Palliative Care in Lung Cancer: When to Start


Purpose of Review

Despite recent advances in the care of patients with advanced non-small cell lung cancer (NSCLC), significant morbidity and mortality remains. Symptoms caused by the cancer and its treatments can be profoundly debilitating. Palliative care aims to reduce this burden. In this review, we discuss the definition, purpose, benefits, and optimal timing of palliative care in advanced NSCLC.

Recent Findings

Several studies evaluating the value of early palliative care for patients with advanced NSCLC and other advanced malignancies have identified benefits for patients, caregivers, and health systems.


For patients with advanced NSCLC, introduction of palliative care early in the disease course improves quality of life and even overall survival. Early institution of palliative care should become standard of care for patients with advanced NSCLC.

This is a preview of subscription content, access via your institution.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.

    SEER Database. Cancer Stat Facts: Lung and Bronchus Cancer. 2018 [cited 2018 4]; Available from:

  2. 2.

    Goldstraw P, Chansky K, Crowley J, Rami-Porta R, Asamura H, Eberhardt WE, et al. The IASLC lung cancer staging project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer. Journal of thoracic oncology: official publication of the International Association for the Study of Lung Cancer. 2016;11(1):39–51. Epub 2016/01/15

    Article  Google Scholar 

  3. 3.

    Wao H, Mhaskar R, Kumar A, Miladinovic B, Djulbegovic B. Survival of patients with non-small cell lung cancer without treatment: a systematic review and meta-analysis. Syst Rev. 2013;2:10.

    Article  Google Scholar 

  4. 4.

    Nichols L, Saunders R, Knollmann FD. Causes of death of patients with lung cancer. Arch Pathol Lab Med. 2012;136(12):1552–7.

    Article  Google Scholar 

  5. 5.

    Iyer S, Roughley A, Rider A, Taylor-Stokes G. The symptom burden of non-small cell lung cancer in the USA: a real-world cross-sectional study. Support Care Cancer. 2014;22(1):181–7.

    Article  Google Scholar 

  6. 6.

    World Health Organization. WHO Definition of Palliative Care [cited 2018 4]; Available from:

  7. 7.

    Hui D, Mori M, Watanabe SM, Caraceni A, Strasser F, Saarto T, et al. Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol. 2016;17(12):e552–e9.

    Article  Google Scholar 

  8. 8.

    • Dionne-Odom JN, Azuero A, Lyons KD, Hull JG, Tosteson T, Li Z, et al. Benefits of early versus delayed palliative care to informal family caregivers of patients with advanced cancer: outcomes from the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33(13):1446–52. Epub 2015/03/25. This study evaluated the effect of timing of palliative care intervention for caregivers, showing the benefit of instituting services earlier rather than later.

    Article  Google Scholar 

  9. 9.

    Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42. Epub 2010/09/08

    CAS  Article  Google Scholar 

  10. 10.

    Pirl WF, Temel JS, Billings A, Dahlin C, Jackson V, Prigerson HG, et al. Depression after diagnosis of advanced non-small cell lung cancer and survival: a pilot study. Psychosomatics. 2008;49(3):218–24.

    Article  Google Scholar 

  11. 11.

    Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med. 2012;367(17):1616–25. Epub 2012/10/26

    CAS  Article  Google Scholar 

  12. 12.

    Temel JS, Greer JA, Admane S, Gallagher ER, Jackson VA, Lynch TJ, et al. 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. 2011;29(17):2319–26. Epub 2011/05/11

    Article  Google Scholar 

  13. 13.

    •• Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA, et al. Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol. 2017;35(8):834–41. This study confirmed the results of the 2010 NEJM study by the same group and expanded the study to patients with advanced GI cancers.

    Article  Google Scholar 

  14. 14.

    • Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721–30. This randomized controlled trial studied benefits of early palliative care intervention in patients with advanced malignancies (including lung, breast, gynecologic, and gastrointestinal malignancies).

    Article  Google Scholar 

  15. 15.

    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.

    CAS  Article  Google Scholar 

  16. 16.

    Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, et al. Early versus delayed initiation of concurrent palliative oncology care: patient outcomes in the ENABLE III randomized controlled trial. J Clin Oncol. 2015;33(13):1438–45. Epub 2015/03/25

    Article  Google Scholar 

  17. 17.

    NCCN Guidelines. Non-small cell lung Cancer. 2018; Available from:

  18. 18.

    Ford DW, Koch KA, Ray DE, Selecky PA. Palliative and end-of-life care in lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e498S–512S.

