The emerging role of palliative medicine in the treatment of lung cancer patients
ABSTRACTThe symptom burden of patients with lung cancer is extensive and includes loss of appetite, dyspnea, and other symptoms that lead to decreased quality of life. Randomized controlled trial data indicate that early palliative care improves quality of life and depressive symptoms and may extend survival in advanced non–small cell lung cancer compared with standard care. Combining an appetite stimulant (megestrol acetate) with an atypical antipsychotic (olanzapine) leads to greater weight gain and appetite improvement compared with an appetite stimulant alone. Cancer-related dyspnea appears to be a “central” effect that stems from altered afferent inputs in the setting of ventilatory muscle weakness; various treatment options that have shown success in treating cancer-related dyspnea are opioids, tunneled pleural catheters, bilevel positive airway pressure, and nebulized furosemide. Buprenorphine is a unique opioid with activity at mu and nociceptin receptors (also called opioid-receptor-like receptors); it improves pain states dominated by central sensitization.
Several important developments in the palliative care of patients with lung cancer have occurred over the past few years, including publication of a landmark study comparing early with as-needed palliative care, the release of new data on the treatment of cancer-related anorexia, elucidation of new mechanisms and treatment options for dyspnea, and the availability of buprenorphine. This article reviews these emerging concepts.
LUNG CANCER SYMPTOMS: COMMON AND SEVERE
The symptom burden of lung cancer is usually great. At least 80% of patients experience fatigue, 65% suffer loss of appetite, 77% have cough, 73% report dyspnea (both from local symptoms and weight loss), 57% have chest pain, and 17% have hemoptysis.1
When symptoms are present, they are usually severe. Thirty-eight percent of the patients who report fatigue have severe fatigue, 47% have inadequate appetite to the point of requiring intervention, and more than one-half of patients who have chest pain require opioids for relief.1
Symptom frequency and severity are worse in individuals who survive 3 months or less.1 Increasing symptom burden is therefore prognostically important, particularly in patients with advanced stages of lung cancer. As a result, self-assessment of quality of life has a significant ability to predict survival in patients with advanced non–small cell lung cancer (NSCLC).2
Patients with lung cancer tend to suffer from groups of symptoms or symptom clusters. Lutz et al1 found that 79% of patients reported three or more symptoms; these results were similar to the findings of a study by Hollen et al,3 in which 81% of patients suffered from three or more symptoms, all them severe except for cough.
EARLY PALLIATIVE CARE HAS CLINICAL BENEFITS
A landmark study by Temel et al4 examined the benefits of early palliative care integrated with standard oncologic care versus standard oncologic care and palliative care only “as needed” on patient-reported outcomes, the use of health services, and the quality of end-of-life care among patients with metastatic NSCLC. The study was a prospective, nonblinded, randomized, controlled trial of outpatients conducted at a single center. The intervention was based on guidelines from the National Consensus Project for Quality Palliative Care, with specific attention to symptom management, goals of care, decision-making regarding treatment, and coordination of care. Patients assigned to the intervention met monthly with both a palliative care service and an oncologist, and 90% of the patients randomized to intervention complied with at least 50% of the visits.
Measures of health-related quality of life and mood were obtained using the Functional Assessment of Cancer Therapy-Lung (FACT-L), the Hospital Anxiety and Depression Scale, and the 9-item depression scale of the Patient Health Questionnaire.
Measures of health care service utilization included use of antitumor therapy within 14 days of death, late or no referral to hospice, hospital admissions, and emergency room visits. Patients were considered to have received aggressive care if they met any one of the following three criteria: chemotherapy within 14 days of death, no hospice care, or admission to hospice within 3 days of death.
Compared with standard care, early palliative care was associated with an increase in the number of advance directives, earlier hospice referral (11 days vs 4 days), fewer hospitalizations and emergency room visits, and fewer instances of inappropriate oncologic care (defined as chemotherapy within 14 days of death). The percentage of patients with depressed mood was also lower among those assigned to early palliative care versus standard care (16% vs 38%).
A 2.7-month difference in median survival (P = .02) in favor of the group assigned to early palliative care was also observed, although survival was not a primary end point of the trial. This outcome needs to be validated in future studies.
