Caregiver burden is higher for individuals caring for patients with glioblastoma (GBM), due to the physical and neurologic deficits associated with this diagnosis, but how does the increased time burden in this setting affect caregiver quality of life?

Researchers at the University of Rochester Medical Center are examining that question and one of the study authors, Lauryn Hemminger, BS, presented results of a prospective study at the recent Palliative Care in Oncology Symposium.

“One study looked at caregivers in neuro-oncology versus caregivers in other oncologic diseases, and it showed that the burden was actually higher for caregivers who were taking care of patients with gliomas,” explained Hemminger. “We think that's likely because of the neurologic deficits and the cognitive decline leading to a little bit more physical and cognitive dependence in patients who have malignant gliomas.”

The study by Hemminger and colleagues involved 43 caregivers of newly diagnosed GBM patients and was conducted between September 2015 and June 2016. Caregivers completed quality-of-life assessments at baseline and 3 months post-diagnosis and recorded the total hours per week spent on patient care.

Results revealed that caregiver time burden is high, even in the early stages of patient diagnosis with GBM. For many caregivers, caring for their loved one quickly turned into a full-time job, even before there were significant declines in physical or neurological function—a result Hemminger said she was surprised to find.

“We thought early in the disease, patients may not have as many symptoms or have as much cognitive decline as they do later in the disease. But we actually found that a lot of caregivers were spending more that 40 hours a week on patient care, even right after the initial diagnosis,” Hemminger said. “This was most noticeable in the primary caregivers.”

The study considered anyone who “thought they played a supportive role [for patients]” as a caregiver, Hemminger said.

Because the dataset was small, Hemminger said that they cannot definitively declare the relationship between caregiver time burden and patient/caregiver quality of life a correlation, but it definitely could be defined as an association.

“So, spending more time on direct patient care was associated with higher distress or lower quality of life, using the measurements that we looked at,” Hemminger said.

The trial is ongoing, and Hemminger said she hopes to broaden the scope of the trial to gain further insight and ultimately create worthwhile interventions that can improve quality of life for both the caregiver and patient.

Though it was proven in other cancer types that caregiver well-being has an effect on patient outcomes, it is a difficult correlation to make in the world of neuro-oncology.

“It's hard to say, because these patients are already going through so much as it is, and it's such a terrible disease,” Hemminger said. “But I do think when caregivers feel more prepared to care for the patient and they feel like they have plans of action in case of a crisis, patients tend to benefit from that because the caregivers are more prepared at home.”

This, Hemminger said, is why it is crucial to prepare caregivers for the difficult road that may be ahead of them when their loved one is diagnosed.

“Ideally, I would love to see direct caregiver care being given alongside disease-directed therapy,” she said. “Just understanding their experience is definitely the first step. From there, being able to develop cost-effective and resource-effective interventions that can target caregivers and actually affect outcomes—that's the future.”

 Hemminger L, Pittman C, Mohile N. Caregiver time burden in newly diagnosed glioblastoma: a prospective analysis. 

Articles

Caregivers of patients with GBM have an increased time burden and can affect the quality of life of the caregiver and, potentially, the patient with cancer.

Intervene Early to Support Caregivers of Patients With Glioblastoma

Researchers at the University of Texas MD Anderson Cancer Center recently tested the feasibility of couples-based yoga. Participants were patients with high grade glioma (HGG) and their caregivers. The goal was to alleviate some of the stress and side effects that come with this cancer.

The single-arm study observed both symptoms and quality of life (QOL) in self-reported assessments that were taken at baseline and after completion of the program, which included up to 12 yoga sessions, usually conducted 2 or 3 times a week, right before or after their radiotherapy treatments.

While yoga has proved beneficial to the health and quality of life of patients with breast cancer, study author Kathrin Milbury, PhD, wanted to see what kind of results yoga and meditation would have on certain patients with brain cancer and their caregivers.

“I was interested in high grade gliomas because that is a patient population with high symptom burden, but there’s really not a whole lot of supportive care intervention out there,” Milbury said. “We know that caregivers are very vulnerable to symptom burden as well, particularly distress, fatigue, and sleep disturbances.”

