

Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities. Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment. Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%). Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.

Qualitative evaluation of motives for acceptance or refusal of early palliative care in patients included in early-phase clinical trials in a French comprehensive cancer center: the PALPHA study.

The integration of palliative care (PC) into oncological management is recommended well before the end of life. It improves quality of life and symptom control and reduces the aggressiveness of end-of-life care. However, its appropriate timing is still debated. Entry into an early-phase clinical trial (ECT) represents hopes for the patient when standard treatments have failed. It is an opportune moment to integrate PC to preserve the patient's general health status. The objective of this study was to evaluate the motives for acceptance or refusal of early PC management in patients included in an ECT. Patients eligible to enter an ECT were identified and concomitant PC was proposed. All patients received exploratory interviews conducted by a researcher. Their contents were analyzed in a double-blind thematic analysis with a self-determination model. Motives for acceptance (PC acceptors: n = 27) were both intrinsic (e.g., pain relief, psychological support, anticipation of the future) and extrinsic (e.g., trust in the medical profession, for a relative, to support the advance of research). Motives for refusal (PC refusers: n = 3) were solely intrinsic (e.g., PC associated with death, negative representation of psychological support, no need for additional care, claim of independence). The motives of acceptors and refusers are not internalized in the same way and call for different autonomy needs. Acceptors and refusers are influenced by opposite representations of PC and a different perception of mixed management.

Effectiveness of early palliative care in patients with head and neck cancer in Taiwan.

Early palliative care (EPC) benefits some cancers, but its clinical outcomes differ depending on patients' racial and ethnic disparities, and customs. To determine whether EPC improves symptoms, emotional distress, and quality of life among Taiwanese patients with early or advanced-stage head and neck cancer (HNC). Based on participants' pathological stages, they were categorized as having early and advanced-stage HNC. Those willing and unwilling to undergo EPC were assigned to the EPC and standard groups, respectively. Their daily cancer-related symptoms were assessed using the Distress Thermometer (DT) and MD Anderson Symptom Inventory (MDASI), whose scores' concurrent validity was evaluated using the European Organization for Research and Treatment of Core Quality of Life (EORTC-QLQ-C30) and Head and Neck 35 (EORTC-QLQ-H&N35) questionnaires. Patients (n = 93) diagnosed with HNC at Taiwan's Chia-Yi Christian Hospital from November 2020 to October 2022 were recruited. The patients voluntarily split into two groups: EPC groups and standard groups (23 and 11 in early-stage; 46 and 13 in advanced-stage, respectively). DT assessment showed significant emotional distress improvements for all patients with HNC who received EPC. The EORTC-QLQ-C30 questionnaire indicated that, compared to standard interventions, EPC groups significantly improved the quality of life and some symptoms for both early and advanced-stage HNC patients. However, the EORTC-QLQ-H&N35 questionnaire found no significant difference between the two groups. Furthermore, advanced-stage patients' anticancer treatment completion rates with EPC and standard interventions were 95.35% and 75%, respectively. EPC improves symptoms, emotional distress, quality of life, and treatment completion rates in Taiwanese patients with early or advanced-stage HNC. Nonetheless, further extensive clinical studies are required for validation.

Outpatient Embedded Palliative Care for Patients with Advanced Thoracic Malignancy: A Retrospective Cohort Study.

Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.

Early Palliative Care Involvement for Acute Myeloid Leukemia

Advanced practice providers are relied on to recognize patients’ need for palliative care, which has supported improved quality of life and reduced aggressive treatments near the end of life in patients with solid tumors. Hematological malignancies have similar disease trajectories and symptom burdens as solid tumors, yet palliative care is underutilized in acute myeloid leukemia, which employs aggressive therapies for management. This systematic literature review examines the 3 studies of early palliative care in patients newly diagnosed with acute myeloid leukemia. There is a strong association between early palliative care and decreased chemotherapy use and decreased intensive care unit admissions at the end of life.

1593MO Combined early palliative care in patients with non small cell lung cancer: A randomised controlled trial in Chongqing, China

1593MO Combined early palliative care in patients with non small cell lung cancer: A randomised controlled trial in Chongqing, China

Early palliative care for patients with metastatic upper gastrointestinal cancers: A survival analysis of the EPIC randomized trial.

