Early Palliative Care Intervention Research Articles

African American Heart Failure Patients’ Perspective on Palliative Care in the Outpatient Setting

Heart failure is a progressive, incurable disease that limits both physical and psychosocial qualities of life. Palliative care is recommended to be used in conjunction with heart failure treatment guidelines to optimize patient care throughout the disease trajectory. The purpose of this study was to explore, from the patient perspective, the understanding of palliative care in African American heart failure patients in an ambulatory care setting. A qualitative, pilot study was conducted using semistructured interviews of 13 African American heart failure patients. Data were analyzed and verified using qualitative research techniques. Overall, none of the participants had heard of palliative care prior to the interview. After an explanation of palliative care was provided, 10 of 13 (77%) felt having palliative care involved in their heart failure treatment would be beneficial. Three themes emerged: (1) improved quality of life, (2) need for strong patient-provider relationships, and (3) need for ongoing education. Early intervention of palliative care in heart failure treatment will provide further support and relief of symptom burden. Participants expressed a need for strong patient-provider relationships and to have ongoing education regarding disease trajectory. Further research is needed to evaluate early palliative care intervention, patient satisfaction, and quality-of-life outcomes.

Characteristics and outcomes of persons with advanced cancer associated with having a family caregiver: A classification tree analysis.

29 Background: Little is known about the impact that having a family caregiver (FCG) has on individuals with advanced cancer. We examined patient characteristics and outcomes most associated with having versus not having a primary FCG. Methods: Secondary data analysis of a randomized controlled trial of an early palliative care intervention (Project ENABLE [Educate, Nuture, Advise, Before Life Ends]) for patients with advanced cancer and their primary FCGs (10/2010-9/2013). Sociodemographic and patient reported outcomes data were abstracted from the baseline questionnaires of 122 patients who enrolled with FCG and 85 patients who enrolled without a FCG. Sociodemographic variables included age, gender, education, race, social support (MSPSS: Multidimensional Scale of Perceived Social Support, score range: 12-84), and Karnofsky Functional status. Patient reported outcomes included symptom impact (QUAL-E Symptom Impact, score range: 4-20), quality of life (QOL) (Functional Assessment of Chronic Illness Therapy-Palliative Care, score range: 0-184), depression (Center for Epidemiological Studies-Depression Scale, score range: 0-60), perceived quality of care (Patient Assessment of Chronic Illness Care, score range: 20-100), and hospital days and emergency department visits in the past 3 months. Structured tree analysis was used to identify a set of variables strongly associated with the presence or lack of a FCG. Results: In the final model, for patients with MSPSS scores <52.5 (N=12), none had a FCG. For male patients with MSPSS scores >52.5 (N=105), 73% (N=77) had a FCG. For female patients with MSPSS scores >77.5 (N=29), 69% (N=20) had a FCG. For female patients with MSPSS scores <77.5 and QOL scores >126.1 (N=25), 20% (N=5) had a FCG. For female patients with MSPSS scores <77.5, QOL scores <126, and depression scores >26 (N=10), 20% (N=2) had a FCG. For female patients with MSPSS scores <77.5, QOL scores <126, and depression scores <26 (N=26), 77% (N=20) had a FCG. Conclusions: The final model suggests that having a FCG is highly associated with having high levels of perceived social support, being male, and lower levels of depression despite having lower QOL.

Patients’ and caregivers’ views on the timing and benefits of early palliative care: A qualitative study.

157 Background: Early palliative care referral can improve quality of life and satisfaction with care, and is increasingly encouraged. However, little is known about patients’ and caregivers’ attitudes towards early referral. We conducted qualitative interviews seeking the opinions of advanced cancer patients (who had been randomized to an early palliative care intervention) and their caregivers, to determine whether they perceived a benefit, and if so in which domains. Methods: We recruited participants from medical oncology clinics at a comprehensive cancer centre, following completion of a randomized controlled trial comparing early palliative care referral with standard oncology care. Selective sampling was employed to ensure equivalent numbers of participants based on study arm, age, gender, high vs. low quality of life scores, and high vs. low satisfaction with care. A grounded theory approach was used to explore emerging themes. Results: Twenty-six patients and 14 caregivers completed interviews. Several benefits of early referral were noted. These included: prompt attention to symptom needs; timely, sensitive information about prognosis and end-of-life care options; and destigmatization of palliative care through routine referral. Although some participants did not feel they currently needed palliative care, they did feel comforted that early referral had provided them with a “safety net” that could quickly be put into place if they required future support. Conclusions: Early referral was perceived as useful in several domains, including immediate symptom control, and preparation for the future.

