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      Effects of Early Integrated Palliative Care on Caregivers of Patients with Lung and Gastrointestinal Cancer: A Randomized Clinical Trial

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          Abstract

          This article reports a single‐center randomized clinical trial that evaluated the effect of early integrated specialty palliative care on patient‐ and caregiver‐reported outcomes in patients with newly‐diagnosed, incurable cancers. It was hypothesized that caregivers of patients assigned to early integrated palliative care would report lower psychological distress and better quality of life compared with caregivers of patients assigned to usual oncology care.

          Abstract

          Background.

          The family and friends (caregivers) of patients with advanced cancer often experience tremendous distress. Although early integrated palliative care (PC) has been shown to improve patient‐reported quality of life (QOL) and mood, its effects on caregivers’ outcomes is currently unknown.

          Materials and Methods.

          We conducted a randomized trial of early PC integrated with oncology care versus oncology care alone for patients who were newly diagnosed with incurable lung and noncolorectal gastrointestinal cancers and their caregivers. The early PC intervention focused on addressing the needs of both patients and their caregivers. Eligible caregivers were family or friends who would likely accompany patients to clinic visits. The intervention entailed at least monthly patient visits with PC from the time of diagnosis. Caregivers were encouraged, but not required, to attend the palliative care visits. We used the Hospital Anxiety and Depression Scale (HADS) and Medical Health Outcomes Survey Short‐Form to assess caregiver mood and QOL.

          Results.

          Two hundred seventy‐five caregivers (intervention n = 137; control n = 138) of the 350 patients participated. The intervention led to improvement in caregivers’ total distress (HADS‐total adjusted mean difference = −1.45, 95% confidence interval [CI] −2.76 to −0.15, p = .029), depression subscale (HADS‐depression adjusted mean difference = −0.71, 95% CI −1.38 to −0.05, p = .036), but not anxiety subscale or QOL at week 12. There were no differences in caregivers’ outcomes at week 24. A terminal decline analysis showed significant intervention effects on caregivers’ total distress (HADS‐total), with effects on both the anxiety and depression subscales at 3 and 6 months before patient death.

          Conclusion.

          Early involvement of PC for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers’ psychological symptoms. This work demonstrates that the benefits of early, integrated PC models in oncology care extend beyond patient outcomes and positively impact the experience of caregivers.

          Implications for Practice.

          Early involvement of palliative care for patients with newly diagnosed lung and gastrointestinal cancers leads to improvement in caregivers’ psychological symptoms. The findings of this trial demonstrate that the benefits of the early, integrated palliative care model in oncology care extend beyond patient outcomes and positively impact the experience of caregivers. These findings contribute novel data to the growing evidence base supporting the benefits of integrating palliative care earlier in the course of disease for patients with advanced cancer and their caregivers.

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          Most cited references17

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          Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial.

          Randomized controlled trials have supported integrated oncology and palliative care (PC); however, optimal timing has not been evaluated. We investigated the effect of early versus delayed PC on quality of life (QOL), symptom impact, mood, 1-year survival, and resource use.
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            Interventions with family caregivers of cancer patients: meta-analysis of randomized trials.

            Family caregivers of cancer patients receive little preparation, information, or support to perform their caregiving role. However, their psychosocial needs must be addressed so they can maintain their own health and provide the best possible care to the patient. The purpose of this article is to analyze the types of interventions offered to family caregivers of cancer patients, and to determine the effect of these interventions on various caregiver outcomes. Meta-analysis was used to analyze data obtained from 29 randomized clinical trials published from 1983 through March 2009. Three types of interventions were offered to caregivers: psychoeducational, skills training, and therapeutic counseling. Most interventions were delivered jointly to patients and caregivers, but they varied considerably with regard to dose and duration. The majority of caregivers were female (64%) and Caucasian (84%), and ranged in age from 18 to 92 years (mean age, 55 years). Meta-analysis indicated that although these interventions had small to medium effects, they significantly reduced caregiver burden, improved caregivers' ability to cope, increased their self-efficacy, and improved aspects of their quality of life. Various intervention characteristics were also examined as potential moderators. Clinicians need to deliver research-tested interventions to help caregivers and patients cope effectively and maintain their quality of life. Copyright 2010 American Cancer Society, Inc.
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              Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care.

              Understanding of prognosis among terminally ill patients impacts medical decision making. The aims of this study were to explore perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer (NSCLC) and to examine the effect of early palliative care on these views over time. Patients with newly diagnosed metastatic NSCLC were randomly assigned to receive either early palliative care integrated with standard oncology care or standard oncology care alone. Participants completed baseline and longitudinal assessments of their perceptions of prognosis and the goals of cancer therapy over a 6-month period. We enrolled 151 participants on the study. Despite having terminal cancer, one third of patients (46 of 145 patients) reported that their cancer was curable at baseline, and a majority (86 of 124 patients) endorsed getting rid of all of the cancer as a goal of therapy. Baseline perceptions of prognosis (ie, curability) and goals of therapy did not differ significantly between study arms. A greater percentage of patients assigned to early palliative care retained or developed an accurate assessment of their prognosis over time (82.5% v 59.6%; P = .02) compared with those receiving standard care. Patients receiving early palliative care who reported an accurate perception of their prognosis were less likely to receive intravenous chemotherapy near the end of life (9.4% v 50%; P = .02). Many patients with newly diagnosed metastatic NSCLC hold inaccurate perceptions of their prognoses. Early palliative care significantly improves patient understanding of prognosis over time, which may impact decision making about care near the end of life.
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                Author and article information

                Contributors
                ael-jawahri@partners.org
                Journal
                Oncologist
                Oncologist
                10.1002/(ISSN)1549-490X
                The Oncologist
                oncologist
                theoncologist
                The Oncologist
                AlphaMed Press
                1083-7159
                1549-490X
                11 September 2017
                December 2017
                1 June 2018
                : 22
                : 12 ( doiID: 10.1002/onco.v22.12 )
                : 1528-1534
                Affiliations
                [ a ] Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital , Boston, Massachusetts, USA
                [ b ] Department of Medicine, Harvard Medical School , Boston, Massachusetts, USA
                [ c ] Division of Oncology, Department of Medicine, University of Washington Seattle , Seattle, Washington, USA
                [ d ]Geisel School of Medicine at Dartmouth , Lebanon, New Hampshire, USA
                Author notes

                Disclosures of potential conflicts of interest may be found at the end of this article.

                [*] [* ]Correspondence: Areej El‐Jawahri, M.D., Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, Massachusetts 02114, USA. Telephone: 617‐726‐5765; e‐mail: ael-jawahri@ 123456partners.org
                Article
                ONCO12250
                10.1634/theoncologist.2017-0227
                5728034
                28894017
                beae221c-d406-456e-9314-9d588713dac2
                © AlphaMed Press 2017
                History
                : 16 May 2017
                : 31 July 2017
                Page count
                Pages: 7
                Categories
                26
                Symptom Management and Supportive Care

                Oncology & Radiotherapy
                caregiver,distress,palliative care,caregiver depression,quality of life
                Oncology & Radiotherapy
                caregiver, distress, palliative care, caregiver depression, quality of life

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