Palliative Care Needs in a Unique Population

Patients with head and neck cancer have unique issues in terms of breathing, eating, swallowing, and speaking, Dr Bauman said.

The symptom and decision-making burden is also very high for these patients, Dr Kumar added.

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“Treatments often involve disfigurement, permanent impairments in ability to speak, communicate, eat, or swallow,” Dr Kumar said. “Thus, the medical decision support needs of these patients may be very high, along with risk of the decisional conflict and/or regret.”

In the study by Dr Patil and colleagues, patients who did not receive the early palliative care intervention still received supportive care, symptom management, counseling, nutritional support, social support, and optimization of appointments with other specialties, noted Katie Neuendorf, MD, FAAHPM, vice chair of the department of palliative and supportive care at Cleveland Clinic Cancer Center in Ohio.

“Therefore, much of the care considered ‘standard’ in this study includes the tenets of palliative care,” Dr Neuendorf said. “It is also possible that this study would have shown benefit if the authors looked beyond 3 months.”

Dr Bauman agreed, pointing out that overall survival in this study was very poor. The median overall survival was 5.73 months for the early palliative care arm and 5.4 months for the standard arm.

“No early palliative care study has had such short survival,” Dr Bauman pointed out.

She added that it’s possible that this patient population — given their extreme symptom burden — may need to be seen more often to see an impact. The median number of palliative care department visits was 5, but only one-quarter (24.4%) of patients had 2 or more palliative care visits.

More Assessments Needed

In their own discussion of the results, Dr Patil and colleagues noted that certain emotional and social subscales were not assessed. The researchers used the Functional Assessment of Cancer Therapy for Head and Neck Cancer (FACT-H&N) and the Edmonton Symptom Assessment System-revised (ESAS-r) at baseline and at 1, 2, and 3 months.

With FACT-H&N, the researchers captured a general score, a head and neck trial outcome index (TOI) score, and a head and neck total score. There were no statistically significant differences in any scores between the 2 study arms.

Dr Patil and colleagues noted that emotional and social subscales are not included in TOI. They wrote that, in early palliative care referrals, when symptom burden is lower, “TOI-like indices are unlikely to be affected and might explain the reason for the negative results of the current study.”

Endpoints based on patient satisfaction or communication goals seem more suitable for early palliative care studies, the authors wrote.

Dr Bauman agreed that the exclusion of emotional and social subscales could be problematic because one of the most pronounced effects of palliative care is on mood. She also pointed out that the ESAS-r is a “very rough assessment tool that doesn’t get at the details that you need if you are assessing mood.”

Dr Kumar added that “a more granular understanding of the psychosocial aspects of the patient experience might have shown some benefit to early palliative care” that was not captured by looking at symptom burden over a period of 12 weeks.