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Embedded palliative care for patients with metastatic colorectal cancer: a mixed-methods pilot study

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Abstract

Purpose

Palliative care is recommended for patients with metastatic cancer, but there has been limited research about embedded palliative care for specific patient populations. We describe the impact of a pilot program that provided routine, early, integrated palliative care to patients with metastatic colorectal cancer.

Methods

Mixed methods pre-post intervention cohort study at an academic cancer center. Thirty control then 30 intervention patients with metastatic colorectal cancer were surveyed at baseline and 1, 3, 6, 9, and 12 months thereafter about symptoms, quality-of-life, and likelihood of cure. We compared survey responses, trends over time, rates of advance care planning, and healthcare utilization between groups. Patients, family caregivers, and clinicians were interviewed.

Results

Patients in the intervention group were followed for an average of 6.5 months and had an average of 3.5 palliative care visits. At baseline, symptoms were mild (average 1.85/10) and 78.2% of patients reported good/excellent quality-of-life. Half (50.9%) believed they were likely to be cured of cancer. Over time, symptoms and quality-of-life metrics remained similar between groups, however intervention patients were more realistic about their likelihood of cure (p = 0.008). Intervention patients were more likely to have a surrogate documented (83.3% vs. 26.7%, p < 0.0001), an advance directive completed (63.3% vs. 13.3%, p < 0.0001), and non-full code status (43.3% vs. 16.7%, p < 0.03). All patients and family caregivers would recommend the program to others with cancer.

Conclusions

We describe the impact of an embedded palliative care program for patients with metastatic colorectal cancer, which improved prognostic awareness and rates of advance care planning.

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References

  1. WHO | WHO Definition of Palliative Care. In: WHO. https://www.who.int/cancer/palliative/definition/en/. Accessed 9 Jan 2020

  2. Parikh RB, Kirch RA, Smith TJ, Temel JS (2013) Early specialty palliative care--translating data in oncology into practice. N Engl J Med 369:2347–2351. https://doi.org/10.1056/NEJMsb1305469

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Brumley R, Enguidanos S, Jamison P, Seitz R, Morgenstern N, Saito S, McIlwane J, Hillary K, Gonzalez J (2007) Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc 55:993–1000. https://doi.org/10.1111/j.1532-5415.2007.01234.x

    Article  PubMed  Google Scholar 

  4. Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J, Hull JG, Li Z, Tosteson TD, Byock IR, Ahles TA (2009) Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial. JAMA 302:741–749. https://doi.org/10.1001/jama.2009.1198

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733–742. https://doi.org/10.1056/NEJMoa1000678

    Article  CAS  Google Scholar 

  6. Zimmermann C, Swami N, Krzyzanowska M et al (2014) Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet Lond Engl 383:1721–1730. https://doi.org/10.1016/S0140-6736(13)62416-2

    Article  Google Scholar 

  7. Haun MW, Estel S, Rücker G, Friederich HC, Villalobos M, Thomas M, Hartmann M (2017) Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 6:CD011129. https://doi.org/10.1002/14651858.CD011129.pub2

    Article  PubMed  Google Scholar 

  8. King JD, Eickhoff J, Traynor A, Campbell TC (2016) Integrated onco-palliative care associated with prolonged survival compared to standard care for patients with advanced lung cancer: a retrospective review. J Pain Symptom Manag 51:1027–1032. https://doi.org/10.1016/j.jpainsymman.2016.01.003

    Article  Google Scholar 

  9. Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, Dionne-Odom JN, Frost J, Dragnev KH, Hegel MT, Azuero A, Ahles TA (2015) Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol Off J Am Soc Clin Oncol 33:1438–1445. https://doi.org/10.1200/JCO.2014.58.6362

    Article  Google Scholar 

  10. Temel JS, Greer JA, El-Jawahri A et al (2017) Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol Off J Am Soc Clin Oncol 35:834–841. https://doi.org/10.1200/JCO.2016.70.5046

    Article  Google Scholar 

  11. Hoerger M, Greer JA, Jackson VA, Park ER, Pirl WF, el-Jawahri A, Gallagher ER, Hagan T, Jacobsen J, Perry LM, Temel JS (2018) Defining the elements of early palliative care that are associated with patient-reported outcomes and the delivery of end-of-life care. J Clin Oncol Off J Am Soc Clin Oncol 36:1096–1102. https://doi.org/10.1200/JCO.2017.75.6676

