Opinion: Stepped Palliative Care Achieves Consistent Outcomes with Enhanced Efficiency in Patients With Lung Cancer

Amanda Brink, DNP, APRN, FNP-BC, AOCNP

In 2010, a landmark study published in The New England Journal of Medicine fundamentally shifted the approach to palliative care in patients with metastatic non-small-cell lung cancer. This study by Temel et al. demonstrated that early integration of palliative care, alongside standard oncologic care, not only significantly improved quality of life but also extended overall survival. Patients receiving early palliative care reported fewer depressive symptoms and less aggressive end-of-life care compared to those who received standard care alone. These findings emphasize the critical role of early palliative care integration in the treatment of patients with lung cancer, highlighting its benefits in improving both quality of life and overall survival.¹

As the demand for palliative care services increases, there is a growing need for adequately trained professionals who can deliver this specialized care. Addressing this challenge requires a multifaceted approach, including expanding palliative care education and training programs, increasing funding for palliative care services, and fostering interdisciplinary collaboration among healthcare providers. Strengthening the palliative care workforce is essential to meeting the needs of patients with lung cancer and fully realizing the benefits of early palliative care integration.

A Stepped Approach to Palliative Care

To address the increased demand for palliative care services, Temel et al. developed a stepped palliative care intervention.²

The authors conducted a prospective, non-blinded, randomized, multisite clinical trial among patients with newly diagnosed advanced lung cancer or mesothelioma. Patients were randomized in a 1:1 fashion to either early palliative care or stepped palliative care. In the early palliative care group, patients were scheduled for palliative care visits every 4 weeks and were seen during hospital admissions if hospitalized. In the stepped palliative care group, patients had an initial palliative care visit within 4 weeks of enrollment, followed by additional palliative care visits scheduled only when there was a change in cancer treatment due to disease progression, treatment toxicity, or after a hospital admission.

A total of 510 patients were randomized to stepped palliative care (n = 250) or early palliative care (n = 257).

Quality-of-life scores for the patients at week 24, measured by the Functional Assessment of Cancer Therapy-Lung (FACT-L), showed that stepped palliative care was noninferior to early palliative care (adjusted mean score: 100.6 vs 97.8; difference: 2.9; lower 1-sided 95% confidence limit: –0.1; P < .001).

By week 24, patients in the stepped palliative care group had significantly fewer palliative care visits compared to those in the early palliative care group (2.4 visits vs 4.7 visits). This trend continued through week 48, with the stepped palliative care group having fewer visits (3.8 visits vs 7.7 visits). The reduction in visits was significant (P < .001).

The proportion of patients who discussed end-of-life care preferences was noninferior in the stepped palliative care group compared to the early palliative care group (30.4% vs 33.0%). Among deceased participants, a similar proportion in each group received hospice services (71.9% in stepped palliative care vs 77.2% in early palliative care), but those in the stepped palliative care group had a shorter hospice length of stay (19.5 days vs 34.6 days).

Nursing Considerations

Oncology and palliative care nurses can advocate for the implementation of a stepped palliative care intervention for all patients, not just those enrolled in a formal clinical trial. This approach ensures that patients receive timely and appropriate palliative care based on their changing needs.

Nurses play a crucial role in educating patients and caregivers about the stepped care model, helping them understand when to seek additional palliative care due to changes in treatment or hospitalization. The finding of a shorter hospice length of stay in the stepped palliative care group highlights the importance of timely hospice referrals and coordination.

Oncology nurses can work closely with the oncology team and hospice care providers to facilitate a smooth transition to hospice care, ensuring patients and families receive the necessary support during this critical time.

Oncology nurses can collaborate with their team members, including oncologists and advanced practice providers, to ensure effective communication with the palliative care team whenever there are changes in treatment.

In conclusion, stepped palliative care intervention presents a viable and effective approach to managing the growing demand for palliative care services. It ensures that patients receive appropriate care tailored to their evolving needs, ultimately improving quality of life and optimizing resource utilization. As frontline caregivers, nurses play a crucial role in the successful implementation and advocacy of this model, ensuring that patients receive the best possible care throughout their cancer journey.

References

1. 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(8):733-742. doi:10.1056/NEJMoa1000678
2. Temel JS, Jackson VA, El-Jawahri A, et al. Stepped Palliative Care for Patients With Advanced Lung Cancer: A Randomized Clinical Trial. JAMA. Published online June 2, 2024. doi:10.1001/jama.2024.10398