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How effective is early palliative care in adult cancer patients?

Commentary by Dr Carla Ripamonti and Dr Raffaele Giusti

The important paper of Jennifer Temel published in the New England Journal of Medicine in 2010 (Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer) demonstrating the efficacy of early palliative care in patients with lung cancer has definitely paved the way for an integrated and multidisciplinary approach to oncological disease. Today, there is an increasing number of evidence reported in literature about the usefulness and the benefit of early patient assessment and symptoms management during the whole course of care, from disease-oriented treatments to the best supportive care. For this reason, Cochrane Collaboration published the first systematic review about the effectiveness of early palliative care in adult cancer patients in June 2017. The aim of this review was to find evidence for the effects of early palliative care on quality of life, survival, depression, and symptom intensity in people with advanced cancer. Seven randomized clinical trials with a total of 1614 patients were analyzed. The authors conclude that the role of early palliative care should be encouraged, as it shows benefit in terms of quality of life and intensity of perceived symptoms over the standard of care (which is often not clearly defined and above all very heterogeneous). However, compared with standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analyzed at post treatment = 1028; evidence of low certainty). Moreover, there is no significant data regarding the rate of depression and overall survival which was an important observation resulting from Temel's work even though it did not fall into the primary objectives of the study. Results from seven studies that analyzed 1054 participants post treatment suggest a small effect with regard to significantly lower symptom intensity in early palliative care compared with the control condition.

According to the authors, the results should be interpreted with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. The data obtained in this Cochrane systematic review surely suffers from non-homogeneity in the methodology of studies and many other biases. We hope that subsequent studies (currently, 20 studies are ongoing) will be able to clarify these issues and provide more details.

Early palliative care for adults with advanced cancer
Haun MW, Estel S, Rücker G, Friederich HC, Villalobos M, Thomas M, Hartmann M
Cochrane Database Syst Rev. 2017 Jun 12;6:CD011129. doi: 10.1002/14651858.CD011129.pub2. [Epub ahead of print]

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