Every once in awhile amidst the weekly deluge of medical articles comes a show-stopper that has the potential to change the way we practice.
Rarer yet is the article that not only changes how we practice, but calls into question why we do what we do.
This recent article from the New England Journal of Medicine is just such an article. Before you bolt, let me simplify it for you.
Here’s the quick take:
The authors enrolled 150 patients with advanced lung cancer and split them up between usual care, which included chemotherapy, and an intervention arm, in which they received the same standard of care treatment plus early enrollment in palliative care.
Now lung cancer, mind you, is one of the bad ones. By the time it’s advanced, i.e. spread either across the chest or elsewhere into a different part of the body (“metastasis”), the prognosis is poor. Survival is less than one year, on average. (Hey! Didn’t I just read a recent article on why doctors are so bad at predicting survival?)
Palliative care is medical care that treats for patient comfort foremost, and does not seek to cure the underlying chronic illness, be it cancer or other advanced disease, like congestive heart failure or emphysema.
It’s often confused with hospice, which is the level of care (or physical place) for patients with a less than 6 month prognosis. Hospice usually involves being less aggressive with the medical care, while palliative care aggressively seeks comfort for the patient, sometimes involving complex treatment. The confusion comes because palliative care is not mutually exclusive to hospice (indeed, they often overlap), nor is it mutually exclusive with standard disease treatment, as evidenced in this article. Cure and comfort can both be vigorously pursued.
In fact, one reason why palliative care gets invoked so infrequently is that families and medical folks often conflate palliation with hospice.
The study results were, in some ways, not so surprising: The patients that received early palliative care along with their cancer treatment had lower self-reported scores for depression and anxiety, and higher scores on “quality of life” scales. [Don't stop the presses. This proves the obvious.]
But surprisingly, the group that received palliative care early survived longer. An average of about two months longer. Not so much, you say. But mathematically, more than 25% longer. Remember, average survival in advanced lung cancer is about a year. When you’re talking survival in months, an extra two months is a lot: more grandkids, more valedictories, more closure, more goodbyes; maybe even more off the bucket list.
And this was achieved without more chemotherapy. Just more contact (on average, 4 visits to palliative care). And more addressing of symptoms.
Isn’t providing comfort and symptom control why we went into medicine in the first place?
Sometimes doing less in the way of fighting for a cure offers more in terms of meaning. And as this study shows, more of life itself….