12102 Background: In 2010, Temel et al. reported that early palliative care (PC) (EPC) led to significant improvements in quality of life and, surprisingly, on overall survival (OS) over standard oncologic care (SOC) for patients (pts) with metastatic lung cancer. The American Society of Clinical Oncology then recommended “combined standard oncology care and PC earlier in the course of the illness for any patient with metastatic cancer”. The median OS of unselected pts with metastatic upper gastrointestinal cancers (mUGIC) does not exceed 11 m. Whether EPC benefits also apply to pts with mUGIC was unknown. Methods: EPIC (NCT02853474) is a randomized 1:1, open-label, multicenter, phase 3 trial aiming to evaluate the OS benefit of EPC compared to SOC in pts with mUGIC (esophageal, HER2 negative esogastric junctional and gastric, pancreatic, and biliary tract cancers), with ECOG PS ≤ 2, to be treated by first-line chemotherapy (CT). EPC included 5 PC visits scheduled every month, starting within 3 weeks of randomization. Pts allocated to SOC could access to PC visits upon request in case of worsening of health status. The primary endpoint was OS. Other endpoints included quality of life, and depression and anxiety assessment. A total of 381 deaths was required (1 year OS 40% vs. 50.3%, HR = 0.75, 2-sided alpha 5%, 80% power). Randomization was balanced on center, ECOG-PS and tumor site. Results: 473 pts were randomized from 10/2016 to 12/2021 in 19 French centers. Modified intention-to-treat population was 470. Median age = 67.5 (range, 24-90); 273 males; tumor site: esophagus 39, esogastric 48, pancreas 297, biliary tract 86; ECOG PS 0/1/2: 104/278/88. 74/233 pts (32%) in EPC arm had less than the planned EPC visits (major deviation): 3 related to treatment, 17 due to pt decision, 45 due to the clinical team decision, 2 other reasons, 7 unknown. 57/237 pts in the SOC arm got at least 1 PC visit, including 3 major deviation (performed &lt; 6 months of treatment and set for a reason other than worsening of the health condition). Median follow-up was 46 m, and 35/470 pts were still alive. We did not observe any OS difference between arms (EPC, median OS: 7.0 m [95%CI: 6.1-8.8 m] and 1-year OS: 33%; SOC, median OS: 8.6 m [6.8-9.8 m] and 1-year OS: 32%; stratified HR = 1.04 [0.86-1.26], p = 0.68). Results were similar on the per-protocol dataset (excluding major violations). Results were homogeneous across the different tumor locations, and ECOG-PS groups. Conclusions: OS was lower than expected in both arms, which may reflect the difference between pharma-sponsored and academic trials with less stringent exclusion criteria. Also, only 68% of the pts got the planned number of PC visits in the experimental arm. EPC was not found to prolong OS over SOC in pts with mUGIC in this EPIC trial. Clinical trial information: NCT02853474 .

61P Early palliative care in patients with non-small cell lung cancer: A 36-weeks randomised controlled trial in China

61P Early palliative care in patients with non-small cell lung cancer: A 36-weeks randomised controlled trial in China

Personalized Palliative and Survivorship Care for Patients With Metastatic Cancer Treated With Radiation Therapy.

While the benefits of early palliative care for patients with metastatic cancer are well established, cancer survivorship remains inadequately integrated into the care of patients with distant metastases. Moreover, the optimal model of care delivery is poorly defined. A prognostic model previously developed and validated at Good Samaritan University Hospital identified four groups of patients with metastatic solid tumor malignancy having very favorable, favorable, standard or unfavorable prognoses with median survival of 31, 14, 4 and 1 month, respectively. This framework holds promise for the personalized delivery of supportive, palliative and survivorship care services in the context of radiation therapy. We review the published literature providing the rationale for a novel multidisciplinary care model where the radiation oncology Clinical Nurse Specialist identifies and coordinates interventions to address unmet physical and emotional issues faced by survivors with metastatic cancer with the goal of improving quality of life and overall survival.

Abstract P5-07-11: Referral patterns of metastatic breast cancer patients to Palliative Care team at a Cancer Center in Brazil

