An educational program can help ease the worries patients with cancer often have about palliative care, an important tool for improving quality of life (QOL) for patients with advanced illness, although many are reluctant to embrace it.

Palliative care can benefit both patients and the healthcare system by reducing healthcare utilization and improving patient satisfaction. However, many patients are unaware of what this type of care involves, and refuse to accept referrals.

A study recently published by the American Psychological Association (APA)

 examined whether an education initiative could help change these perceptions. The intervention, called Project EMPOWER, provided information to nearly 300 patients with cancer building on the Early Palliative Care Study; the remaining half of the study participants received no information.

The influential Early Palliative Care Study, published in 2010,

 found that patients with lung cancer demonstrated improved QOL and fewer depressive symptoms if they received early palliative care. They were less likely to receive aggressive end-of-life care than the control group receiving normal care, but had a longer median survival time by almost 3 months.  

Researchers on this APA study found that Project EMPOWER “had a favorable impact on participants’ preferences for outpatient palliative cancer care relative to controls.” Patients receiving the intervention reported that they now viewed palliative care as “less scary” and had more positive perceptions of its efficacy.

Importantly, this change in attitude was accompanied by a change in potential behavior, as these patients showed stronger intentions to use palliative care services if referred.  

These encouraging findings did not come as a surprise to lead study author Michael Hoerger, PhD, assistant professor of psychology, psychiatry, and oncology at Tulane University. “Most people are scared of palliative care because they believe it means stopping treatments, giving up, or starting hospice,” he explained in a statement.

“When people learn they can still do their treatments and that there is good evidence that palliative care helps with side effects and the stress of their illness, of course they want it.”  

Study results were based on statistical analyses that controlled for potentially influential factors like patient demographics or their severity of illness. The study also presented a relatively simple and low-cost strategy for boosting awareness and acceptance of palliative care.   “Usually it takes 20 to 30 years before effective interventions are widely accessible,” Hoerger said. “We hope that by educating people about the benefits of palliative care, more patients and families will feel empowered to use it.”

Christina Mattina is a writer and assistant editor for the 

Hoerger M, Perry LM, Gramling R, et al. does educating patients about the early palliative care study increase preferences for outpatient palliative cancer care? findings from project EMPOWER [published online before print March 9, 2017]. 

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small cell lung cancer. 

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A recent study determined that an education initiative could help to ease worries patients with cancer may have about palliative care, thus improving quality of life.

Palliative Care: When Patients Understand It, They Are More Likely to Use It

Helping patients with cancer to stop smoking has been a mission Paul M. Cinciripini, PhD, has spent the better part of his life working on. With more than 480,000 deaths in the US each year attributable to smoking, he shared with clinicians attending the recent 22nd Annual Conference of the National Comprehensive Cancer Network (NCCN) some good news about smoking cessation approaches to help reduce that number.

Cinciripini, is a professor and chair of the Department of Behavioral Science at the University of Texas MD Anderson Cancer Center and directs its Tobacco Treatment Program. The beneficial effects of cessation go beyond reducing mortality, he said, and include lowering depression, anxiety, and stress, along with improved positive mood and qualityof life (QOL).

In the cancer population, these outcomes—both the dangers of smoking and the benefits of cessation&mdash;are magnified. Smoking during cancer treatment is associated with an increased risk of recurrence, greater symptom burden, and reduced survival.

Response to radiotherapy is diminished in smokers, and they have an increased risk of pulmonary embolism, infection, and poor wound healing. Smokers also experience worsened toxicities and immune impairment while undergoing chemotherapy, although the efficacy of the treatment is diminished.  

In 1 study, patients who quit smoking had a 78% overall survival rate 2 years after radiotherapy, compared with 69% among those who continued to smoke. From a QOL perspective, patients who quit smoking report easier breathing and a boost in energy. Clearly, Cinciripini said, there is a “need for intervention” among this population.  

Smoking Cessation Interventions: What Works

The most effective interventions, he explained, involve a combination of counseling and medications. Recommended first-line medications include varenicline, bupropion, and nicotine-replacement therapies like patches or gum.  

Cinciripini cited a large study called the EAGLES trial that found varenicline to be more effective than bupropion, nicotine patch, or placebo in patients with and without psychiatric disorders. The occurrence of severe neuropsychiatric events during treatment, including suicide, was similar across all the tested therapies. Cinciripini advised clinicians to think about the patient’s psychiatric background and history when prescribing these treatments, and to “be on the lookout for any untoward changes in their psychiatric profile.”  

He then highlighted several studies demonstrating better cessation rates associated with higher intensity counseling, defined as more than 4 sessions lasting 30 to 300 minutes, compared with minimal intensity counseling. Although this more intense treatment costs more, Cinciripini explained that its increased effectiveness makes it more cost effective. He also cited research that found a combination of intense counseling plus the introduction of nicotine replacement therapy before quitting was more effective at 16 and 26 weeks than either intervention alone.  