Abstract 13: Cost effectiveness of early palliative care intervention in recurrent platinum resistant ovarian cancer

Abstract 13: Cost effectiveness of early palliative care intervention in recurrent platinum resistant ovarian cancer

Cost-effectiveness of early palliative care intervention in recurrent platinum-resistant ovarian cancer

ObjectiveTo determine if early palliative care intervention in patients with recurrent, platinum-resistant ovarian cancer is potentially cost saving or cost-effective. MethodsA decision model with a 6month time horizon evaluated routine care versus routine care plus early referral to a palliative medicine specialist (EPC) for recurrent platinum-resistant ovarian cancer. Model parameters included rates of inpatient admissions, emergency department (ED) visits, chemotherapy administration, and quality of life (QOL). From published ovarian cancer data, we assumed baseline rates over the final 6months: hospitalization 70%, chemotherapy 60%, and ED visit 30%. Published data from a randomized trial evaluating EPC in metastatic lung cancer were used to model odds ratios (ORs) for potential reductions in hospitalization (OR 0.69), chemotherapy (OR 0.77), and emergency department care (OR 0.74) and improvement in QOL (OR 1.07). The costs of hospitalization, ED visit, chemotherapy, and EPC were based on published data. Ranges were used for sensitivity analysis. Effectiveness was quantified in quality adjusted life years (QALYs); survival was assumed equivalent between strategies. ResultsEPC was associated with a cost savings of $1285 per patient over routine care. In sensitivity analysis incorporating QOL, EPC was either dominant or cost-effective, with an incremental cost-effectiveness ratio (ICER) <$50,000/QALY, unless the cost of outpatient EPC exceeded $2400. Assuming no clinical benefit other than QOL (no change in chemotherapy administration, hospitalizations or ED visits), EPC remained highly cost-effective with ICER $37,440/QALY. ConclusionEarly palliative care intervention has the potential to reduce costs associated with end of life care in patients with ovarian cancer.

Cost-effectiveness of early palliative care intervention in recurrent plati- num-resistant ovarian cancer

Objective: Early palliative care intervention has been shown to reduce hospital admissions, emergency department (ED) visits, and chemotherapy administration in the last 30days of life in patients with metastatic non-small cell lung cancer. Platinum-resistant ovarian cancer and metastatic non-small cell lung cancer share an aggressive clinical course. The purpose of our study was to determine if early palliative care intervention (EPC) in patients with recurrent, platinum-resistant ovarian cancer has the potential to be cost-saving or cost-effective.

WS7-3 - Palliative Care Improve the Prognosis of Cancer Patients

ABSTRACT Purpose According to the World Health Organization (WHO), palliative care-targeted patients whose disease is not responsive to curative treatment. One sentence of ‘Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, and such as chemotherapy or radiation therapy’ was added WHO's definition of palliative care in 2002. Early palliative care intervention is necessary for advanced cancer patients. One report shows that early palliative care intervention to metastatic non-small-cell lung cancer patients improved their prognosis. There is a possibility that the cooperation of active anti-cancer treatment and early palliative care intervention improves patient's prognosis. We made a comparative study of inpatients and outpatients of advanced cancer to clarify the appropriate time for palliative care intervention. Subjects and methods Two hundred one cases that had died in our department over a period of four years were divided into two groups of inpatients who experienced outpatient's service for less than 6 days (64 patients) and outpatients who experienced outpatient's service for more than 6 days (137 patients). Overall survival (OS), duration of chemotherapy and post-progression survival (PPS) in retrospect through analysis of medical records were examined respectively. Results OS of the outpatient group was longer than the inpatient group in all cases (19.0 months versus 6.5 months, P Conclusion In advanced non-small-cell lung cancer with anti-cancer treatment, it was suggested that the intervention of early palliative care to outpatients lead to an improvement of their prognosis.

