Early routine specialist palliative care for patients recently diagnosed with malignant pleural mesothelioma did not impact quality of life, an international multicenter study has found.1 “Regular early specialist palliative care for patients was not associated with improved quality of life, as compared to standard care alone, with referral to palliative care based on clinical judgment and symptom burden as needed. We think it’s likely our current standard of care in the United Kingdom and Australia is already meeting patients’ needs,” said Fraser Brims, MBChB, MD, MRCP, FRACP, Deputy Director of the Institute for Respiratory Health in Western Australia and Curtin University.
The results came from the RESPECT-MESO trial, which evaluated the benefit of offering early palliative care regardless of perceived need, and were presented at the 2017 International Association for the Study of Lung Cancer (IASLC) World Conference on Lung Cancer.
It’s likely our current standard of care in the United Kingdom and Australia is already meeting patients’ needs.— Fraser Brims, MBChB, MD, MRCP, FRACP
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These findings are in contrast to the landmark 2010 study by Temel et al, which reported that early intervention with a palliative care protocol significantly improved quality of life, symptoms of depression, and overall survival in patients with metastatic non–small cell lung cancer (NSCLC).2
“At first, I was surprised by the results, and we have evaluated: Is this a real effect? We do think it is a real signal in terms of the trial design and the quality of the data,” Dr. Brims said. “If we look at the current provision of care in Australia and the United Kingdom... we have specialists, senior thoracic cancer nurses, and chemotherapy nurses who support patients in their journey, and that is already standard care now. It is possible, therefore, that the addition of specialist palliative care to all-comers—regardless of perceived need—hasn’t made much of a difference to a patient’s unmet needs.”
Mesothelioma, caused by exposure to asbestos, has a high symptom burden and is relatively resistant to treatment. Average survival for patients with mesothelioma is less than 1 year. Dr. Brims and his team aimed to evaluate whether the benefit observed in the Temel study of NSCLC could also be achieved in mesothelioma.
The 24-site study randomly assigned 174 patients to receive standard care alone or with early specialist palliative care for up to 24 weeks. Patients’ median age was 73 years; 80% were men, and 78% had an epithelioid histology; Eastern Cooperative Oncology Group (ECOG) performance status was 1 in 62% of patients and 0 in 38%. At baseline, 77% of patients reported dyspnea, and 57% had chest pain. More than half of patients (59%) underwent at least one cycle of chemotherapy.
Patients in the early specialist care group had specialist palliative care visits every 4 weeks throughout the study period. Researchers used the European Organisation for Research and Treatment of Cancer (EORTC) 30-item Quality-of-Life (QLQ-C30) questionnaire to assess quality of life and the General Health Questionnaire (GHQ-12) to assess depression and anxiety at baseline and at every 4 weeks up to 24 weeks. The mean change adjusted for baseline in EORTC QLQ-C30 global health status quality-of-life score at 12 weeks served as the primary endpoint.
No Differences Between Arms
In the intervention arm, 78% of patients completed all monthly visits at 12 weeks and 53%, by 24 weeks. A total of 15 patients (17%) crossed over from the control arm to receive specialist palliative care by 12 weeks. At 24 weeks, 17% of participants had died. Overall median survival was 52 weeks.
The mean global health status quality-of-life score at 12 weeks was 60.2 for the specialist care group and 59.5 for the control group—for a mean difference of 1.8, which was not statistically significant (P = .60). At 24 weeks, these scores were 61.3 and 63.7, respectively (P = .55).
The GHQ-12, anxiety and depression scores were also similar between control and specialist care patients at 12 and 24 weeks. The researchers observed no significant differences in any of the quality-of-life variables between the two groups, and there were no differences in survival between the groups, Dr. Brims reported.
“Is this a true signal? There was no hint of a trend in quality of life or mood,” he noted. He believes it is unlikely the study was underpowered to detect differences.
Possible Explanations for Different Outcomes
There may be several reasons why this study showed a different outcome than the study published in 2010, Dr. Brims suggested. “The different finding of this study as compared to the Temel paper may be explained by the different settings and health-care systems the studies were performed in or perhaps can be explained by the different disease,” Dr. Brims proposed. “Although the results were surprising—as, intuitively, many of us felt the intervention was likely to help—this highlights why we need high-quality multicenter studies like this.” ■
DISCLOSURE: Dr. Brims reported no conflicts of interest.
1. Brims F, Gunatilake S, Lawrie I, et al: RESPECT-MESO: An international randomised controlled trial to assess early specialist palliative care in malignant pleural mesothelioma. 2017 World Conference on Lung Cancer. Abstract OA 02.05. Presented October 16, 2017.
2. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363:733-742, 2010.