Florian Scotté, MD, PhD
It was June 2010, and Jennifer Temel, MD, took the podium during the annual ASCO meeting. She presented the results of a randomized trial comparing standard of care with an early intervention approach by a mobile palliative care team called Early Palliative Care (EPC) in patients newly diagnosed with metastatic NSCLC.
The results confirmed an improvement in quality of life as measured on the Functional Assessment of Cancer Therapy-Lung (FACT-Lung) scale, particularly on the depression item on the PHQ9 questionnaire. The results also showed a 3-month survival gain in this population of patients.1 The positive results with respect to quality of life observed in this study were confirmed by several subsequent trials, particularly in the US.2,3 The results of these randomized trials have had a lasting impact on the evolution of patient care throughout the world. In France, the fifth national plan for the end of life, published on January 28, 2022, lists early assessment of palliative care patients among its three priorities.4
What is Early Palliative Care?
The definition of the EPC is similar in Europe, the US, and other regions. However, its implementation may vary according to the level of resources and according to the involvement of local academic societies. Associations such as AFSOS (French Speaking Association of Supportive Care in Cancer) in France, NICSO (Italian Network of Supportive Care in Cancer) in Italy, and AICSO (Associaçao de Investigaçao de Cuidados de Suporte em Oncologia) in Portugal promote EPC as well as early involvement of supportive care during the curable, localized stages of cancer.
The message that has emerged from different studies and groups is the importance of patient needs assessment and early multidisciplinary patient-centered management in conjunction with cancer treatments. Studies on the actions of EPC teams have shown that most of their work is focused on the management of symptoms related to cancer and its treatment, in addition to educational work.1,2,3,5
More recently, this approach has demonstrated an impact on overall survival in a population of Chinese patients undergoing management of unresectable metastatic esogastric cancer in a randomized comparison of early interdisciplinary supportive care versus standard support.6 The joint intervention of an oncologist, oncology nurse, dieticians, and psychologists improved survival from 11.9 to 14.8 months (HR, 0.68; 95% CI, 0.51 to 0.9; P = .021) in favor of the intervention arm.
Interdisciplinary Collaboration
The strength of this approach lies in joint management and most importantly in shared considerations on the appropriateness and adaptation of cancer treatments by focusing on the tumor target as much as on the patient and their environment. This has been underscored by the work of a Lancet Oncology committee, led by the Norwegian researcher Stein Kaasa, MD, PhD.7
This group has put forward the notion of integrative oncology, which promotes interactions between the various players in the patient’s care pathway, and the collaborative work of palliative and therapeutic cancer teams, to act in a coordinated manner. The main goal is to be able to analyze the patient’s situation through a global vision and to offer the patient the most personalized course of treatment possible.
The impact on survival—and quality of life—of patient self-assessment and personalized follow-up has been demonstrated in a randomized study comparing digital monitoring to standard of care.8 The intervention arm included follow-up by a specific team of coordination nurses, in liaison with the referral and cross disciplinary teams, with a digital reporting tool for symptoms experienced by the patient.
Following the same concept of remote monitoring by navigator nurses and within the framework of a randomized study versus standard of care, The CAPRI (Cancerologie Parcours Région Ile de France) study showed an improvement in relative dose intensity, patient satisfaction, and quality of life, as well as a decrease in severe toxicities and emergency room visits, in a cohort of patients receiving oral anticancer drugs.9
Integrating Early Palliative Care
A European review of the literature addressed the question, not whether to support EPC, but rather how to integrate palliative care into the patient’s journey. Assessment and support skills need to be effectively integrated early on, based on the patient’s needs and according to set objectives, allowing patients to remain hopeful.11 Such integration has remained a challenge.
Despite its proven benefits, palliative care often carries a negative connotation. It has historically been aimed at a population of patients with advanced, often refractory tumors and is commonly misinterpreted as an abandonment of active anti-cancer treatment. However, as Dr. Temel showed more than a decade ago, involvement of the EPC team does not influence the number of lines of treatment.
In the Temel study1, the same number of patients in each treatment arm received one line (p=0.30), two lines (p=0.86), three lines (p=0.83), four or more lines (p=0.64) or no lines (p=0.49) of treatment. The only impact found on cancer treatment was on the time at which injectable therapies were halted; these were stopped earlier in the EPC cohort compared with the standard of care cohort. No difference was found for the use of oral therapies in either cohort.
The impact of early intervention, specifically anticipating the occurrence of complications of cancer and its treatment was also evaluated in an Italian real-life observational study. An increased estimated survival probability at 12 months, from 45.5% (95% CI 37.6% to 55.0%) in the delayed group to 74.5% (95% CI 65.0% to 85.4%) in the early supportive/palliative care group has been reported, with significant improvement in performance status, pain, and Edmonton Symptom Assessment System items.10
Then why—despite its recognized value and active promotion by various palliative care teams—has EPC not been fully embraced? Is this a question of terminology and preconceived notions?