Cluster-randomized trial of early palliative care for patients with metastatic cancer.

9003 Background: Patients with metastatic cancer have compromised quality of life (QOL), which tends to worsen towards the end of life. We conducted a cluster-randomized trial of early versus routine palliative care in patients with metastatic cancer, to assess impact on QOL, symptom control and satisfaction with care. Methods: Twenty-four medical oncology clinics were randomized, stratified by tumour site (4 lung clinics, 8 gastrointestinal, 4 genito-urinary, 6 breast, 2 gynecological), to intervention and follow-up (at least monthly) by a palliative care team, or to routine cancer care. Eligible patients had ECOG performance status 0-2 and a clinical prognosis of 6 months to 2 years. Patients completed measures of QOL (FACIT-Sp, including physical, social, emotional, functional and spiritual well-being; range 0-156, with higher scores indicating better QOL), symptom severity (Edmonton Symptom Assessment System; range 0-90, with higher scores indicating worse symptom severity), and satisfaction with care (FAMCARE-P16; score range 16-80) at baseline and monthly for 4 months. The primary outcome was the change in FACIT-Sp at 3 months. The planned sample size was 225 patients per arm, assuming 80% power and a 2-sided significance level of 0.05. Results: From December 2006 to September 2010, 461 patients completed baseline measures (228 intervention, 233 control); 442 patients completed at least one follow-up assessment (mean patients/cluster 18.8±11.6 control, 18.1±12.6 intervention). At 3 months, patients in the intervention group had marginally improved QOL (mean change in intervention vs. control, 1.6±14.5 vs. -2.0±13.6, p=0.07) but not symptom severity (0.1±16.9 vs. 2.1±13.9, p=0.34). At 4 months the change in QOL was more marked (2.5±15.5 vs. -4.0±14.2, p=0.008) and symptom severity was marginally better (-1.3±16.0 vs. 3.2±13.9, p=0.05). Improvement in satisfaction with care was evident at one month (p=0.001) and remained significant at both 3 months (2.3±9.1 vs.-1.8±8.2, p=0.001) and 4 months (3.7±8.6 vs. -2.4±8.3, p&lt;0.001). Conclusions: In patients with metastatic cancer, early palliative care intervention immediately improved satisfaction with care, while QOL and symptom control improved later.

A Nurse Practitioner Directed Intervention Improves the Quality of Life of Patients with Metastatic Cancer: Results of a Randomized Pilot Study

There is a paucity of randomized studies evaluating the value of palliative interventions on a prospective basis in newly diagnosed oncology patients. We sought to prospectively evaluate quality of life (QoL) outcomes in advanced cancer patients who received discussion-based palliative care interventions from an advanced registered nurse practitioner (ARNP) integrated into the oncology team, and compare these outcomes with a control population. Patients with metastatic cancer were randomized to standard care or an ARNP-directed intervention that included discussions of the benefits of hospice, discussions on living wills and advanced directives (Five Wishes document) along with an assessment of QoL. Relevant endpoints included change from baseline QoL and improvement in hospice knowledge. From November 13, 2008, through July 28, 2009, 26 patients were accrued at the Mayo Clinic in Jacksonville, Florida. The study closed early due to published data demonstrating the benefits of early palliative care interventions in the management of metastatic cancer patients. Statistically significant improvements from baseline were noted in emotional and mental QoL assessments in the intervention group that were not seen in the control group. Patients found it useful to have the living will and Five Wishes documents offered as part of the ARNP intervention. An ARNP-directed intervention that explains the benefits of hospice and addresses advanced directives early in the course of metastatic cancer patients' treatment, is well received by the patients and their relatives and leads to measurable improvement in the patient's emotional and mental QoL.

