Christopher Lo

Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial

BACKGROUND Patients with advanced cancer have reduced quality of life, which tends to worsen towards the end of life. We assessed the effect of early palliative care in patients with advanced cancer on several aspects of quality of life. METHODS The study took place at the Princess Margaret Cancer Centre (Toronto, ON, Canada), between Dec 1, 2006, and Feb 28, 2011. 24 medical oncology clinics were cluster randomised (in a 1:1 ratio, using a computer-generated sequence, stratified by clinic size and tumour site [four lung, eight gastrointestinal, four genitourinary, six breast, two gynaecological]), to consultation and follow-up (at least monthly) by a palliative care team or to standard cancer care. Complete masking of interventions was not possible; however, patients provided written informed consent to participate in their own study group, without being informed of the existence of another group. Eligible patients had advanced cancer, European Cooperative Oncology Group performance status of 0-2, and a clinical prognosis of 6-24 months. Quality of life (Functional Assessment of Chronic Illness Therapy--Spiritual Well-Being [FACIT-Sp] scale and Quality of Life at the End of Life [QUAL-E] scale), symptom severity (Edmonton Symptom Assessment System [ESAS]), satisfaction with care (FAMCARE-P16), and problems with medical interactions (Cancer Rehabilitation Evaluation System Medical Interaction Subscale [CARES-MIS]) were measured at baseline and monthly for 4 months. The primary outcome was change score for FACIT-Sp at 3 months. Secondary endpoints included change score for FACIT-Sp at 4 months and change scores for other scales at 3 and 4 months. This trial is registered with ClinicalTrials.gov, number NCT01248624. FINDINGS 461 patients completed baseline measures (228 intervention, 233 control); 393 completed at least one follow-up assessment. At 3-months, there was a non-significant difference in change score for FACIT-Sp between intervention and control groups (3·56 points [95% CI -0·27 to 7·40], p=0·07), a significant difference in QUAL-E (2·25 [0·01 to 4·49], p=0·05) and FAMCARE-P16 (3·79 [1·74 to 5·85], p=0·0003), and no difference in ESAS (-1·70 [-5·26 to 1·87], p=0·33) or CARES-MIS (-0·66 [-2·25 to 0·94], p=0·40). At 4 months, there were significant differences in change scores for all outcomes except CARES-MIS. All differences favoured the intervention group. INTERPRETATION Although the difference in quality of life was non-significant at the primary endpoint, this trial shows promising findings that support early palliative care for patients with advanced cancer. FUNDING Canadian Cancer Society, Ontario Ministry of Health and Long Term Care.

Pathways to distress: The multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients

We tested a model in which psychosocial and disease-related variables act as multiple protective and risk factors for psychological distress in patients with metastatic cancer. We hypothesized that depression and hopelessness constitute common pathways of distress, which mediate the effects of psychosocial and disease-related factors on the desire for hastened death. This model was tested on a cross-sectional sample of 406 patients with metastatic gastrointestinal or lung cancer recruited at outpatient clinics of a Toronto cancer hospital, using structural equation modeling. The results supported the model. High disease burden, insecure attachment, low self-esteem, and younger age were risk factors for depression. Low spiritual well-being was a risk factor for hopelessness. Depression and hopelessness were found to be mutually reinforcing, but distinct constructs. Both depression and hopelessness independently predicted the desire for hastened death, and mediated the effects of psychosocial and disease-related variables on this outcome. The identified risk factors support a holistic approach to palliative care in patients with metastatic cancer, which attends to physical, psychological, and spiritual factors to prevent and treat distress in patients with advanced disease.