Milbury added that patients and caregivers can often have similar symptoms but with different causes. Patients are often fatigued as a side effect of radiation therapy, while caregivers feel the same due to the stress and long list of duties of caring for someone who is ill.

To combat these symptoms, the 60-minute yoga sessions included four main components: joint loosening with mindfulness training, postures (asanas) with deep relaxation techniques, breath energization (pranayama) with sound resonance, and meditation/guided imagery.

“We structured the intervention for patients and caregivers on some of the guided imageries that were used specifically to address the issues of accepting uncertainty, coping, and focusing on the connection the patient has with the family caregiver,” Milbury said.

The program emphasized the fact that it was important for the patients, who are typically on the receiving-end of the caregiving, to also contribute to the couple by being present and offering support. This, she said, is key to their well-being and QOL.

“We make it clear that the intervention is for both of them together,” Milbury said. “It’s actually for them to cope together through this cancer journey.”

By the end of the intervention, side effects, including psychological distress, sleep, fatigue, and overall QOL were improved for both patients and caregivers. In fact, 33% rated the program as “useful” and 67% said that it was “very useful.”

However, not all aspects of QOL were significantly improved for the caregivers. Milbury suggested that this may be because the trial was single-arm without a control group and that side effects could have possibly gotten worse without the intervention.

Milbury and her team are currently working on a larger randomized trial to get even more information on the effects of yoga on patients with difficult prognoses.

“Yoga is more than just stretching,” she said. “The mind—body connection, being able to regulate emotions through relaxation techniques, I think, is one of the key aspects. Also, the physical component of it is very helpful.”

Some patients even said they used the mindful breathing techniques taught in the intervention during radiotherapy to help cope with being in a confined space.

“We got very positive feedback,” said Milbury. “They definitely enjoyed participating together with their caregivers. It made them feel relaxed and helped them to cope.”

Milbury K, Mallaiah S, Mahajan A, et al. Yoga program for patients with brain tumors undergoing radiotherapy (XRT) and their family caregivers. 

A recent study found that yoga could improve overall quality of life for patients with high grade glioma, as well as their caregivers.

Couples-Based Yoga Improves Quality of Life for Patients and Caregivers

As clinical providers, the ability to meet the science of medicine with its physical, emotional, spiritual, and financial impact it has on patients is often unintentionally overlooked or, at the very least, minimized during the active treatment phase of care; therefore, the purpose and potential benefits that result from integrating palliative care early on in the process is missed.

 led by Areej El-Jawahri, MD, of Massachusetts General Hospital Cancer Center in Boston, 160 patients with hematologic malignancies admitted for autologous or allogeneic HCT noted improvement in quality of life as evidenced by increased understanding of illness, lower rates of depression, anxiety, and symptom burden during hospitalization as a result of receiving palliative care services.

Logically, the next question becomes why haven’t we been more proactive in setting into motion these services, which seemingly only benefit this patient population? In my opinion, it is the historical stigma that surrounds “palliative care” that detracts both providers from implementing it early on in the care plan as well as patients from embracing the resources inherently connected to it.

Palliative care is wrongly thought of as only “end of life” care and consequently often implemented as such. As the ability to transplant older patients with higher risk comorbidities continues to grow, we need to acknowledge that the net result is a patient population with greater needs both emotionally and financially. What happens to the 70-year-old man who has limited financial means because he is not actively working, and then is forced to cope with chronic graft-vs-host disease—an all-too-common and potentially debilitating complication associated with allogeneic stem cell transplantation? It is this scenario, as well as a multitude of others, that must empower providers to truly understand what palliative care is, what it does, who it can benefit, and how to convey it to their patients in an appropriate and timely fashion so that the patient is willing to accept the services that palliative care can provide for them.

This discussion would be remiss if we did not acknowledge, however, that the “end of life” aspect of palliative care does exist, and it, too, is often not discussed until a patient is actively passing or in the immediate days prior to his or her death. Thus, neither the patient nor the patient’s family members truly benefit from the variety of services available to them. Once again, it is the responsibility of the provider and healthcare team to become knowledgeable and comfortable speaking about what is truly important—the quality of life of the patient and how best to optimize it.