Anxiety and depression disorders in cancer patients: incidence, diagnosis and therapy

Psycho-oncologist research in recent years has focused on assessment of distress and mental disorders in cancer patients. Primary objective has been the implementation of individually tailored psychosocial support during routine medical care. This review shows that based on validly structured clinical interviews, 30–40% of the studied patient population had a mental disorder in accordance with the updated Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Most common diagnoses were depression, adjustment and anxiety disorders. Risk factors included among others younger age, previous history of mental disorders and lack of social support. Screening instruments are useful, easy to complete and allow early detection of high distress in patients, enabling appropriate interventions in affected patients. Established methods in psycho-oncology are cognitive behavioural therapy, psycho-educational groups and relaxation trainings. A positive influence of early palliative care intervention on cancer patients' mood has been shown. Adequate resources in acute and outpatient routine care shall be offered.

Pain and Palliative Care Pharmacotherapy Literature Summaries and Analyses

ABSTRACTTimely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Symptoms, interventions, and treatment-related adverse events addressed in this issue are optimizing buprenorphine antinociception with the addition of naltrexone; reliably assessing the internal state of persons with cognitive impairment, for the purpose of measuring perception of their sense of purpose; improving understanding of prognosis over time by means of early palliative care intervention in patients with non-small cell lung cancer (NSCLC); and examining reasons for cancer patients’ emergency department (ED) visits and outcomes of the visits.

Pilot Study of Palliative Care Consultation in Patients with Advanced Heart Failure Referred for Cardiac Transplantation

Heart failure (HF) in its chronic form is an irreversible and progressive disease. Palliative care (PC) interventions have traditionally been focused on patients with advanced cancer. We performed a pilot study to assess the feasibility of implementing the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for early PC intervention in patients with advanced HF who were seeking or received potentially curative therapies. Twenty consecutive patients with advanced HF referred to PC from the heart transplant service with stage D, New York Heart Association (NYHA) class III-IV symptoms were analyzed retrospectively in a tertiary care setting. Data were reviewed to assess the clinical impact of PC intervention. Feedback was obtained to assess satisfaction of the patients, their families, and the health care professionals. An independent assessment of the impact of the PC service in the care of each patient was performed by a cardiologist and PC physician by use of a scoring system. Twenty consecutive patients with HF were analyzed. PC consult was obtained for a variety of reasons. All patients complained of a high symptom burden. PC consultation resulted in a decrease in the use of opioids and increased patient satisfaction. Patients and their family members generally reported improved holistic care, continuity of care, more focused goals of care, and improved planning of treatment courses. The nonstandardized scoring system used to determine the impact of the PC service showed an average of moderate to significant impact when assessed by both a cardiologist and a PC physician. PC consultation appears to be beneficial in the treatment and quality of life of advanced HF patients, independent of their prognosis. This pilot study demonstrated feasibility and sufficient evidence of clinical benefit to warrant a larger randomized clinical trial assessing the benefit of standard involvement by PC in patients with advanced HF, independent of the patient's prognosis or treatment goals.

Quality of life and mental health in caregivers of outpatients with advanced cancer

This study evaluates the quality of life (QOL) and mental health (MH) of caregivers of patients with advanced cancer who are receiving ambulatory oncology care and associations with patient, caregiver and care-related characteristics. Patients with advanced gastrointestinal, genitourinary, breast, lung or gynaecologic cancer, and their caregivers, were recruited from 24 medical oncology clinics for a cluster-randomized trial of early palliative care. Caregivers completed the Caregiver QOL--Cancer scale and the Medical Outcomes Study Short Form, version 2, and a questionnaire including care-related factors such as hours/day providing care and change in work situation. Patients completed a demographic questionnaire and measures of their QOL and symptom severity. Associations of these factors with caregiver QOL and MH were examined using linear regression analyses. Of the 191 caregivers, 84% were spouses/partners, 90% cohabited with the patient, half were working and 25% had a change in work situation since the patient's diagnosis. On multiple regression analysis, better caregiver QOL was associated with better caregiver MH and patient physical well-being and with not providing care for other dependents. Worse caregiver MH was associated with female caregiver sex, worse patient emotional well-being, more hours spent caregiving and change in the caregiver's work situation. Caregivers of ambulatory patients with advanced cancer may have compromised QOL and MH associated with worse patient physical and emotional well-being and with simultaneously caring for others and working outside the home. Early palliative care interventions directed at patient symptoms and caregiver support may improve QOL in this population.