After presenting this literature, Cinciripini discussed the NCCN clinical guidelines for smoking cessation in oncology. First, clinicians must assess patients’ nicotine dependency, history of quit attempts, and readiness to quit. If a patient is ready to quit, the clinician should involve him or her in establishing a plan and setting a quit date. If he or she is not ready, the clinician can help address concerns and suggest pharmacotherapy to reduce the number of cigarettes smoked per day. The goal of this reduction is eventually quitting, Cinciripini emphasized, not just harm reduction.  

The primary recommended therapies are a combination of behavioral therapy and either nicotine replacement therapies or varenicline. If a patient succeeds in quitting, the guidelines recommend “motivational strategies for continued abstinence.” If a patient relapses, clinicians can switch the type of therapy, but must be sure to maintain consistent engagement with the patient.  

Smoking cessation is “not a one and done” event, Cinciripini emphasized, and requires consistent contact and follow-up by the clinician. “If they quit, great, stay engaged. If they don’t, great, stay engaged,” he summarized.  

When the audience was invited to ask questions, an attendee asked Cinciripini his opinion on e-cigarettes as a form of risk mitigation, though he’d previously said he was focusing on complete cessation, not harm reduction.  

“I knew I was going to get that question,” Cinciripini sighed jokingly. “The answer is it depends.” Although there aren’t enough data to establish effectiveness and long-term safety for the devices, he said, the reduction in carcinogens makes it preferable to cigarettes and can provide an opening for patients to transition towards eliminating nicotine.

Cinciripini said he would not rule out e-cigarettes as a potential tool if researchers had more data, but reiterated he was “most comfortable talking about valid nicotine therapies” as a means for cessation.

Christina Mattina is a writer and assistant editor for the American Journal of Managed Care. Read more at 

For patients with cancer, smoking cessation should include counseling and pharmacology. Encouragement throughout, especially if a patient relapses is important.

Smoking Cessation "Not a One-and-Done" Event for Patients With Cancer

Findings from a study of participants enrolled in 9 multicenter, oncology clinical trials show that the vast majority of patients can successfully and accurately self-report their adverse events (AEs) if given the opportunity, suggesting the potential for an elevated role for patient-reported outcomes in these investigations.

Under current protocol, AEs resulting from cancer clinical trials are reported by the investigators, not the patients, but the growing emphasis on patient-centered care has led some to question the necessity of this system, especially as some 

 have shown that investigators’ reports of such data could be incomplete or inaccurate.

Against this backdrop, a group of researchers set out to test the feasibility of a system that allowed patients to report their own symptoms at each clinical visit, and published their results in 

In this study, 285 patients participating in cancer clinical trials were given the opportunity at each visit to answer plainly-worded questions about symptomatic AEs using a mobile tablet, while the investigators continued to note any adverse events as they normally would have. Subsequent analysis found that the clinicians tended to underreport symptoms compared with patients, especially for events like anorexia, fatigue, nausea, and pain.

The study authors explained that patient reports of symptoms that the investigators had overlooked, “reflect an area of the patient’s experience that may warrant particular attention in the future, both to alleviate patient discomfort and identify currently undocumented safety signals.” They added that a focus on patient-reported outcomes (PROs) could become even more important when investigating new therapies like immuno-oncology, since these treatments can have “long-standing, low-grade toxic effects” that might go unnoticed by clinicians.

Investigators surveyed about the new system responded with positive feedback, with 94% agreeing that the PROs were useful for monitoring toxicities and 83% stating they accurately reflected the patients’ clinical status. Similarly, patients had positive feelings about the experience, as 93% agreed that the reporting system was easy to use and helpful.

The idea of allowing clinical trial participants to report their own symptoms is not a novel one; in fact, trials in some fields other than oncology have already adopted this approach. A prior survey of cancer investigators and researchers found that more than 90% believed that patient-reported AE reporting “could improve data completeness, accuracy, meaningfulness, and actionability,” compared with the present system of clinician reporting.

The results of this study, the authors suggested, add to the evidence indicating that patient self-reporting could be successfully implemented in oncology trials. Collection of symptom reports from patients could provide a more complete picture of a trial treatment’s effects as well make patients and their families feel empowered by this patient-centered approach.

 Basch E, Dueck AC, Rogak LJ, et al. Feasibility assessment of patient reporting of symptomatic adverse events in multicenter cancer clinical trials [published online ahead of print February 16, 2017]. 

Christina Mattina, is a writer and editor for the American Journal of Managed Care. Read more at AJMC.com.

A recent study found that most patients are able to accurately self-report adverse events during clinical trials, if given the opportunity.

Christina Mattina

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Palliative Care: When Patients Understand It, They Are More Likely to Use It

Smoking Cessation "Not a One-and-Done" Event for Patients With Cancer

Patients Accurately Self-Report Adverse Events in Cancer Trials and Welcome the Opportunity