    Article  Google Scholar 

  12. Yoong J, Park ER, Greer JA, Jackson VA, Gallagher ER, Pirl WF, Back AL, Temel JS (2013) Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med 173:283–290. https://doi.org/10.1001/jamainternmed.2013.1874

    Article  PubMed  Google Scholar 

  13. Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, Lennes IT, Dahlin CM, Pirl WF (2011) Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol Off J Am Soc Clin Oncol 29:2319–2326. https://doi.org/10.1200/JCO.2010.32.4459

    Article  Google Scholar 

  14. Greer JA, Pirl WF, Jackson VA, Muzikansky A, Lennes IT, Heist RS, Gallagher ER, Temel JS (2012) Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J Clin Oncol Off J Am Soc Clin Oncol 30:394–400. https://doi.org/10.1200/JCO.2011.35.7996

    Article  Google Scholar 

  15. Muir JC, Daly F, Davis MS, Weinberg R, Heintz JS, Paivanas TA, Beveridge R (2010) Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manag 40:126–135. https://doi.org/10.1016/j.jpainsymman.2009.12.017

    Article  Google Scholar 

  16. Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, Ferrell BR, Loscalzo M, Meier DE, Paice JA, Peppercorn JM, Somerfield M, Stovall E, von Roenn J (2012) American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol Off J Am Soc Clin Oncol 30:880–887. https://doi.org/10.1200/JCO.2011.38.5161

    Article  Google Scholar 

  17. Wong A, Vidal M, Prado B et al (2019) Patients perspective of timeliness and usefulness of an outpatient supportive care referral at a comprehensive cancer center. J Pain Symptom Manag. https://doi.org/10.1016/j.jpainsymman.2019.04.027

  18. Glare PA (2013) Early implementation of palliative care can improve patient outcomes. J Natl Compr Cancer Netw JNCCN 11(Suppl 1):S3–S9

    Article  Google Scholar 

  19. Rocque GB, Cleary JF (2013) Palliative care reduces morbidity and mortality in cancer. Nat Rev Clin Oncol 10:80–89. https://doi.org/10.1038/nrclinonc.2012.211

    Article  PubMed  Google Scholar 

  20. Hui D, Bruera E (2016) Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol 13:159–171. https://doi.org/10.1038/nrclinonc.2015.201

    Article  PubMed  Google Scholar 

  21. Hui D, Kim YJ, Park JC, Zhang Y, Strasser F, Cherny N, Kaasa S, Davis MP, Bruera E (2015) Integration of oncology and palliative care: a systematic review. Oncologist 20:77–83. https://doi.org/10.1634/theoncologist.2014-0312

    Article  PubMed  Google Scholar 

  22. Rabow MW, Dahlin C, Calton B et al (2015) New frontiers in outpatient palliative care for patients with cancer. Cancer Control J Moffitt Cancer Cent 22:465–474. https://doi.org/10.1177/107327481502200412

    Article  Google Scholar 

  23. Davis MP, Temel JS, Balboni T, Glare P (2015) A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses. Ann Palliat Med 4:99–121. https://doi.org/10.3978/j.issn.2224-5820.2015.04.04

    Article  PubMed  Google Scholar 

  24. Back AL, Park ER, Greer JA, Jackson VA, Jacobsen JC, Gallagher ER, Temel JS (2014) Clinician roles in early integrated palliative care for patients with advanced cancer: a qualitative study. J Palliat Med 17:1244–1248. https://doi.org/10.1089/jpm.2014.0146

    Article  PubMed  PubMed Central  Google Scholar 

  25. Survival Rates for Colorectal Cancer. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/survival-rates.html. Accessed 9 Jan 2020

  26. Cleeland CS, Zhao F, Chang VT, Sloan JA, O’Mara AM, Gilman PB, Weiss M, Mendoza TR, Lee JW, Fisch MJ (2013) The symptom burden of cancer: evidence for a core set of cancer-related and treatment-related symptoms from the eastern cooperative oncology group symptom outcomes and practice patterns study. Cancer 119:4333–4340. https://doi.org/10.1002/cncr.28376