Palliative care needs of patients with cancer living in the community.

With improved effectiveness of early detection and treatment, many patients with cancer are now living with advanced disease and associated symptoms. As cancer becomes a chronic illness, adequate attention to patients' symptoms and psychosocial needs in the community setting requires positioning of palliative care alongside cancer care. This article describes the current palliative care needs of a population of community-dwelling patients with advanced cancer who are not yet ready for transition to hospice. This secondary analysis used quality-monitoring data collected in three community-based palliative care organizations. Analyses focused on people with cancer-related diagnoses who were receiving palliative care during 2008 to 2011. The analytic data set included 4,980 people, 10% of whom had cancer. Median age was 71 years. Forty-eight percent had been hospitalized at least once in the 6 months before palliative care referral. Forty-nine percent had a Palliative Performance Score (PPS) of 40% to 60%; 40% had PPS ≤ 30%. Although 81% had an estimated prognosis of ≤ 6 months, 58% were expected to live weeks to months. Thirty-three percent had no identified healthcare surrogate; 59% had no do-not-resuscitate order despite declining functional status and limited prognosis. Ninety-five percent reported ≥ 1 symptom, and 67% reported ≥ 3 symptoms; a substantial proportion did not receive treatment for symptoms. Patients referred to community-based palliative care experience multiple often-severe symptoms that have been insufficiently addressed. They tend to have declining performance status. Earlier palliative care intervention could improve outcomes but will require delivery models that better coordinate inpatient/outpatient oncology and community-based palliative care.

Preparation for the end of life in patients with advanced cancer and association with communication with professional caregivers

Previous studies regarding patients' end of life (EOL) preparation have focused mainly on practical tasks, such as advance directives. In this study, we investigate the relational and personal aspects of EOL preparation, using a patient-completed questionnaire, and examine associations with clinician-patient communication (CPC) and other variables. Patients with advanced cancer but with good performance status were recruited from 24 medical oncology clinics, to participate in a cluster-randomised controlled trial of early palliative care intervention. Measures included the Quality of Life at the End of Life preparation for EOL subscale, and measures of CPC, functional status, comorbidity, spiritual well-being and symptom severity. Using chi-squared tests, t-tests and multivariate regression analyses, we examined the variables associated with preparation for EOL. We also examined the frequency distributions of individual EOL preparation items and used logistic regression to examine their associations with adequacy of CPC. In the 469 patients, characteristics associated with better EOL preparation were better CPC, older age, living alone, less symptom burden and better spiritual well-being. Thirty-one per cent agreed that they worried 'quite a bit' or 'completely' about their family's preparation to cope with the future, and 27% agreed that they would be a burden to their family. All preparation items except regrets about life were associated with adequacy of communication. A substantial minority of patients with advanced cancer but with good performance status are concerned about EOL preparation, particularly in relation to their families. Better CPC may help patients prepare not only practically but also personally and socially in relation to the dying process and the welfare of their families.

Effect of a nurse practitioner (ARNP)–directed intervention on the quality of life of patients with metastatic cancer: Results of a randomized pilot study.