Longitudinal Study of Depressive Symptoms in Patients With Metastatic Gastrointestinal and Lung Cancer

PURPOSE Although early intervention is increasingly advocated to prevent and relieve distress in patients with metastatic cancer, the risk factors for such symptoms and their trajectory are not well established. We therefore conducted a longitudinal study to determine the course and predictors of depressive symptoms. PATIENTS AND METHODS Patients (N = 365) with metastatic gastrointestinal or lung cancer completed measures of physical distress, self-esteem, attachment security, spiritual well-being, social support, hopelessness, and depression at baseline; physical distress, social support, hopelessness, and depression were subsequently assessed at 2-month intervals. RESULTS Of the sample, 35% reported at least mild depressive symptoms, with 16% reporting moderate to severe depressive symptoms that persisted in at least one third of such individuals. Moderate to severe depressive symptoms were almost three times more common in the final 3 months of life than > or = 1 year before death. Predictors of depressive symptoms included younger age, antidepressant use at baseline, lower self-esteem and spiritual well-being, and greater attachment anxiety, hopelessness, physical burden of illness, and proximity to death. The combination of greater physical suffering and psychosocial vulnerability put individuals at greatest risk for depression. CONCLUSION Depressive symptoms in advanced cancer patients are relatively common and may arise as a final common pathway of distress in response to psychosocial vulnerabilities, physical suffering, and proximity to death. These findings support the need for an integrated approach to address emotional and physical distress in this population and to determine whether early intervention may prevent depression at the end of life.

Predictors of Referral for Specialized Psychosocial Oncology Care in Patients With Metastatic Cancer: The Contributions of Age, Distress, and Marital Status

PURPOSE This study examines the rate and prediction of referral for specialized psychosocial oncology care in 326 patients with metastatic GI or lung cancer. PATIENTS AND METHODS Referral information was abstracted from medical records and hospital databases. Patients completed measures of psychosocial and physical distress and functioning. RESULTS Routine referral occurred in 33% of patients, and in 42% and 44%, respectively, of those scoring high on measures of depression (Beck Depression Inventory [BDI]-II >or= 15) and hopelessness (Beck Hopelessness Scale >or= 8). Univariate analyses indicated that referral was associated with younger age, unmarried status, living alone, presence of more depressive symptoms, hopelessness, and attachment anxiety, and with less social support, self-esteem, and spiritual well-being (all P < .05). Among the significantly depressed (BDI-II >or= 15), 100% of those less than 40 years of age, but only 22% of those age 70 years or older were referred. Multivariate analyses indicated that referral was associated with younger age, unmarried status, and presence of more depressive symptoms. Moreover, increasing age was associated with a progressively lower likelihood of referral independent of the level of distress. CONCLUSION Routine referral of patients with metastatic cancer for psychosocial oncology care was predicted by presence of more severe depressive symptoms, younger age, and unmarried status. The rate of referral progressively declined with each decade of age, even among those with significant distress. These findings are consistent with some aspects of Andersens model of health care utilization. The extent to which referred patients represent those who are most likely to benefit deserves further investigation.

Measuring attachment security in patients with advanced cancer: psychometric properties of a modified and brief Experiences in Close Relationships scale.

Objective: Attachment security has been identified as an important buffer of distress in patients with cancer and other medical illnesses but current measures have not been adapted for this population who may be older, in long‐term stable relationships, and suffering from considerable disease burden. This study reports on (1) the psychometric properties of a modified 36‐item Experiences in Close Relationships scale (ECR), adapted for this population; and (2) the validity of a brief 16‐item version of our modified scale.

Quality of life and mental health in caregivers of outpatients with advanced cancer

This study evaluates the quality of life (QOL) and mental health (MH) of caregivers of patients with advanced cancer who are receiving ambulatory oncology care and associations with patient, caregiver and care‐related characteristics.

Managing Cancer And Living Meaningfully (CALM): phase 2 trial of a brief individual psychotherapy for patients with advanced cancer.