The emotional and physical “roller coaster ride” that each of our patients embarks on as they undergo hematopoietic stem cell transplants should automatically guarantee them a holistic care approach of medicine that includes the input and expertise of physicians, nurses, mental health experts, social workers, allied health professionals, and ancillary services—all working in partnership as a palliative care team. It is there that the “missing link” in the care provided for these patients is found.

Mary E. DiLorenzo, MSN, RN-C, NP-C, is an advanced practice nurse in the Blood and Marrow Transplantation Program at John Theurer Cancer Center in Hackensack, New Jersey.

The "Missing Link" in Hematopoietic Stem Cell Transplantation

Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most common reasons patients with cancer stop treatment early, according to the National Cancer Institute. However, massage therapy (MT) may be a way to ease symptoms and improve quality of life, researchers reported at the 2016 Palliative Care in Oncology Symposium.

The study, by a team of researchers from Boston University School of Medicine and Roger Williams Medical Center in Providence, Rhode Island, tested MT as a primary and secondary preventive treatment of CIPN symptoms.

Sixty-two patients participated in this single-arm, 10-week study that included a pre- and post-intervention survey assessment adapted from a prior study  of novel approaches to CIPN in patients with multiple myeloma.

 Of the total, 97% had at least 2 CIPN-related symptoms prior to their first session. After the first MT session, at least 50% of patients reported improvements in all CIPN-related symptom categories. Up until at least the second session of MT, all patients maintained symptom improvement, except for those with from auditory-related symptoms.

The most common CIPN symptom experienced by patients was numbness or tingling in the feet (52%), and after the first session of massage therapy, 72% saw an improvement. Additionally, 47% reported that the improvement lasted until the second session.

The symptom which received the highest average improvement was the feeling of overall weakness, with an average 67.5% improvement after the first session. The highest sustained average improvement from the first to the second session was in difficulty walking, which improved by 45% and 50%, respectively.

Researchers also noted that patients using painkillers may benefit from MT. Twenty-five patients in the study cohort were taking pain medication, of whom 56% experienced no symptom progression after the first MT session, and of the 13 patients who attended the second MT session, 38% reported no progression, and 31% reported a complete resolution of symptoms. The remaining 31% did have a progression of symptoms.

Overall, CIPN symptoms improved an average of 45%, with the exception of vestibulocochlear symptoms, such as difficulty hearing and buzzing or ringing in the ears.

Study authors wrote that they hoped their findings would promote the use of MT as, “an effective prophylactic and therapeutic option,” and that the data suggest a benefit for the subset of patients who are taking analgesics.

The researchers also noted that, “a median of 97% of patients who did not complain of CIPN-related symptoms never develop the symptom. Although no control group was present, we hypothesize that massage therapy might also be a viable preventive modality for CIPN,” and they called for further studies focused on approaches to treat auditory symptoms related to CIPN.

1. Menendez AG, Cobb R, Carvajal AR, et al. Effectiveness of massage therapy (MT) as a treatment strategy and preventive modality for chemotherapy-induced peripheral neuropathy (CIPN) symptoms. 

2. Tairiman JD, Love G, McCullagh E, et al. Peripheral neuropathy associated with novel therapies in patients with multiple myeloma: consensus statement of the IMF Nurse Leadership Board. 

Massage therapy may offer relief to patients suffering from chemotherapy-induced peripheral neuropathy (CIPN). 

Healing Hands: Massage Therapy Can Offer Relief for CIPN Symptoms

Communication for any couple can be challenging, but especially when one partner has advanced cancer. In an effort to give patients and their partners the skills they need to facilitate end-of-life conversations, a group of researchers in North Carolina evaluated a couple’s communication skills training (CCST) intervention, and findings from their pilot study suggest the tool has benefits for both patients and their spouses.

The study findings follow on an earlier quantitative analyses pointing to the effectiveness of CCST in improving relationship satisfaction. The results, presented at the recent 2016 Palliative Care in Oncology Symposium, dig deeper into the content of the conversations, focusing on themes important to the couples and how CCST specifically assists them in addressing difficult topics.