9097 Background: It is rare for patients who are early in their clinical course of metastatic cancer to receive information about the benefits of hospice programs or about advanced directives. The anti-cancer efforts of the medical oncology teams caring for newly diagnosed metastatic cancer patients do not often include improving the patients’ quality of life (QOL)-related needs. There is still a paucity of prospective randomized studies evaluating these interventions. We sought to examine QOL outcomes in advanced cancer patients who received early discussion-based palliative care interventions, and compare these outcomes with a control population. Methods: Patients were randomized to standard care or an ARNP-directed intervention that included discussions of the benefits of hospice, discussions on advanced directives (Five Wishes document) along with an assessment of quality of life. The primary endpoint was change from baseline in overall QOL (via the FACT-G measure), utilizing a single t-test with 80% power to detect a moderate effect size. Results: From November 3, 2008 through July 28, 2009, 26 patients were accrued at the Mayo Clinic in Jacksonville, Florida. The study closed early as a result of recently published data demonstrating the benefits of early palliative care interventions in the management of metastatic cancer patients. A statistically significant improvement from baseline in the FACT-G emotional domain was noted in the intervention group that was not seen in the control group (p=0.0106). Patients found it useful to have the living will and Five Wishes documents offered as part of the ARNP intervention. Conclusions: An early ARNP-directed intervention that explains the benefits of hospice and addresses advanced directives is well-received by metastatic cancer patients and their relatives, and leads to improvement in the patient’s emotional quality of life as assessed by the FACT-G tools. This represents a cost-effective approach that is integrated with the oncology team care and brings effective palliative care interventions early in the management of patients with metastatic cancers. Further studies are ongoing with a larger study cohort.

ED HELP: Can Early ED Consultation Impact Care (316-A)

1.Identify the PC needs of low-income emergency department (ED) patients with end-stage chronic illness.2.Determine the impact of ED-based palliative care consultation on ED utilization and hospital length of stay. Background. Palliative care (PC) improves quality of life of seriously ill patients through the prevention and relief of suffering. Little data exist examining the role of early PC intervention in the emergency department (ED). Research objectives. (1) Identify the PC needs of low-income ED patients with end-stage chronic illness. (2) Determine the impact of ED-based PC consultation on ED utilization and hospital length of stay. Methods. Prospective, randomized controlled trial using time randomization in a large public hospital ED, comparing ED-based PC consultation versus usual care. Patients included adults able to participate in informed consent, not on psychiatric hold. Baseline PC needs were explored with a comprehensive enrollment interview. Outcome measures included use of hospital inpatient and emergency services during subsequent year. Descriptive statistics, bivariate comparisons, and general linear models univariate and repeated measures analyses were conducted using SPSS. Results. Of 393 patients approached, 198 consented and were assigned to intervention (88) and control (110) groups; 51% males; average age 51.7 years; 62.4% had < 12 years education; 74.6% foreign born; 10.2% reported any employment. Participants reported high levels of pain (75% rated average ≥ 5 on 10-point scale) and depression (53.8% scored 3+ on PHQ-2) and poor overall quality of life (71.9% rated “fair”, “poor” or “very poor”). Just 15 (7.6%) reported having a durable power of attorney or living will. Of n =164 with known vital status, 54.3% died within one year. Based on intention-to-treat comparisons, there were no differences for survival or service use (adjusted for survival time) in the follow-up period. Aim. Understand the impact of palliative care consults in the ED on outcomes. Methods/session descriptions. Presentation of scientific study. Conclusion. Results suggest a need for PC consultation among vulnerable patients in ED. More complex analyses of health and social factors are needed to evaluate the effect of PC intervention on health system outcomes. Implications for research, policy, or practice. Little data exists on the integration of PC in the ED and how this impacts quality measures and outcomes. Structure and Processes of Care

Validation of the QUAL-EC for assessing quality of life in patients with advanced cancer

