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. 2019 Dec 1;5(12):1702-1709.
doi: 10.1001/jamaoncol.2019.3105.

Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration

Donald R Sullivan  1   2   3 , Benjamin Chan  4 , Jodi A Lapidus  4 , Linda Ganzini  2   5 , Lissi Hansen  6 , Patricia A Carney  7 , Erik K Fromme  8   9 , Miguel Marino  4   7 , Sara E Golden  2 , Kelly C Vranas  1   2 , Christopher G Slatore  1   2   3   10
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Free PMC article

Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration

Donald R Sullivan et al. JAMA Oncol. .
Free PMC article

Abstract

Importance: Palliative care is a patient-centered approach associated with improvements in quality of life; however, results regarding its association with a survival benefit have been mixed, which may be a factor in its underuse.

Objective: To assess whether early palliative care is associated with a survival benefit among patients with advanced lung cancer.

Design, setting, and participants: This retrospective population-based cohort study was conducted among patients with lung cancer who were diagnosed with cancer between January 1, 2007, and December 31, 2013, with follow-up until January 23, 2017. Participants comprised 23 154 patients with advanced lung cancer (stage IIIB and stage IV) who received care in the Veterans Affairs health care system. Data were analyzed from February 15, 2019, to April 28, 2019.

Exposure: Palliative care defined as a specialist-delivered palliative care encounter received after lung cancer diagnosis.

Main outcomes and measures: The primary outcome was survival. The association between palliative care and place of death was also examined. Propensity score and time-varying covariate methods were used to calculate Cox proportional hazards and to perform regression modeling.

Results: Of the 23 154 patients enrolled in the study, 57% received palliative care. The mean (SD) age of participants was 68 (9.5) years, and 98% of participants were men. An examination of the timing of palliative care receipt relative to cancer diagnosis found that palliative care received 0 to 30 days after diagnosis was associated with decreases in survival (adjusted hazard ratio [aHR], 2.13; 95% CI, 1.97-2.30), palliative care received 31 to 365 days after diagnosis was associated with increases in survival (aHR, 0.47; 95% CI, 0.45-0.49), and palliative care received more than 365 days after diagnosis was associated with no difference in survival (aHR, 1.00; 95% CI, 0.94-1.07) compared with nonreceipt of palliative care. Receipt of palliative care was also associated with a reduced risk of death in an acute care setting (adjusted odds ratio, 0.57; 95% CI, 0.52-0.64) compared with nonreceipt of palliative care.

Conclusions and relevance: The results suggest that palliative care was associated with a survival benefit among patients with advanced lung cancer. Palliative care should be considered a complementary approach to disease-modifying therapy in patients with advanced lung cancer.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Hansen reported receiving grants from the National Institute of Nursing Research of the National Institutes of Health and airfare and honorarium for an in-person presentation at the 2018 Association of VA Hematology/Oncology Annual Meeting outside the submitted work. Dr Fromme reported receiving grants from the Gordon and Betty Moore Foundation, The John A. Hartford Foundation, and The Pew Charitable Trusts, and compensation for coauthorship and presentation of a paper entitled “Serious Illness Workforce Training” at a University of California, San Francisco, summit from the Gordon and Betty Moore Foundation outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patients Who Received Palliative Care by Facility
Caterpillar plot of palliative care use by facility in the US Department of Veterans Affairs (VA) health care system by proportion point estimates (with 95% Wald CIs), rank ordered from the lowest to highest users of palliative care between January 1, 2007, and December 31, 2013. Twenty-two facilities that provided care for less than 40 patients over the study period were not included in this plot because of the instability of effect estimates. Among the 109 VA facilities plotted, mean palliative care use was 57%, as indicated by the dashed blue horizontal line. Facilities are grouped by color-coded regions. VISN indicates Veterans Integrated Service Network; NE, northeast; MW, midwest; SE, southeast; SW, southwest; and W, west. eMethods 1 in the Supplement contains more information.
Figure 2.
Figure 2.. Association of Survival With Receipt of Palliative Care (PC)
Survival functions were estimated using time-dependent Cox proportional hazards regression models from the time of cancer diagnosis to the time of death or censoring (measured in days). Each function was estimated using mean values for model covariates. Among groups that received PC, survival estimates before the receipt of PC were excluded. Patients were stratified based on the timing of PC receipt. PC 0-30 indicates PC received 0 to 30 days after diagnosis; PC 31-365, PC received 31 to 365 days after diagnosis; PC >365, PC received more than 365 days after diagnosis; and NO PC, no PC received. Model estimates were based on 5720 participants in PC 0-30, 6055 participants in PC 31-365, 1331 participants in PC >365, and 10 038 participants in NO PC at the time of cancer diagnosis, and curves represent the hypothetical survival for patients in each group.
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