Abstract Introduction: Breast cancer is the most common cancer in women and the leading cause of cancer- related death in women worldwide. The high prevalence of physical and psychosocial suffering among breast cancer patients and their families justifies the need for an early interdisciplinary approach by a palliative care team. The effectiveness of early palliative care for patients with advanced cancer has been demonstrated in many studies. Early referral to outpatient palliative care services improves symptom control, reduces suffering and improves quality of end-of-life care. Aim: Evaluation of referral patterns of metastatic breast cancer patients to the outpatient embedded palliative care team. Methods: We retrospectively retrieved data from electronic medical records of patients who were treated at a private community oncology practice in Brazil who died from metastatic breast cancer during the years of 2018 until 2021.We evaluated the patient’s follow-up time by the palliative care team (follow-up &amp;gt; 12 weeks or not) and the year of referral to the service (pre-2020 vs 2020 and later) associated to the service referral type: Late referral (more than 8 weeks of metastatic diagnosis) or early referral. Each group was followed-up by cancer physicians and after referral was also followed-up by a palliative care multidisciplinary team who regularly evaluated cancer patients during their treatments at outpatient setting. During COVID-19 pandemic, some patients were evaluated by telemedicine appointments. We performed univariate comparisons analysis by Fisher’s Exact Test. p &amp;lt; 0.1 was deemed as statistically significant. Results: Of the 211 patients whose data were assessed, 99 patients were referred to Palliative Care team before 2020 and 112 patients after 2020. 13.1% of patients pre-2020 received early palliative care versus 33.9% of patients in the post-2020 referral group, resulting in a 3.37-fold odds of an early palliative care integration after 2020 (OR 3.37, CI95: 1.61 – 7.45; p&amp;lt; 0.001). Overall, 30.4% of longer follow-up patients were an early referral versus 19.3% of the shorter follow-up, resulting in an 82% greater chance (OR 1.82, CI: 0.92-3.63; p&amp;lt; 0.1) of prolonged assistance with early referral. Conclusions: In this analysis, early palliative care integration for patients with metastatic breast cancer has increased after 2019 despite the COVID-19 pandemic, leading to prolonged time of accompaniment by the multidisciplinary palliative care team. This suggests that even in the face of this challenging moment, a mature and consolidated service is offered by the palliative care team. Also, according to previous data in literature, prematurely integration show signs of correlation with better quality of life and death, supporting early palliative care for this group of patients. However, further work is needed to examine the effect of this care model in our cohort. Table: Palliative Care Assistance by time-referral Citation Format: Sarah A. GOMES, Danielle N. Silva, Thais Passarini, Julia A. Petrocchi, Marcela M. de Paula, Julia S. de sá, MatheusCosta e Silva, Tatiana A. Coelho, Rafaella L. de Aquino, Flávia S. Sorice, Patrícia Santos, Daniela Madureira, Erika Martins, Heloísa Cruz, Bruno L. Ferrari. Referral patterns of metastatic breast cancer patients to Palliative Care team at a Cancer Center in Brazil [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-07-11.

Abstract ED5-1: Early palliative care

Abstract This education session will review early palliative care in oncology and applications in patients with metastatic breast cancer. This presentation provides an overview of the field of research in early palliative care for patients with advanced solid tumors and discusses considerations specific to breast cancer. The speaker will present current challenges that we face in integrating palliative care into our practice and future areas for clinical innovation and research in palliative care. The speaker will present practical tips for how breast oncologists can deliver early palliative care to patients. The speaker will present guiding principles on when to consider referral to interdisciplinary, specialty palliative care. Citation Format: Tara Kaufmann. Early palliative care [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr ED5-1.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team.

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care. This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task. An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care. This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

Quality of Life and Depression Symptoms in a Cross-Section of Patients with Advanced Lung Cancer Before and During the Coronavirus Disease 2019 (COVID-19) Pandemic (RP322)

Outcomes1. Evaluate the effect of the COVID-19 pandemic on quality of life (QOL) and depression symptoms among patients recently diagnosed with lung cancer2. Apply the results of these analyses to identify patients with newly diagnosed cancer at risk of worse QOL or psychological symptoms during a pandemic or other major crisis in order to allocate supportive care resourcesImportanceAdults with advanced lung cancer commonly experience reduced quality of life (QOL) and psychological symptoms at diagnosis. The COVID-19 pandemic has caused universal distress, but whether it has worsened the experience of patients recently diagnosed with cancer is unclear.Objective(s)This study evaluates associations between the COVID-19 pandemic and QOL and depression among adults with newly diagnosed advanced lung cancer.Method(s)We analyzed baseline data from two randomized controlled trials of early palliative care for patients recently diagnosed with advanced lung cancer (n = 856) to compare QOL and depression among those who enrolled during the COVID-19 pandemic (March 2020 to January 2021) relative to those enrolled prior to the pandemic (March 2018 to January 2019). We used analysis of covariance with the COVID-19 timeframe as the independent variable and QOL (using the Functional Assessment of Cancer Therapy–General score) and depression (using the Patient Health Questionnaire–9 score) as dependent variables, adjusting for age, gender, relationship status, performance status, lung cancer symptoms, and time since diagnosis. We also tested for an interaction between the COVID-19 timeframe and relationship status.IV. ResultsThere was no difference in QOL (adjusted mean difference –1.78; p = 0.137) or depression (0.06; p = 0.889) between patients enrolled before COVID-19 relative to those enrolled during COVID-19 in adjusted analyses. Relationship status moderated the effect of the COVID-19 timeframe on QOL; unmarried patients enrolled during the pandemic experienced significantly worse QOL relative to unmarried patients enrolled pre-pandemic (adjusted mean difference: –5.25; p = 0.011).V. Conclusion(s)The COVID-19 pandemic did not further reduce QOL or increase depression overall for patients recently diagnosed with lung cancer, which suggests that QOL reflects other factors, such as symptoms, that do not vary with this external crisis. Reduced QOL among unmarried patients points to increased supportive care needs.VI. ImpactThese results emphasize the profound effect of a new diagnosis of cancer on QOL and highlight the need for psychosocial evaluation and supportive care for all patients.