Objective Improving quality of life is the main goal of palliative cancer care. However, there is a lack of measures validated specifically for advanced cancer. The purpose of this study was to validate the Quality of Life at the End of Life (QUAL-E) measure in a sample of patients with advanced cancer. Methods Data were analysed for 464 patients with advanced cancer who were participating in a randomised controlled trial of early palliative care intervention versus routine care. Patients completed the 26-item QUAL-E, the Functional Assessment of Cancer Therapy (FACT-G) quality of life measure and measures of spiritual well-being, performance status, symptom burden, satisfaction with care and communication with health care providers. We conducted a confirmatory factor analysis on the QUAL-E to test for the hypothesised four-factor structure and examined construct validity by calculating correlations with relevant scales. Results A 17-item reduced version of the QUAL-E, the QUAL-E-Cancer (QUAL-EC) achieved an acceptable fit to a four-factor model. Both the full and reduced versions of the QUAL-E were internally reliable and showed good construct validity. Symptom Control was correlated with other measures of physical functioning; Relationship with Healthcare Provider was correlated with satisfaction with care and better physician and nurse communication; Preparation for End of Life was strongly associated with emotional well-being; and Life Completion was strongly associated with social and spiritual well-being. Conclusions Due to its good factor structure and sound psychometrics, we recommend the reduced QUAL-EC scale to assess quality of life in patients with advanced cancer.

End-of-Life Care for Hospitalized Patients with Lung Cancer: Utilization of a Palliative Care Service

High symptom burden and hospital mortality among patients with lung cancer argues for early palliative care intervention. Patient characteristics and discharge dispositions in hospitalized patients with lung cancer receiving usual care were compared to those referred to a new palliative care service. A retrospective database review of all lung cancer discharges receiving usual care (UC) and palliative care service (PCS) consultation was conducted. Demographics, length of stay, discharge disposition, and mortality were described and compared. Palliative Performance Scale scores were described according to discharge disposition in the PCS group. Disposition of all patients receiving either chemotherapy or surgery was also noted. A total of 1476 hospital discharges with a diagnosis of lung cancer occurred between March 15, 2006 and June 30, 2009. Among all discharges, 9% received chemotherapy and 29% had surgery. The PCS was consulted for 8% of all lung cancer patients most commonly to address end-of-life-issues. PCS patients were more likely to be at the end-of-life than UC patients as evidenced by higher hospital mortality (31% versus 7%), higher intensive care (ICU) mortality (67% versus 16%) and more frequent discharge to hospice (41% versus 7%). PCS patients were hospitalized a median of 6 days before a referral was made. Hospitalization was significantly longer for PCS patients (M = 16.3 days, p < 0.001) than UC patients (M = 8.3 days). In the first 3 years of a new palliative care initiative consults for lung cancer patients occurred late in the hospital stay or when death was imminent.

Palliative care from the beginning of treatment for advanced pancreatic cancer. Highlights from the "2010 ASCO Gastrointestinal Cancers Symposium". Orlando, FL, USA. January 22-24, 2010.

Palliative care ought to be offered at the initiation of treatment for people who are diagnosed with pancreatic cancer, given the poor relative survival rate and the intractable symptom profile of those who have this life-limiting disease. In this article, we argue that palliative treatment of people with pancreatic cancer is not found in extending survival, but rather, in promoting quality of life. This argument is made by reviewing the literature on the state of palliative care in pancreatic cancer and by summarizing key studies presented at the "2010 ASCO Gastrointestinal Cancers Symposium" held in Orlando, FL, USA on January 22-24, 2010. The studies discussed here include: i) a study of a random sample of 564 patients with pancreatic cancer that found that the symptom cluster of fatigue and pain predicted survival (Abstract #265); ii) a retrospective study of 108 patients that identified anticoagulation therapy in those who developed portal vein thrombosis prolonged survival (Abstract #143); iii) a double-blind randomized control trial of 50 patients with gastrointestinal cancers who were cachexic in which a thalidomide-olanzapine-megasterol acetate combination attenuated the effects of cancer-anorexia-cachexia syndrome (Abstract #209); iv) a retrospective study on the role of adjuvant chemoradiation and chemotherapy in the treatment of advanced pancreatic cancer (Abstract #230); and v) the benefit of chemotherapy in patients with metastatic pancreatic cancer 80-year-old or more (Abstract #232). Based on the results presented at the meeting, we believe that the discussion of palliative care in the treatment of advanced pancreatic cancer must not conflate the notion of increased survival with increased quality of life, the latter of which is part and parcel of the goal of palliative care. We believe that future study on the effect on quality of life of early palliative-care interventions among people with pancreatic cancer is necessary.