A team from Duke University Medical Center and the VA Medical Center in Durham, North Carolina recruited 12 couples for this pilot study. The patients had a diagnosis of stage III or IV gastrointestinal cancer (45% had colorectal cancer and 26% pancreatic cancer) with a life expectancy of at least 6 months. 

Ten of the 12 patients in the study were male. The mean age of participants was 54, and they had been married for an average of 19 years. Either the patient or the partner of each couple scored high on the measure of holding back from disclosing cancer-related thoughts or feelings.

The CCST intervention, delivered via Skype and facilitated by a skilled therapist, trained couples in communication skills for sharing their thoughts and feelings, as well as making decisions as a couple; couples were encouraged to use the CCST skills to discuss cancer-related issues between sessions.

Researchers then analyzed the audio recordings from 72 sessions to identify common and recurrent topics that patients and spouses raised in conversations. Based on frequency, they determined which topics were most important and accessible to the couples. These included themes previously described as being important to patients at the end of life, such as treatment (including side effects and logistics); roles (responsibilities at home, work, with family, social groups); family interactions, conflicts, and participation in treatment decisions; understanding prognosis and dealing with uncertainty about the future, and preparation (getting affairs in order, ending treatment).

New themes also emerged when the content of the CCST sessions were explored, including difficulties with communication, providing emotional support to each other, and a desire for greater emotional intimacy. Also identified were worries over “protective buffering,” putting one’s needs second to those of the spouse, and concerns over the surviving spouse’s living and financial situation and grief.

Study authors, led by Laura S. Porter, PhD, an associate professor at Duke University's Schools of Medicine and Nursing, said that these findings, “support the feasibility of an intervention that combines training in communication skills with guidance for using these skills to discuss topics most meaningful to couples facing advanced illness.”

The authors noted that the conversations were helped by training in communication techniques, as well as the involvement of a skilled therapist who created a safe environment for the discussions. In addition to improving conversations about life-limiting illnesses, providing couples with communication training could also improve general relationship satisfaction between partners, the authors concluded.

Porter LS, Fish L, Uronis HE, et al. The elephant in the room: Facilitating conversations about advanced cancer between patients and their spouses. 

Couple's communication skills training can help couples facilitate important conversations when one partner has advanced cancer, 

Helping Couples Communicate When the Prognosis is Poor

Palliative care can improve quality of life for patients hospitalized for hematopoietic stem cell transplantation (HCT), according to a study presented at the recent 2016 Palliative Care in Oncology Symposium.

“Hematopoietic stem cell transplantation is an intensive potentially curative therapy for patients with hematologic malignancies,” said lead author Areej El-Jawahri, MD. “However, patients who undergo the procedure experience physical and psychological symptoms that can negatively affect quality of life and mood.”

In the study, 160 patients with hematologic malignancies admitted for autologous or allogeneic HCT were randomized into two groups; 81 patients received the inpatient palliative care intervention integrated with transplant care, and 79 received transplant care alone. Most participants were white, female and over 50 years of age.

During integrated palliative and transplant care, patients had at least 2 weekly visits during hospitalization. For those patients getting only transplant care, palliative care was available upon request.

Patients were accessed for quality of life, symptom burden and mood during week 2 after transplant, then again at 3 months post-HCT. The 6-month assessment results have not yet been revealed.

The research team, led by El-Jawahri, an oncologist specializing in hematologic malignancies at Massachusetts General Hospital Cancer Center in Boston used the Functional Assessment of Cancer Therapy-Bone Marrow Transplant to assess quality of life; the Hospital Anxiety and Depression Scale and Patient Health Questionnaire to assess mood; and Edmonton Symptom Assessment Scale to measure symptoms at baseline, week 2 and 3 months post-HCT. Post-traumatic stress (PTSD) symptoms were measured using the PTSD checklist at baseline and 3 months post-HCT.

At week 2, there were improvements in quality of life, depression, anxiety and symptom burden in the intervention group. At 3 months, the intervention led to improvements in quality of life, depression, and PTSD.

