Nelson J. Chao, MD, MBA
Dr. Chao indicated no relevant conflicts of interest.
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med. 2010;363:733-742.
pal·li·ate: (v) To alleviate (a disease or its symptoms) without effecting a cure; to relieve or ease (physical or emotional suffering) temporarily or superficially; to mitigate the sufferings of
– Oxford English Dictionary, 2010
It is not often that one writes about metastatic lung cancer in The Hematologist. But, there have been two excellent recent articles on the need for palliation and end-of-life care. The first was a moving and thought-provoking article, “Letting Go,” in The New Yorker (August 2, 2010) by Atul Gawande. In this article, he is able to portray the pain and complexity of difficult medical decisions in the face of terrible and incontrovertible odds for both the patients and their families. More importantly, the humanism needed on the medical provider side to understand all of the stated and especially unstated concerns is an area in which we (as hematologists) are generally not very adept. More recently, Temel et al. presented a landmark article in the New England Journal of Medicine comparing outcomes among 151 metastatic lung cancer patients randomized to early referral to outpatient palliative care and standard oncology services versus standard oncology services alone. Those patients who were randomized to both experienced significantly:
- Lengthened survival (11.6 months vs. 8.9 months, p = 0.02)
- Improved quality of life (mean score on the FACT-L scale 98.0 vs. 91.5; p = 0.03)
- Reduced depressive symptoms (16% vs. 38%; p = 0.01)
- Fewer aggressive end-of-life interventions (33 percent vs. 54 percent, p = 0.05)
It is important to emphasize that palliative care is not synonymous with hospice care (a common concern that we, both patients and physicians, are giving up). While there may be situations where they overlap, a focus of symptom management should always be a goal in any condition. The data from this randomized study clearly demonstrate that not only was there a benefit in terms of improvement in quality of life, but there was even a survival advantage. These data suggest that it is a win-win situation, in which standard therapy and palliative care resulted in the best outcomes for patients.
How broadly applicable are these results? The survival benefit is certainly encouraging, and these data need to be reproduced. It is not possible from this study to determine what led to the improvement. Was the benefit simply due to more face time with providers? Early management or preemptive interventions could also lead to less depression or fewer symptoms of the disease or treatments. Understanding which components of palliative care led to the improved outcomes will be necessary if such approaches are broadened to other clinical settings. Moreover, given the reduced end-of-life interventions combined with better survival, studies of cost effectiveness of such an approach in the new era of health-care reform are also required. These data, and other similar studies, suggest that a focus on palliation should be a critical component of patient care; this too is targeted therapy, albeit not of a particular molecular pathway. In any case, we keep in mind our Hippocratic oath, part of which states:
“… I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.”
–The Hippocratic Oath: Modern Version; Louis Lasagna, 1964, WGBH Foundation.
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