    Article  PubMed  Google Scholar 

  27. Merchant SJ, Brogly SB, Booth CM, et al (2019) Palliative care and symptom burden in the last year of Life: A Population-Based Study of Patients with Gastrointestinal Cancer. Ann Surg Oncol. https://doi.org/10.1245/s10434-019-07320-z

  28. Bischoff K, Yang E, Kojimoto G, Shepard Lopez N, Holland S, Calton B, Adkins SH, Cheng S, Miller BJ, Rabow MW (2018) What we do: key activities of an outpatient palliative care team at an academic cancer center. J Palliat Med 21:999–1004. https://doi.org/10.1089/jpm.2017.0441

    Article  PubMed  Google Scholar 

  29. Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K (1991) The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 7:6–9

    Article  CAS  Google Scholar 

  30. Steinhauser KE, Bosworth HB, Clipp EC, McNeilly M, Christakis NA, Parker J, Tulsky JA (2002) Initial assessment of a new instrument to measure quality of life at the end of life. J Palliat Med 5:829–841. https://doi.org/10.1089/10966210260499014

    Article  PubMed  Google Scholar 

  31. Steinhauser KE, Clipp EC, Bosworth HB, McNeilly M, Christakis NA, Voils CI, Tulsky JA (2004) Measuring quality of life at the end of life: validation of the QUAL-E. Palliat Support Care 2:3–14. https://doi.org/10.1017/s1478951504040027

    Article  PubMed  Google Scholar 

  32. Jacobsen PB, Donovan KA, Trask PC, Fleishman SB, Zabora J, Baker F, Holland JC (2005) Screening for psychologic distress in ambulatory cancer patients. Cancer 103:1494–1502. https://doi.org/10.1002/cncr.20940

    Article  PubMed  Google Scholar 

  33. Steinhauser KE, Voils CI, Clipp EC, Bosworth HB, Christakis NA, Tulsky JA (2006) “Are you at peace?”: one item to probe spiritual concerns at the end of life. Arch Intern Med 166:101–105. https://doi.org/10.1001/archinte.166.1.101

    Article  PubMed  Google Scholar 

  34. Lim CT, Tadmor A, Fujisawa D, MacDonald J, Gallagher ER, Eusebio J, Jackson VA, Temel JS, Greer JA, Hagan T, Park ER (2017) Qualitative research in palliative care: applications to clinical trials work. J Palliat Med 20:857–861. https://doi.org/10.1089/jpm.2017.0061

    Article  PubMed  PubMed Central  Google Scholar 

  35. Groh G, Vyhnalek B, Feddersen B, Führer M, Borasio GD (2013) Effectiveness of a specialized outpatient palliative care service as experienced by patients and caregivers. J Palliat Med 16:848–856. https://doi.org/10.1089/jpm.2012.0491

    Article  PubMed  Google Scholar 

  36. Dyar S, Lesperance M, Shannon R, Sloan J, Colon-Otero G (2012) A nurse practitioner directed intervention improves the quality of life of patients with metastatic cancer: results of a randomized pilot study. J Palliat Med 15:890–895. https://doi.org/10.1089/jpm.2012.0014

    Article  PubMed  PubMed Central  Google Scholar 

  37. Yennurajalingam S, Urbauer DL, Casper KLB, Reyes-Gibby CC, Chacko R, Poulter V, Bruera E (2011) Impact of a palliative care consultation team on cancer-related symptoms in advanced cancer patients referred to an outpatient supportive care clinic. J Pain Symptom Manag 41:49–56. https://doi.org/10.1016/j.jpainsymman.2010.03.017

    Article  Google Scholar 

  38. Prince-Paul M, Burant CJ, Saltzman JN, Teston LJ, Matthews CR (2010) The effects of integrating an advanced practice palliative care nurse in a community oncology center: a pilot study. J Support Oncol 8:21–27

    PubMed  Google Scholar 

  39. Follwell M, Burman D, Le LW et al (2009) Phase II study of an outpatient palliative care intervention in patients with metastatic cancer. J Clin Oncol Off J Am Soc Clin Oncol 27:206–213. https://doi.org/10.1200/JCO.2008.17.7568