“Palliative care physicians were asked to document what they focused on during the palliative care visits and during the initial consultation visit,” explained El-Jawahri. “Predominantly, they focused on symptoms, establishing rapport with patients and families, as well as coping. When it came to specific symptoms, they focused on pain, nausea, constipation, and diarrhea.”

Overall, researchers concluded that intervention has a positive effect on quality of life, depression, anxiety and symptom burden in patients hospitalized for HCT. Those improvements also remained 3 months post-HCT.

The authors noted that involvement of palliative care for patients with hematologic malignancies can improve their outcomes and substantially reduce the morbidity of HCT.

“This is important because this is really the first study showing the benefits of palliative care for patients with hematologic malignancies undergoing curative therapy,” El-Jawahri said.

El-Jawahri urged more multisite randomized controlled trials to demonstrate the efficacy of the care model for patients hospitalized for HCT. Future studies are needed to evaluate the impact of early integration for this population on illness understanding and end-of-life outcomes.

El-Jawahri A, LeBlanc TW, Van Dusen H, et al. Randomized trial of inpatient palliative care in patients hospitalized for hematopoietic stem cell transplantation (HCT).  

Palliative care can be beneficial to patients treated with hematopoietic stem cell transplantation. 

Palliative Care Improves Quality of Life Among Patients Undergoing Stem Cell Transplant

Oncology nurses are known and respected to be the frontline of communication with their patients, but that does not mean that coordinating between families and palliative care clinicians or providing life-altering news always comes easy.

To strengthen communication, the National Cancer Institute granted City of Hope in Duarte, California, the funds to create the COMFORT curriculum, an evidence-based communication training course and the first train-the-trainer program for oncology nurses across the United States.

“Communication, empathy, and relationship-building are among the top three concerns reported by patients,” said Elaine Wittenberg, PhD, associate professor of Nursing Research and Education at City of Hope, and author on the results of the study. “Patients and families who report good healthcare experiences describe communication practices as timely, truthful, and compassionate.”

The curriculum, which emphasizes team communication, focuses on providing life-altering news, assessing patient/family health literacy needs, practicing mindful communication, acknowledging family caregivers, and addressing communication openings and goals. These issues are looked at across the cancer care continuum: diagnosis, treatment, survivorship, recurrence, and end of life.

After learning the curriculum, the 187 nurses then taught what they learned to additional healthcare providers, including primary nurses and physicians, ultimately educating an additional 2460 individuals, 1961 of them nurses.

“The goal of the course is to develop oncology nurses as experts who will return to their individual institutions, share information with others, and cultivate organizational change aimed at improving communication,” Wittenberg said.

COMFORT is currently 3 years into a 5-year grant, and researchers have captured 12-month follow up for the first course and post-course evaluation for courses 1 and 2.

“We are extremely pleased with the outcomes thus far,” Wittenberg said.

The modules most commonly taught included communication (25.5%), mindful communication (22.3%), team communication (18.5%), and family caregivers (11.4%).

“The train-the-trainer model for communication training appears to be a viable and promising strategy for broadly teaching communication across the cancer continuum,” the study says. “Train-the-trainer is less costly than traditional on-site training methods and allows instruction to be tailored to address the institution’s least effective communication practices across the cancer continuum.”

Many course participants said that their institution was least effective in communication between bereavement and time of death, and were most effective with communication during treatment.

Wittenberg said that this is because at diagnosis and throughout treatment, nurses are responsible for providing information about their diagnosis and treatments to patients and their families and caregivers. Nurses can explain the disease, the different treatment options, what kind of side effects can be expected and likely outcomes. During treatment, nurse communication takes place simultaneously with assessment and administration of treatment.

“In all of these instances, nurses have information to offer the patient and family. Communication at the end of life is challenging because patients and family members often avoid these topics, stress is high, and patients and families may lack of awareness that quality of life is as important as quantity of life,” Wittenberg said. “Overall, nurses are not clear what they should say or do for patients and families during this time. As a result, many nurses focus on physical care topics.”

But thanks to the COMFORT course, healthcare providers are improving their communication in many aspects, while also improving their scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a patient-reported survey which accounts for about 30% of value-based payments.