From Palliative to Early Supportive Care
Recently, the ESMO has taken a position in favor of improving the integration of supportive care into standard treatment to increase the quality of life and survival of patients with stage III non-small cell lung cancer, i.e., in the curative setting. One aim is to strengthen the patient before starting treatment by anticipating the occurrence of iatrogenic toxicities (physical activity, nutrition, prevention of esophageal radiation toxicities, anti-emetics, etc.) but also by providing support during treatment.12
This approach incorporates the recommendation for a patient-centered, integrated, multidisciplinary approach to all phases of care, from the time of diagnosis, throughout the patient’s treatment course, with an emphasis on patient-reported outcome programs.13
ESMO’s use of the term supportive care versus early palliative care may be key to improving adoption of multidisciplinary approaches to support patients. The terminology issue has been discussed by Zimmermann et al on the necessary evolution of the definition of palliative care.14
As proposed in Europe, we should move toward better terminology, e.g. “early personalized interdisciplinary management of all patients with cancer, whether localized or advanced.” This change in nomenclature integrates the whole of the patient’s pathway, whether in the curative setting or not.
Specifically, this is recalled in the definition of supportive care proposed by the Multinational Association of Supportive Care in Cancer: Supportive care in cancer is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side-effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship and end of life care are integral to supportive care.15
References:
- 1. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010
- 2. Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. Jama. 2009;302(7):741–9. https://doi.org/10.1001/jama.2009.1198.
- 3. Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, Moore M, Rydall A, Rodin G, Tannock I, Donner A, Lo C. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014 May 17;383(9930):1721-30. doi: 10.1016/S0140-6736(13)62416-2. Epub 2014 Feb 19. PMID: 24559581
- 4. https://solidarites-sante.gouv.fr/actualites/presse/communiques-de-presse/article/developpement-des-soins-palliatifs-et-accompagnement-de-la-fin-de-vie-la
- 5. Temel JS, Greer JA, El-Jawahri A, et al: Effects of early integrated palliative care in patients with lung and GI cancer: A randomized clinical trial. J Clin Oncol 35: 834-841, 2017
- 6. Zhihao Lu, MD, PhD1; Yu Fang, MPH2; Chang Liu et al. Early Interdisciplinary Supportive Care in Patients With Previously Untreated Metastatic Esophagogastric Cancer: A Phase III Randomized Controlled Trial. J Clin Oncol 39:748-756. © 2021
- 7. Kaasa S, Loge JH, Aapro M, et al. Integration of oncology and palliative care : a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-653..
- 8. Basch E, Deal AM, Dueck AC, et al: Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 318:197-198, 2017
- 9. Mir O, Ferrua M, Fourcade A, et al. Intervention combining Nurse Navigators (NNs) and a mobile application vs. standard of care (SOC) in cancer patients (pts) treated with oral anticancer agents (OAA): results of CAPRI, a single-center, randomized phase 3 trial. DOI: 10.1200/JCO.2020.38.15_suppl.2000 Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020) 2000-2000.
- 10. Elena Bandieri, Federico Banchelli, Fabrizio Artioli et al. Early versus delayed palliative/supportive care in advanced cancer: an observational study. BMJ Journals http://dx.doi.org/10.1136/bmjspcare-2019-001794
- 11. Gärtner J, Daun M, Wolf J, von Bergwelt-Baildon M, Hallek M. Early Palliative Care: Pro, but Please Be Precise! Oncol Res Treat. 2019;42(1-2):11-18. doi: 10.1159/000496184. Epub 2019 Jan 26. PMID: 30685764
- 12. D. De Ruysscher, C. Faivre-Finn, K. Nackaerts et al. Recommendation for supportive care in patients receiving concurrent chemotherapy and radiotherapy for lung cancer. Annals Oncol 2020; 31 (1): 41-49
- 13. Jordan K, Aapro M, Kaasa S, et al: European Society for Medical Oncology (ESMO) position paper on supportive and palliative care. Ann Oncol 29:36-43, 2018
- 14. Zimmermann ; Ryan, S., Wong, J., Chow, R. et al. Evolving Definitions of Palliative Care: Upstream Migration or Confusion?. Curr. Treat. Options in Oncol. 21, 20 (2020). https://doi.org/10.1007/s11864-020-0716-4
- 15. Consensus on the Core Ideology of MASCC. Definition of Supportive Care; http://www.mascc.org/index.php?Option=com_content&view=article&id=493:mascc-strategic-plan&catid=30:navigation (29 November 2017, date last accessed).