    Article  Google Scholar 

  19. 19.

    •• Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM, et al. Integration of palliative care into standard oncology care: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017;35(1):96–112. Practice guidelines proposed by ASCO for integration of palliative care into care for patients with advanced malignancies.

    Article  Google Scholar 

  20. 20.

    Greer JA, Tramontano AC, McMahon PM, Pirl WF, Jackson VA, El-Jawahri A, et al. Cost analysis of a randomized trial of early palliative care in patients with metastatic nonsmall-cell lung cancer. J Palliat Med. 2016;19(8):842–8.

    Article  Google Scholar 

  21. 21.

    May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17(9):1054–63. Epub 2014/07/02

    Article  Google Scholar 

  22. 22.

    Cassel JB, Kerr KM, Kalman NS, Smith TJ. The business case for palliative care: translating research into program development in the U.S. J Pain Symptom Manag. 2015;50(6):741–9. Epub 2015/08/25

    Article  Google Scholar 

  23. 23.

    Triplett DP, LeBrett WG, Bryant AK, Bruggeman AR, Matsuno RK, Hwang L, et al. Effect of palliative care on aggressiveness of end-of-life care among patients with advanced cancer. J Oncol Pract. 2017;13(9):e760–e9. Epub 2017/08/23

    Article  Google Scholar 

  24. 24.

    Humphreys J, Harman S. Late referral to palliative care consultation service: length of stay and in-hospital mortality outcomes. The Journal of Community and Supportive Oncology. 2014;12(4):129–36. Epub 2014/06/28

    Article  Google Scholar 

  25. 25.

    Edens PS, Harvey CD, Gilden KM. Developing and financing a palliative care program. Am J Hosp Palliat Care. 2008;25(5):379–84. Epub 2008/06/10

    Article  Google Scholar 

  26. 26.

    Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med. 2016;19(1):8–15. Epub 2015/09/30

    Article  Google Scholar 

  27. 27.

    von Gunten CF. Secondary and tertiary palliative care in US hospitals. JAMA. 2002;287(7):875–81. Epub 2002/02/20

    Article  Google Scholar 

  28. 28.

    Hui D, Elsayem A, De la Cruz M, Berger A, Zhukovsky DS, Palla S, et al. Availability and integration of palliative care at US cancer centers. JAMA. 2010;303(11):1054–61. Epub 2010/03/18

    CAS  Article  Google Scholar 

  29. 29.

    Bickel KE, McNiff K, Buss MK, Kamal A, Lupu D, Abernethy AP, et al. Defining high-quality palliative care in oncology practice: an American Society of Clinical Oncology/American Academy of Hospice and Palliative Medicine guidance statement. J Oncol Pract. 2016;12(9):e828–38. Epub 2016/08/18

    Article  Google Scholar 

  30. 30.

    Sweeney CJ, Zhu J, Sandler AB, Schiller J, Belani CP, Langer C, et al. Outcome of patients with a performance status of 2 in Eastern Cooperative Oncology Group study E1594: a phase II trial in patients with metastatic nonsmall cell lung carcinoma. Cancer. 2001;92(10):2639–47. Epub 2001/12/18

    CAS  Article  Google Scholar 

  31. 31.

    Brustugun OT, Sprauten M, Helland A. Real-world data on nivolumab treatment of non-small cell lung cancer. Acta Oncol. 2017;56(3):438–40. Epub 2016/11/29

    CAS  Article  Google Scholar 

  32. 32.

    Masuda E, Sista AK, Pua BB, Madoff DC. Palliative procedures in lung cancer. Semin Intervent Radiol. 2013;30(2):199–205.

    Article  Google Scholar 

  33. 33.

    NCCN Guidelines. Adult Cancer Pain. 2018 [cited 2018 4]; Available from:

  34. 34.

    Guidelines N. Palliative Care. 2018 [cited 2018 4]; Available from:

  35. 35.

    Shih A, Jackson KC 2nd. Role of corticosteroids in palliative care. J Pain Palliat Care Pharmacother. 2007;21(4):69–76.

    Article  Google Scholar 

  36. 36.

    Lossignol D. A little help from steroids in oncology. J Transl Int Med. 2016;4(1):52–4.

    Article  Google Scholar 

  37. 37.

    Farbicka P, Nowicki A. Palliative care in patients with lung cancer. Contemp Oncol (Pozn). 2013;17(3):238–45.

    Google Scholar 

  38. 38.