Background: Advanced cancer brings substantial physical and psychosocial challenges that may contribute to emotional distress and diminish well-being. In this study, we present preliminary data concerning the effectiveness of a new brief individual psychotherapy, Managing Cancer And Living Meaningfully (CALM), designed to help individuals cope with this circumstance. Aim: To test the feasibility and preliminary effectiveness of CALM to reduce emotional distress and promote psychological well-being and growth. Design: CALM is a brief, manualized, semi-structured individual psychotherapy for patients with advanced cancer. This study employed a phase 2 intervention-only design. The primary outcome was depressive symptoms and the secondary outcomes were death anxiety, attachment security, spiritual well-being and psychological growth. These were assessed at 3 months (t1) and 6 months (t2). Multilevel regression was used to model change over time. Setting/participants: A total of 50 patients with advanced or metastatic cancer were recruited from the Princess Margaret Cancer Centre, Toronto, Canada. Results: A total of 39 patients (78%) were assessed at baseline, 24 (48%) at t1, and 16 (32%) at t2. Analyses revealed reductions over time in depressive symptoms: beta = −0.13, confidence interval (CI.95) = (−0.23, −0.022) and death anxiety: beta = −0.23, CI.95 (−0.40, −0.061); and an increase in spiritual well-being: beta = 0.14, CI.95 (0.026, 0.26). Conclusions: CALM may be a feasible intervention to benefit patients with advanced cancer. The results are encouraging, despite attrition and small effect sizes, and support further study.

Managing Cancer and Living Meaningfully (CALM): A qualitative study of a brief individual psychotherapy for individuals with advanced cancer

Background: Although psychosocial care has been regarded as central to palliative and supportive care, there have been few empirically tested approaches to individual intervention. Aim: The subjective experience of advanced cancer patients receiving a new manualized brief individual psychotherapy, referred to as Managing Cancer and Living Meaningfully (CALM), was examined prior to the initiation of a randomized controlled trial testing the effectiveness of this intervention. Design: Semi-structured interviews were conducted with patients who had a diagnosis of advanced cancer, and who underwent the intervention. Setting/Participants: Patients were recruited from a large urban regional cancer center in Toronto, Canada. The 10 interviewees included seven women and three men. All had completed between three to six CALM sessions prior to the interview. Results: The CALM intervention was associated with profound and unique patient-identified benefits and no patient-identified risks or concerns. Five interrelated benefits of the intervention were identified: (1) a safe place to process the experience of advanced cancer; (2) permission to talk about death and dying; (3) assistance in managing the illness and navigating the healthcare system; (4) resolution of relational strain; and (5) an opportunity to ‘be seen as a whole person’ within the healthcare system. These benefits were regarded by participants as unique in their cancer journey. Conclusions: Findings from a qualitative study suggest that the CALM intervention provides substantial benefits for patients with advanced cancer prior to the end of life. Findings informed the development of a randomized controlled trial to evaluate the effectiveness of this intervention.

Symptom burden and supportive care in patients with acute leukemia.

We examined the symptoms and referral rates to specialized palliative care and psychosocial oncology services of patients with acute leukemia. The Memorial Symptom Assessment Scale (MSAS) was completed by 249 adult patients with acute leukemia. Patients reported a median of 9 physical and 2 psychological symptoms, and those with intense lack of energy, difficulty sleeping and pain were more likely to report intense worrying/sadness (P<0.001). No patients with moderate-severe pain were referred for specialized symptom control and only 13% of those with severe worrying/sadness were referred to psychiatry/psychology within one month of the assessment. Patients in this population have a substantial symptom burden; further research is needed to determine the benefit of early referral to specialized supportive care services.

Measuring patient satisfaction in oncology palliative care: psychometric properties of the FAMCARE-patient scale

PurposeWe provide preliminary psychometric results concerning the use of a modified FAMCARE scale, adapted for patient use, to assess satisfaction with outpatient care in advanced stage cancer patients.MethodsParticipants were 145 outpatients with advanced cancer who were participating in a phase II trial of an outpatient palliative care intervention. Patients completed our modified FAMCARE measure of patient satisfaction and the Edmonton Symptom Assessment Scale, a measure of symptom burden. Individuals were also assessed for performance status using the Eastern Cooperative Oncology Group scale. We conducted an exploratory factor analysis of the patient satisfaction measure and performed correlations of satisfaction with symptom burden as well as with performance status.ResultsFactor analysis of the satisfaction measure revealed a one-factor structure and suggested the removal of one nonloading item, producing a 16-item scale (FAMCARE-P16) with high internal reliability. Patient satisfaction was not correlated with performance status, but was inversely associated with symptom burden, particularly with depression and anxiety.ConclusionsThe FAMCARE-P16 may be used to assess satisfaction with outpatient palliative care interventions of patients with advanced stage cancer in both clinical settings and prospective trials.