    Article  Google Scholar 

  40. Barbera L, Seow H, Howell D, Sutradhar R, Earle C, Liu Y, Stitt A, Husain A, Sussman J, Dudgeon D (2010) Symptom burden and performance status in a population-based cohort of ambulatory cancer patients. Cancer 116:5767–5776. https://doi.org/10.1002/cncr.25681

    Article  PubMed  Google Scholar 

  41. Bischoff KE, Sudore R, Miao Y, Boscardin WJ, Smith AK (2013) Advance care planning and the quality of end-of-life care in older adults. J Am Geriatr Soc 61:209–214. https://doi.org/10.1111/jgs.12105

    Article  PubMed  Google Scholar 

  42. Silveira MJ, Kim SYH, Langa KM (2010) Advance directives and outcomes of surrogate decision making before death. N Engl J Med 362:1211–1218. https://doi.org/10.1056/NEJMsa0907901

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Smith AK, Facebook, Twitter, et al What is in the palliative care syringe? https://www.geripal.org/2013/01/what-is-in-palliative-care-syringe.html. Accessed 9 Jan 2020

  44. Kamal A, Bull J, Abernethy A (2013) What’s in the palliative care syringe?: association between specific palliative care interventions and improvement in quality of life (TH330-B). J Pain Symptom Manag 45:351–352. https://doi.org/10.1016/j.jpainsymman.2012.10.063

    Article  Google Scholar 

  45. Fadul N, Elsayem A, Palmer JL, del Fabbro E, Swint K, Li Z, Poulter V, Bruera E (2009) Supportive versus palliative care: what’s in a name?: a survey of medical oncologists and midlevel providers at a comprehensive cancer center. Cancer 115:2013–2021. https://doi.org/10.1002/cncr.24206

    Article  PubMed  Google Scholar 

  46. Sarradon-Eck A, Besle S, Troian J, Capodano G, Mancini J (2019) Understanding the barriers to introducing early palliative care for patients with advanced cancer: a qualitative study. J Palliat Med 22:508–516. https://doi.org/10.1089/jpm.2018.0338

    Article  PubMed  Google Scholar 

  47. Scibetta C, Kerr K, Mcguire J, Rabow MW (2016) The costs of waiting: implications of the timing of palliative care consultation among a cohort of decedents at a comprehensive cancer center. J Palliat Med 19:69–75. https://doi.org/10.1089/jpm.2015.0119

    Article  PubMed  Google Scholar 

  48. Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E (2014) Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer 120:1743–1749. https://doi.org/10.1002/cncr.28628

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

We would like to thank the Stupski Foundation for the funding to support this study.

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Authors and Affiliations

  1. Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, Box 0131, 533 Parnassus Avenue, San Francisco, CA, 94143, USA

    Kara E. Bischoff, Carly Zapata, Sarah Sedki, David L. O’Riordan & Michael W. Rabow

  2. Division of Hematology and Oncology, Department of Medicine, University of California, San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA

    Carling Ursem

  3. Department of Psychology, Central Michigan University, Mount Pleasant, MI, USA

    Ashley Eaton England

  4. Osher Center for Integrative Medicine, Department of Medicine, University of California. San Francisco, San Francisco, CA, USA

    Nicole Thompson

  5. Division of Hematology and Oncology, Department of Medicine and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA

    Ariceli Alfaro & Chloe E. Atreya

Authors
  1. Kara E. Bischoff
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  2. Carly Zapata
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  3. Sarah Sedki
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  10. Chloe E. Atreya
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Corresponding author

Correspondence to Kara E. Bischoff.

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Conflict of interest

None of the authors have a financial relationship with the Stupski Foundation, which funded this study. None of the authors have any other conflicts of interest to report. We retain full control of the primary data and will allow the journal to review data if requested.

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Bischoff, K.E., Zapata, C., Sedki, S. et al. Embedded palliative care for patients with metastatic colorectal cancer: a mixed-methods pilot study. Support Care Cancer 28, 5995–6010 (2020). https://doi.org/10.1007/s00520-020-05437-6

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