Timing of palliative care referral before and after a cluster randomized controlled trial (RCT) of early palliative care

Abstract

Background: Between December 2006 and February 2011, our cancer center undertook an RCT of early palliative care in patients with lung, gastrointestinal (GI), genitourinary (GU), breast, and gynecological (Gyne) cancers. The trial showed benefits in quality of life favoring early palliative care (at clinical prognosis 6‐24 months) over standard care. We hypothesized that there would be an increase in earlier referrals to the oncology palliative care clinic (OPCC) following the RCT. Methods: Administrative databases were reviewed for 2 groups of patients: Group 1 (before RCT) was seen in the OPCC June‐October 2006; Group 2 (following RCT) seen May 2015 ‐ April 2016. Death dates were retrieved in January 2018. Data have been collected for 337/407 patients in Group 1 and 387/1007 in Group 2. Timing of referral was categorized as early (>6 months from referral to death) and late (≤6 months from referral to death). Using chi‐square tests for categorical predictors and t‐tests for continuous predictors, we compared distributions and means between groups 1 and 2 for demographics, primary tumor site, referring service and referral reason (pain & symptom management [PSM], palliative planning [PP], PSM together with PP [PSM+PP], other). Results: Early referrals to OPCC increased from 105/337 (31%) to 180/387 (47%) (p<0.001). For women, early referrals increased from 33% to 51%, and for men from 30% to 42%. Although there was no change in the timeliness of referrals for PSM alone, earlier referrals increased significantly among patients referred for PSM+PP, and those referred for PP. Early referrals increased among medical oncologists from 32% (65/ 206) to 48% (118/244) (p<0.001) but not among radiation oncologists (29% [23/80] to 40% [28/70], p=0.17). Early referrals tended to increase for all tumor site groups except head and neck, with significant increases among patients with GI cancers (25% [22/87] to 48% [50/104], p=0.001), and Gyne cancers (23% [8/35] to 58% [32/55], p=0.001). Conclusions: Following an RCT supporting early palliative care for patients with advanced cancer, oncologists referred patients substantially earlier to an outpatient palliative care clinic.