Reasons for acceptance and refusal of early palliative care in patients included in early-phase clinical trials in a regional comprehensive cancer centre in France: protocol for a qualitative study

IntroductionA few studies have highlighted the potential synergy between early palliative care and inclusion in an early-phase clinical trial that may improve quality of life, reduce symptoms of exhaustion related...

Early Palliative Care in Patients With Non-Small-Cell Lung Cancer: A Randomized Controlled Trial in Southwest China.

Effective interventions to improve prognosis in non-small-cell lung cancer (NSCLC) are urgently needed. We assessed the effect of the early integration of interdisciplinary palliative care (based on WARM model) for patients with NSCLC on the quality of life (QoL), psychological state, cancer pain and nutritional status. In this randomized controlled trial, 120 newly diagnosed NSCLC patients were enrolled and randomly assigned (1:1) to the combined early palliative care (CEPC) group integrated with standard oncologic care or standard oncological care (SC) group. QoL and psychological state were assessed at baseline and at 24weeks by Functional Assessment of Cancer Therapy-Lung (FACT-L) scale, the Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire-9 (PHQ-9), respectively. Cancer nutritional and pain status were assessed with the use of the Patient-Generated Subjective Global Assessment (PG-SGA) and Numerical Rating Scale (NRS), respectively. The primary outcome was the change in the quality of life, psychological state and nutritional status at 24weeks. Analysis was by intention to treat. 120 patients were enrolled: 60 in CEPC group (38 completed) and 60 in the SC group (32 completed). CEPC group had a better QoL than SC group (P < .05). In addition, fewer patients in the CEPC group than in the SC group had depressive (P = .005) symptoms. Furthermore, patients in CEPC group had a better nutritional status than SC group (P = .001). Among patients with non-small-cell lung cancer, early palliative care led to significant improvements in quality of life, psychological state and nutritional status.

Comparative Analysis of Patient Outcomes while Receiving Early Palliative Care in Patients with Cancer Using ESAS Score

Comparative Analysis of Patient Outcomes while Receiving Early Palliative Care in Patients with Cancer Using ESAS Score

Early Palliative Care Is Associated With Reduced Emergency Department Utilization in Pancreatic Cancer.

Most patients with pancreatic cancer have high symptom burden and poor outcomes. Palliative care (PC) can improve the quality of care through expert symptom management, although the optimal timing of PC referral is still poorly understood. We aimed to assess the association of early PC on health care utilization and charges of care for pancreatic cancer patients. We selected patients with pancreatic cancer diagnosed between 2000 and 2009 who received at least 1 PC encounter using the Surveillance, Epidemiology, and End Results (SEER)-Medicare. Patients who had unknown follow-up were excluded. We defined "early PC" if the patients received PC within 30 days of diagnosis. A total of 3166 patients had a PC encounter; 28% had an early PC. Patients receiving early PC were more likely to be female and have older age compared with patients receiving late PC (P<0.001). Patients receiving early PC had fewer emergency department (ED) visits (2.6 vs. 3.0 visits, P=0.004) and lower total charges of ED care ($3158 vs. $3981, P<0.001) compared with patients receiving late PC. Patients receiving early PC also had lower intensive care unit admissions (0.82 vs. 0.98 visits, P=0.006) and total charges of intensive care unit care ($14,466 vs. $18,687, P=0.01). On multivariable analysis, patients receiving early PC were significantly associated with fewer ED visits (P=0.007) and lower charges of ED care (P=0.018) for all patients. Early PC referrals were associated with lower ED visits and ED-related charges. Our findings support oncology society guideline recommendations for early PC in patients with advanced malignancies such as pancreatic cancer.

Timing of Palliative Care Referral Before and After Evidence from Trials Supporting Early Palliative Care.

Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence. Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral. Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites. Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care. Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.