“Each module of the COMFORT curriculum matches items on the HCAHPS survey,” Wittenberg said. “We are seeing some great results ranging around a 5% and higher change in improvement.”

Nevertheless, Wittenberg said that the need for improvements in the field of patient-centered communication remain, such as discussing spirituality, which many healthcare providers say their patients bring up. Patients who are approaching end of life may want to review their life or gain forgiveness from self, others, or a higher power, Wittenberg said.

“Spiritual care is an intervention accomplished solely through communication, requiring nurses to engage in communication to facilitate spiritual meaning and explore forgiveness,” she explained, “Assessing spiritual and forgiveness concerns are important to ensuring quality end-of-life care and talking about spiritual concerns increases patient satisfaction.”

Wittenberg E, Ferrell BR, Hanson J, et al. Results from a train-the-trainer program for oncology nurses. 

The COMFORT curriculum is an evidence-based communication training course and train-the-trainer program for oncology nurses, who then pass their education on to other healthcare providers. 

With COMFORT Curriculum, Nurses Teach Peers and Physicians to Communicate Better

Palliative care and supportive care services are an essential part of cancer treatment, and currently, all National Cancer Institute (NCI)-designated comprehensive cancer centers report having these services available to patients. However, barriers to accessing these services exist that some healthcare practitioners may not even be aware of, according to the findings of a study presented at the ASCO 2016 Palliative Care in Oncology Symposium.

Researchers with Duke University and the Duke Cancer Institute sought to determine how easy it would be for new patients to access the palliative care system when they first contact a major cancer center.

Palliative care services, along with 6 other supportive care services (cancer education, multidisciplinary care teams, patient navigation, counseling/psychiatric care, genetic counseling and clinical trials), are required for accreditation by the Commission on Cancer, and all NCI-designated cancer centers state the availability of consultative palliative care services.

The study consisted of simulated calls to 40 NCI-designated cancer centers, using a novel “mystery shopper” format. The calls all followed a standard script, involving a family member seeking palliative care for a 58-year-old woman with inoperable liver cancer. Researchers called each center 4 times on different days, twice with the caller reporting Medicaid insurance and twice with private insurance. Researchers then reported on the quantitative and qualitative components of the answers they received. Overall, 160 calls were made, 46 of which did not reach a person (29%).

Researchers found that 38.2% of callers were unable to receive complete information about supportive care services. Additionally, only 37.6% of callers were told all 7 supportive care services were offered. In 9.5% of the calls, the call recipient could not confirm whether palliative care services were offered at the cancer center. While specific responses varied when the “mystery callers” asked if palliative care was available, the authors wrote, “Ten call recipients told us that they were unsure whether palliative care was available, while five more told us that they were sure it was not available.”

In addition, when answering “yes” to palliative care services being available at a particular cancer center, call recipients often referred the callers to patient navigation and genetic assessment services.

“The availability of these services does not guarantee their accessibility; efforts must be made to close this availability/accessibility gap,” study authors noted.

Overall, they found that if the frontline cancer center office staff members do not understand some services, it can impede patients’ accessibility to them.

“As oncologists, we like to believe that when we refer patients to our institution’s helpline, they will get connected to the services they need, but that doesn’t always happen,” said Arif Kamal, MD, an oncologist at Duke Cancer Institute and co-investigator on the study, in a statement. “It’s important for oncologists to be aware of these barriers and to work to eliminate them.”

The researchers suggest expanding awareness and education to “patient-facing” cancer center employees about the services available. Kathryn Hutchins, a third-year medical student at Duke University and lead author on the study, pointed out that this study “provides an opportunity for cancer centers to empower their frontline staff, as well as the oncology care team, through education and training so the entire enterprise has a common understanding of palliative care and how to access it.”

Hutchins K, Hamlyn G, Johnston A, et al. The availability/accessibility gap of palliative care and supportive care services at 40 National Cancer Institute-designated cancer centers.

Palliative care access can be impeded by frontline cancer center office staff members if they do not understand the services.