    Barnes H, McDonald J, Smallwood N, Manser R. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst Rev. 2016;3:CD011008.

    PubMed  Google Scholar 

  39. 39.

    Galbraith S, Fagan P, Perkins P, Lynch A, Booth S. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manag. 2010;39(5):831–8.

    Article  Google Scholar 

  40. 40.

    Navigante AH, Cerchietti LC, Castro MA, Lutteral MA, Cabalar ME. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manag. 2006;31(1):38–47.

    CAS  Article  Google Scholar 

  41. 41.

    Wildiers H, Dhaenekint C, Demeulenaere P, Clement PM, Desmet M, Van Nuffelen R, et al. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manag. 2009;38(1):124–33.

    CAS  Article  Google Scholar 

  42. 42.

    Back IN, Jenkins K, Blower A, Beckhelling J. A study comparing hyoscine hydrobromide and glycopyrrolate in the treatment of death rattle. Palliat Med. 2001;15(4):329–36.

    CAS  Article  Google Scholar 

  43. 43.

    Mucke M, Mochamat, Cuhls H, Peuckmann-post V, Minton O, Stone P, et al. Pharmacological treatments for fatigue associated with palliative care: executive summary of a Cochrane Collaboration systematic review. J Cachexia Sarcopenia Muscle. 2016;7(1):23–7. Epub 2016/04/12

    Article  Google Scholar 

  44. 44.

    Cramp F, Byron-Daniel J. Exercise for the management of cancer-related fatigue in adults. Cochrane Database Syst Rev. 2012;11:CD006145. Epub 2012/11/16

    PubMed  Google Scholar 

  45. 45.

    • Dionne-Odom JN, Hull JG, Martin MY, Lyons KD, Prescott AT, Tosteson T, et al. Associations between advanced cancer patients' survival and family caregiver presence and burden. Cancer medicine. 2016;5(5):853-62. Epub 2016/02/11. This study identified an adverse effect of increased caregiver burden on patient survival.

    Article  Google Scholar 

  46. 46.

    • Sun V, Grant M, Koczywas M, Freeman B, Zachariah F, Fujinami R, et al. Effectiveness of an interdisciplinary palliative care intervention for family caregivers in lung cancer. Cancer. 2015;121(20):3737-45. This study evaluated benefits of palliative care for caregivers.

    Article  Google Scholar 

  47. 47.

    Wentlandt K, Krzyzanowska MK, Swami N, Rodin GM, Le LW, Zimmermann C. Referral practices of oncologists to specialized palliative care. J Clin Oncol. 2012;30(35):4380–6. Epub 2012/10/31

    Article  Google Scholar 

  48. 48.

    Zimmermann C, Swami N, Krzyzanowska M, Leighl N, Rydall A, Rodin G, et al. Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ: Canadian Medical Association journal = journal de l'Association medicale canadienne. 2016;188(10):E217–27. Epub 2016/04/20.

    Article  Google Scholar 

  49. 49.

    Temel JS, McCannon J, Greer JA, Jackson VA, Ostler P, Pirl WF, et al. Aggressiveness of care in a prospective cohort of patients with advanced NSCLC. Cancer. 2008;113(4):826–33. Epub 2008/07/12

    Article  Google Scholar 

  50. 50.

    Ersek M, Miller SC, Wagner TH, Thorpe JM, Smith D, Levy CR, et al. Association between aggressive care and bereaved families' evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities. Cancer. 2017;123(16):3186–94. Epub 2017/04/19

    CAS  Article  Google Scholar 

  51. 51.

    Mack JW, Chen K, Boscoe FP, Gesten FC, Roohan PJ, Weeks JC, et al. Underuse of hospice care by Medicaid-insured patients with stage IV lung cancer in New York and California. J Clin Oncol. 2013;31(20):2569–79.

    Article  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Tracey L. Evans.

Ethics declarations

Conflict of Interest

Prianka Bhattacharya declares that she has no conflict of interest.

Scott K. Dessain declares that he has no conflict of interest.

Tracey L. Evans has received compensation from Genentech for service on speaker’s bureaus and as a consultant.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Lung Cancer

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Bhattacharya, P., Dessain, S.K. & Evans, T.L. Palliative Care in Lung Cancer: When to Start. Curr Oncol Rep 20, 90 (2018).

Download citation


  • Palliative care
  • Advanced non-small cell lung cancer
  • Palliation
  • Caregiver
  • Symptom management
  • Quality of life