A new study has shed light on how palliative care interventions may improve patient outcomes. According to data presented at the 2017 Palliative and Supportive Care in Oncology Symposium,1 patients with incurable cancer who received early integrated palliative care had an increased use of active coping strategies, including positive reframing and acceptance, from baseline to 24 weeks compared to a standard oncology care group. What’s more, this increase in active coping strategies was associated with better quality of life and fewer symptoms of depression.
“Based on these results, improving adaptive coping strategies in patients with incurable cancer may lead to better outcomes,” said Jamie M. Jacobs, PhD, a psychologist at Harvard Medical School, Boston. “Palliative care appears to provide patients with the skills to cope effectively with life-threatening illness.”
As Dr. Jacobs reported, although a recent trial by Temel et al showed that early integrated palliative care improved quality of life and reduced depressive symptoms in patients with newly diagnosed incurable lung and gastrointestinal cancers, the mechanisms underlying these benefits remain unclear.2
“We wanted to see whether patients who received early integrated palliative care had an increase or decrease in the use of certain coping strategies,” said Dr. Jacobs. “We then analyzed the degree to which changes in coping mediated improvements we see in patient-reported outcomes of quality of life and depression.”
Palliative care appears to provide patients with the skills to cope effectively with life threatening illness.— Jamie M. Jacobs, PhD
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From May 2011 to July 2015, Drs. Temel, Greer, and colleagues at Massachusetts General Hospital enrolled 350 patients with newly diagnosed incurable lung or noncolorectal gastrointestinal cancer. Investigators randomized the patients to receive either early palliative care integrated with oncology care or oncology care alone (unless palliative care consultation was requested).
From the time of diagnosis, patients in the intervention group met with palliative care clinicians at least every 4 weeks in conjunction with standard oncology care. These visits were offered by phone if necessary, said Dr. Jacobs, who also noted that palliative care clinicians met with all hospitalized patients in the intervention group over the course of the study.
Patients completed self-report measures of quality of life (Functional Assessment of Cancer Therapy–General), depressive symptoms (Patient Health Questionnaire–9), and use of various coping strategies (Brief Cope) at baseline, 12 weeks, and 24 weeks. As Dr. Jacobs reported, active or approach-oriented coping strategies involved positive reframing and acceptance of cancer diagnosis and treatment as well as taking action to make the situation better. Avoidant coping, on the other hand, was associated with self-blame and denial.
“Avoidant coping is a more passive approach,” Dr. Jacobs explained. “We don’t see these patients engaging as meaningfully because they’re living in a more resistant state.”
Investigators then applied linear regression analysis to assess the effects of the early palliative care intervention on active and avoidant coping strategies. Finally, a multiple mediation regression was modeled to examine whether changes in the use of coping strategies mediated intervention effects on quality of life and depressive symptoms.
Improved Coping Strategies, Patient-Reported Outcomes
Patients who received early integrated palliative care showed increased use of active approach–oriented coping strategies from baseline to 24 weeks compared to patients who received oncology care alone. In addition, patients in the control group had a slight reduction in the “ability to cope actively with approach-oriented techniques,” said Dr. Jacobs. Although not statistically significant, patients in the intervention arm also had a slight reduction in the use of avoidant coping strategies compared to patients who received standard oncology care alone.
Improvements in 24-week quality of life in patients assigned to palliative care were also partially mediated by an increased use of active coping strategies (indirect effect = 1.27, 95% confidence interval [CI] = 0.31–2.86) but not by a decreased use of avoidant coping. Similarly, said Dr. Jacobs, reductions in 24-week depressive symptoms in patients receiving palliative care were partially mediated by an increased use of active coping strategies (indirect effect = –0.42, 95% CI = –0.89 to –0.08) but not by a decreased use of avoidant coping.
“Our group previously reported that patients in the early palliative care intervention experienced a decrease in depressive symptoms,” said Dr. Jacobs. “It turned out that patients who had improved active coping had corresponding reductions in depressive mood, and this indirect effect was also significant.”
Nevertheless, while palliative care may improve quality of life and depressive symptoms, there are other contributing factors. According to investigators, 42% of the effect can be attributed to changes observed in active coping, but symptom management, spiritual support, and improved self-efficacy are also driving these outcomes.
Dr. Jacob’s colleagues are conducting a qualitative study involving audio recordings of palliative care encounters to elucidate more precisely the communication strategies being used by palliative care clinicians to teach or bolster the use of adaptive coping strategies.
Brief but Cost-Effective Interventions
Gary Rodin, MD, Professor of Psychiatry at the University of Toronto and Head of the Department of Supportive Care at Princess Margaret Cancer Centre, called the results “impressive,” particularly with respect to the search for mechanisms to explain the effects.3
“This kind of research is very important because it brings us closer to understanding how palliative care consultations may affect psychosocial outcomes, which helps us build an evidence base for early palliative care integration and what we ought to be doing,” said Dr. Rodin. “However, we must also recognize the power and limits of cross-sectional tests of mediation; directionality and causality cannot be determined from such analyses.”
These are very brief, very cost-effective interventions, and I think this is powerful evidence that they can show benefit.— Gary Rodin, MD
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According to Dr. Rodin, while the emphasis on active coping and positive reframing in interventions is “extremely important,” there are also limits to these strategies with disease progression.
“What is common with advanced disease is that many of the problems that emerge and losses that occur cannot easily be eliminated with active coping or be positively reframed,” he explained. “Patients may need help to process their feelings about these losses and their fears about what may lie ahead while also continuing to find meaning in their lives.”
“Nevertheless, this study highlights the psychological benefit that patients can derive from conversations with physicians and from minimal specialized interventions,” Dr. Rodin continued. “These are very brief, very cost-effective interventions, and this is powerful evidence that they can show benefit.” ■
DISCLOSURE: Drs. Jacobs and Rodin reported no conflicts of interest.
1. Jacobs JM, Greer JA, El-Jawahri A, et al: The positive effects of early integrated palliative care on patient coping strategies, quality of life, and depression. 2017 Palliative and Supportive Care in Oncology Symposium. Abstract 92. Presented October 28, 2017.
2. Temel JS, Greer JA, El-Jawahri A, et al: Effects of early integrated palliative care in patients with lung and GI cancer: A randomized clinical trial. J Clin Oncol 35:834-841, 2017.