Earlier Palliative Care Improves QOL and Cuts Cost

ORLANDO—Allowing advanced cancer patients to start palliative care without giving up aggressive treatment substantially increased end-of-life hospice enrollment in one study and reduced cost of care in another. Both studies were presented at the 38th Annual Meeting of the American Society of Clinical Oncology (ASCO).

Frederick J. Meyers, MD, medical director of the hospice program at the University of California, Davis, Medical Center, Sacramento, reported that 91% of patients who received palliative care while enrolled in phase I/II chemotherapy trials eventually enrolled in hospice (abstract 1440). They also had higher quality-of-life (QOL) scores on the Functional Assessment of Cancer Therapy (FACT-G) than control patients who did not receive extra palliative services. Only 20% of the control group went on to hospice.

John W. Finn, MD, medical director of Hospice of Michigan, a statewide program based in Detroit, presented a preliminary cost analysis showing a 27% reduction in Medicare costs for terminally ill patients who received palliative care in a similar experiment (abstract 1452). These patients also declined less on QOL measures than a control group of terminal patients who received standard care.

While data are available for only 55 patients out of 160 enrolled in the Michigan trial, Dr. Finn suggested the final analysis might show the patients living longer than their prognoses. Eligible patients had a life expectancy of less than 6 months, but many are still alive 7 to 8 months later, he said.

No survival differences have been reported in the California trial, but Dr. Meyers said the patients who received early palliative care were more likely to finish all their chemotherapy cycles than patients in the control group. A nurse and a social worker visited the patients at home, addressing symptom management and offering emotional support while discussing end-of-life issues.

The California study was small, with 44 patients in the palliative care group and 20 in the control arm. The National Institutes of Health has awarded a $2.5 million grant for a larger multicenter investigation of the simultaneous care model. It will be led by Dr. Meyers, who is also director of the West Coast Center for Palliative Education and Research and chair of internal medicine at UC Davis.

In the Michigan study, a palliative care nurse coordinated ongoing treatments and hospice care for the patients. The patients continued to be treated by participating oncologists at a comprehensive cancer center, two community-based cancer centers, and private practices. Some patients never stopped seeking aggressive treatments, Dr. Finn said.

Avoiding the ‘Terrible Choice’

Both studies were designed to relieve patients of having to make what Dr. Finn called "the terrible choice." When cancer becomes advanced, patients and their families "have to decide whether to continue ongoing treatments that may be aggressive, painful, expensive, and burdensome, or to go to hospice and get maximum comfort care," he said.

Because the word hospice is so strongly associated with end of life, the Michigan program deliberately avoided "the H word" in describing the palliative program. "In order to buffer this harsh reality, we gave it a different name, but it’s hospice care—hospice plus," Dr. Finn said. "It allowed the doctors to do whatever they deemed necessary and appropriate." The choice is especially cruel for patients in clinical trials, Dr. Meyers said, because being admitted to a study often means that the oncologists do not expect them to survive much longer. "It’s false hope to think that phase I-II studies are going to help them get better or live longer," he said. "And it’s unethical not to prepare them for those results."

Cost savings were not a primary objective of either study, but the investigators each suggested that early palliative care would prove less expensive than having patients wait until their last weeks to go into hospice—if they go at all.

"I think, if done correctly, the net cost will be close to zero because if patients and families are given the support to address QOL issues, they won’t pursue ill-advised chemotherapy," Dr. Meyers said. "Using ad hoc chemotherapy as a surrogate for addressing quality of life is not only fallacious but it’s bad care."

Dr. Finn said that the extrapolated Medicare cost in his study was $2,540 less per patient receiving palliative care because these patients used less chemotherapy and received less diagnostic, professional, and hospital services. They had the same number of scheduled outpatient visits but were less likely to be rushed to the emergency room in the last weeks of life. "The last hospitalization was effectively avoided because families feeling supported decided to keep their loved ones at home at the end," he said.