by Jill Clendening

One of the most important advances in palliative care in oncology over the past 15 years has been the recognition that palliative care specialists can improve cancer patients’ outcomes well before their end of life.

Palliative care is specialized care provided to individuals with a serious illness that focuses on decision-making support, pain and symptom management, as well as psychosocial interventions to improve quality of life.

Several past randomized clinical trials have shown palliative care specialists can improve the quality of life and lengthen the survival of patients receiving chemotherapy for metastatic cancer. Other randomized trials have shown palliative care benefits patients undergoing curative treatments, like bone marrow transplantation for hematologic malignancies, or cancers of the blood or blood-forming tissue.

Because of this evidence, in 2016 the American Society of Clinical Oncology recommended specialist palliative care be included along with active treatment for advanced malignancies.

Palliative care specialists and oncology surgeons from Vanderbilt University Medical Center and the VA Tennessee Valley Healthcare System have published a study in JAMA Surgery providing evidence that the addition of palliative care services earlier in the disease process, specifically to patients having surgery for cancer, does not demonstrate benefits to the patients. The study also indicates the provision of palliative care at the point of surgery does not increase the patients’ distress or harm them in any way.

“Palliative care specialists are in short supply, so we don’t want to expand the patient population for palliative care specialists without good data that they help that population,” said lead author Myrick “Ricky” Shinall Jr., MD, PhD, associate professor of Surgery and Medicine.

“The study was important to test whether this further move upstream in the cancer care continuum would be a good use of a limited resource.

“Prior to the study, I could come up with an explanation of why the intervention would benefit patients since the research had been continually discovering the benefits of specialist palliative care for patients earlier and earlier in the cancer care continuum. I could also come up with the rationale that the issues patients face while undergoing cancer surgery are vastly different than what they face undergoing chemotherapy or stem cell transplant, and they therefore would have much lower levels of unmet palliative care needs and would not show much evidence of benefit from seeing palliative care specialists. It turns out the latter is the case, but we could only know that by doing the trial.”

The study was a randomized clinical trial in which 235 adults undergoing major abdominal operations for cancer were randomly assigned to either an intervention group where they received specialist palliative care or to a control group where they received usual care.

The intervention group received a preoperative consultation with a board-certified palliative care physician or nurse practitioner, inpatient visits from these palliative care specialists at least twice weekly during their hospital stay, three follow-up visits or phone calls with the specialists between their hospital discharge and postoperative day 90, and an inpatient palliative care specialist visit if the patient was readmitted to the hospital.

Assessments measured physical and functional quality of life, depression, anxiety, caregiver burden and survival, and there was no evidence that a specialist palliative care intervention significantly improved outcomes.

The study did show no adverse effects or additional stress to the patients who received the palliative care intervention.

“One of the concerns people had when the study started was whether incorporating palliative care specialists in perioperative care would distress the patients, and our data really don’t show any evidence of distress or harm caused by the intervention,” Shinall said.

“This matches up with our personal experience delivering the palliative care intervention, which we found the patients welcomed. So, one important lesson from this study is that surgeons should not be reluctant to call for palliative care consultations based on a fear this will upset their patients.”

The study team is building on the strengths of this research and designing a new, multicenter randomized controlled trial (RCT) to test whether a palliative care intervention is beneficial for patients being evaluated for liver transplantation. A second multicenter RCT is also planned to test whether a consultation with geriatricians can improve the outcomes of older surgical oncology patients.

This research was funded by grants AG068436, 3AG060085, CA090625 and TR002243 from the National Institutes of Health.