Early Supportive/Palliative Care Intervention in Lung Cancer

Ashique Ahamed

Central Manchester University Hospitals NHS Foundation Trust

Outline

• Lung Cancer Incidence

• Symptom burden in Lung Cancer

• Evidence for early Supportive/Palliative care intervention

• Future plans

Lung Cancer Incidence

• Third most common cancer in the UK

• Accounts for 13% of all cancers

• 44% in age >75 yrs.

• Most diagnosed at late stage

• More common in people living in deprived areas

Lung Cancer statistics

• 5 year survival 8.4%

• One year survival -30%

• Most common cancer death in the UK

• Mortality rates projected to decrease for men but increase for women

Symptom Burden in Lung Cancer

• Pain (90%)

• Respiratory problems (94%)

• Cough (93%)

• Lack of Appetite (98%)

• Fatigue (98%)

• Depression (upto 40%)

• Fear and Anxiety(16-23%)

“Sympotms often present at the time of diagnosis”

Early Intervention

• Early Referral

• Early assessment for symptoms

• Reduce incidence of treatment toxicity

• Support for the patient and family

• Support for staff

• Improved quality of life

Evidence for Early Intervention

Early Palliative Care in Patients with NSCLC. Temel et al NEJM 210 • RCT

• 151 patients

• Stand care (N=74) Vs. Early Palliative care (N=77)

• Results :

Domain Early Pall Care Standard Care

Fact-L Score 98.0 91.5

Depression 16 38

Median Survival

(Months)

11.6 8.9

Zimmerman et al :Lancet 2014

• Early Palliative Care for patents with advanced cancer

• Cluster randomised controlled trial

• Results: patients assigned to early pall care showed significant improved QOL at 3-4 moths , improved symptom burden and improved satisfaction with care.

Bakitas et al JAMA:2009

Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer :RCT

Method: 4 weekly educational sessions . Then monthly phone calls.

Results: Improved QOL , mood and improved symptom control in the EPC group

Enhanced Supportive Care-Christie NHS Foundation Trust

• Earlier involvement of supportive care services

• Supportive care teams that work together

• A more positive approach to supportive care

• Cutting-edge and evidence-based practice in supportive care

• Technology to improve communication

• Best practice in (SACT) chemotherapy care

Macmillan Cancer Improvement Programme

Early Referral to Palliative Care Pilot

Early Referral to Palliative

Care • NMGH Lung oncology clinic

• New diagnosis of lung cancer

• Prognosis <3 months

• Complex physical and/or psychosocial symptoms

• Study period June-July 2016

• Patients attending the lung oncology clinic

Results

• Total 17 patients

• 76% <3 months prognosis

• 24%complex physical and psychosocial symptoms

• 65% referrals made to community pall care teams

• 41%on GSF register

• Further pilots planned for CMFT/UHSM

Barriers to Referral

• Perception around palliative care (deals with only dying patients)

• Reactive rather than proactive approach

• Prognosis based

• Delayed identification of symptom burden, QOL indicators

• Resource limitations

Screening Tool for Referral

Integrated Palliative Outcome

Scale (IPOS) • Validated tool

• Holistic tool

• Assessment and outcome tool

• Enables oncologist to screen patients that may require Supportive/Palliative Care input

• Overview of the patient issues prior to the initial assessment

Model of Palliative Care

“Although often Palliative care involvement is at the latter stages of the disease trajectory”

Supportive Versus Palliative Care: What’s in a Name?

• Easier for oncologists to refer early

• Removes barriers and association with EOLC

• Hope and positivity

Supportive Versus Palliative Care: What's in a Name? A Survey of Medical Oncologists and Midlevel Providers at a Comprehensive Cancer Centre .Fadul et al Cancer May 2009

The New Approach

• Standardised referral pathway

• Screening tools (IPOS)

• Enhanced supportive care clinics. Proactive approach

(Christie Enhanced Supportive Care Clinic)

• Citywide MCIP pilot projects

• “Rebranding “

Supportive care Vs Palliative Care