An intervention of palliative care visits triggered only by changes in course of disease, treatment or quality of life was as effective as monthly visits for maintaining quality of life in patients with advanced lung cancer.

Early palliative care, shown to improve quality of life (QOL) and survival, is recommended for patients with advanced cancer, yet implementation is challenging due to limited resources. In this multicentre, nonblinded, noninferiority trial, 507 adults with advanced lung cancer diagnosed within the prior 12 weeks were randomised to receive early or stepped palliative care.

Early care involved outpatient visits every four weeks and inpatient palliative care during hospital admissions. Stepped care involved an initial outpatient visit and subsequent visits only with specific events (cancer progression, treatment toxicity, discontinuation of therapy) or after hospitalisation; in addition, patients were stepped up to visits every four weeks if they had a 10-­point or greater decrease from baseline on a QOL measure assessed every six weeks (Functional Assessment of Cancer Therapy – Lung [FACT­L]; 0 to 136­-point scale).

By 24 weeks, the stepped-­care group had significantly fewer palliative care visits than the early-­care group (mean, 4.7 vs 2.4; p<0.001). QOL at week 24 (the primary outcome) was noninferior in the stepped­-care group compared with the early-care group (adjusted mean FACT-­L score, 100.6 vs 97.8; p<.001 for non­inferiority). Depression symptoms, use of coping strategies, understanding of prognosis and communication about end-­of-­life care did not differ between groups. However, hospice use was less in the stepped-­care group than the early­-care group (adjusted mean days, 19.5 vs 34.6; p=0.91 for noninferiority). 

Comment: These findings fill an important gap in clinical care delivery. Stepped palliative care, occurring at specific points during the cancer care trajectory or in response to a reduction in QOL, maintained patients’ QOL life benefit, with fewer visits than the early-­care approach. However, the stepped-­care approach was associated with fewer days in hospice. Overall, given the significant shortage of palliative care clinicians, especially in community and rural settings, the stepped approach may support scalable care in these settings, while improving QOL among patients with advanced cancer.

Elizabeth Prsic, MD, Director, Adult Inpatient Palliative Care, Yale New Haven Hospital; Firm Chief, Medical Oncology, Yale Cancer Center; Assistant Professor, Yale School of Medicine, New Haven, USA.

Temel JS, et al. Stepped palliative care for patients with advanced lung cancer: a randomized clinical trial. JAMA 2024 Jun 2; e-pub (https://doi.org/10.1001/jama.2024.10398).

This summary is taken from the following Journal Watch titles: Oncology and Hematology, Hospital Medicine.