Answering the Call: Palliative Care Access Depends on Knowledgeable Frontline Staff

When it comes to palliative care, sooner is helpful for many patients with cancer, according to results of randomized trial presented at the recent 2016 Palliative Care in Oncology Symposium that showed that patients with newly diagnosed incurable lung and gastrointestinal (GI) cancer saw a benefit from intervening early to provide palliative care (PC) services.

“By the 24-week time point, we did see a significant difference favoring the earlier palliative care intervention,” said lead study author Joseph Andrew Greer, PhD.

The study, which was conducted over the past 5 years at Massachusetts General Hospital, where Greer is clinical director of psychology and a research scientist in the Center for Psychiatric Oncology & Behavioral Services, involved a group of 350 newly diagnosed patients with one of the following diagnoses: non—small cell and small cell lung cancer, or mesothelioma, or GI cancers (pancreatic, hepatobiliary, gastric, and esophageal).

Eligible patients had to meet a number of criteria, including being within 8 weeks of original diagnosis and not requiring more immediate hospice or palliative care as recommended by their clinicians.

Patients were divided into two equal groups: one receiving early palliative care integrated with their oncology care, whereas the other group received only usual oncology care for their malignancies.

At least once per month, patients assigned to early PC saw a palliative care clinician who documented the contents of every visit. The two topics discussed most were symptom management (discussed in 74.7% of meetings) and coping (discussed in 70.2% of meetings).

Researchers used the Functional Assessment of Cancer Therapy-General (FACT-G) to assess quality of life and the Patient Health Questionniare-9 (PHQ-9) for mood at baseline. Patients who received early palliative care reported significantly higher quality of life (QOL) and lower levels of depression at the 24-week mark, but not at 12 weeks.

The early PC group was also “significantly more likely to report using active and engaged coping styles compared to the usual care group,” according to the results. These strategies included active coping, positive reframing, and acceptance.

Other aspects discussed in palliative care appointments included rapport (44.4%), illness understanding (38.4%), treatment decisions (16.3%), advanced care planning (14.2%), and disposition, such as discussions about options like hospice care (2.1%).

When it came to patient-led discussion with their care team about end-of life-care, more than double the percentage of those receiving early PC had those discussions compared with those in usual care (30.2% vs 14.5%).

However, Greer said that these numbers are still not high enough in either cohort: “Those rates are quite low, demonstrating that we can still do a lot of work in that arena.”

Greer also recommended more research on palliative care interventions by cancer type because the study reported QOL differences between patients with lung and GI cancers in each cohort.

Patients with lung cancer saw an improvement in QOL with early palliative care at 12 weeks, and then the improvement became even more pronounced by week 24. Meanwhile, both sets of patients with GI cancers had improvements in QOL by the 12-week time point, regardless of whether they received early palliative care.

“The quality of life and mood trajectories in these samples is really varied by cancer types and raises a number of important questions about further research,” he said. “First, should we be tailoring our palliative care interventions to different patient populations? As the cancer therapeutic world becomes more targeted and personalized, so should, perhaps, our patients’ palliative care interventions.”

Greer JA, El-Jawahri A, Pirl WF, et al. Randomized trial of early integrated palliative care. 

Patients with newly diagnosed incurable lung and GI cancer saw benefits from early palliative care services.

Palliative Care Needs Can Differ by Tumor Type, and Providing It Early Shows Benefits

Christopher R. Friese, PhD, RN, AOCN, FAAN, assistant professor, Division of System Leadership and Effectiveness Science, University of Michigan School of Nursing, discusses the benefits of using a systematic approach to assess toxicities of patients treated with chemotherapy.

Friese says there are a variety of approaches that clinicians currently use to assess symptoms, toxicities, and burdens on patients. Although many clinicians simply ask the patient how they are doing, Friese says he believes that clinicians should move towards a systematic approach where clinicians ask about specific events that are likely to occur during chemotherapy.

There is great value to providing patients with a tool, whether it’s a piece of paper, a recorded telephone call, or an electronic device, to systematically assess their toxicity, Friese says. By implementing a tool, clinicians can learn more about the side effects of novel drugs. Friese says asking patients to grade their toxicity also helps clinicians better adjust the care for the patient. With this being said, Friese says it is still unknown which approach is best. â€‹

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