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. 2022 Oct 1;32(4):505–511. doi: 10.5737/23688076324505

The early integration of palliative care into oncology care: A rapid review

Asma Fadhlaoui 1,✉, Hazar Mrad 2, Billy Vinette 3, Karine Bilodeau 4
PMCID: PMC11195655  PMID: 38919785

Abstract

With the number of cancer diagnoses and cancer-related deaths on the rise, palliative care is becoming a more important consideration for helping to improve the quality of life of patients and families and the support they receive during their healthcare journey. Accordingly, the early integration of palliative care into standard oncology care would appear to be an underutilized and novel approach that could be used to address the specific needs of palliative oncology patients. Oncology nurses play a central role in this process, delivering care throughout the health continuum, including palliative care. The purpose of this rapid review is to outline the benefits of early palliative care interventions and describe their characteristics. A literature search on CINAHL and PubMed returned five randomized trials conducted between 2010 and 2018. An analysis of these papers showed that the majority of the selected studies concluded that the early integration of palliative care into standard oncology care, which includes such treatments as chemotherapy and radiation therapy, can lead to improvements in quality of life, symptoms of anxiety and depression, and overall survival rate.

Keywords: palliative care, early palliative care, intervention, cancer, oncology

INTRODUCTION

Statistics show that one out of two Canadians will receive a cancer diagnosis in their lifetime and that about 36% of this population will die as a result of the disease (Canadian Cancer Statistics Advisory Committee/Comité consultatif des statistiques canadiennes sur le cancer, 2020). As part of their experience, cancer patients often endure severe symptoms (e.g., symptoms of a physical, psychological, emotional, spiritual and social nature) that can impair their quality of life (Nayak et al., 2017). In the past few decades, palliative care has been recognized as a way of helping to manage the symptoms associated with cancer (Hui & Bruera, 2015). The purpose of palliative care is to improve the quality of life of those for whom the prognosis is grim, as well as the people who are supporting them, up to and including end-of-life care (Canadian Hospice Palliative Care Association/Association canadienne de soins palliatifs [CHPCA/ACSP], 2013). In Canada, federal and provincial measures have been put into place to improve palliative care and make it more accessible to multiple healthcare fields (Government of Canada/Gouvernement du Canada, 2019).

The concept of early palliative care (EPC) has emerged in the past 20 years. In 2002, the World Health Organization came out in support of the early integration of palliative care into the disease trajectory, concomitantly with other types of treatments, including curative treatments (WHO/OMS, 2007). The focus of EPC is on patient-centred care, improved quality of life for patients and their families, the respect of patients’ wishes and the promotion of psychosocial support (WHO/OMS, 2007). Accordingly, the American Society of Clinical Oncology (ASCO) recommends that palliative care be integrated early into standard care for patients at an advanced stage of lung cancer (Smith et al., 2012). Likewise, a number of Canadian organizations, including the Canadian Partnership Against Cancer (CPAC), encourage healthcare professionals to include EPC in care planning to optimize the health continuum in this context (Government of Canada/Gouvernement du Canada, 2019). Moreover, the Canadian Association of Nurses in Oncology has identified seven practice standards applicable to oncology nurses, namely: (1) comprehensive health assessment; (2) supportive and therapeutic relationships; (3) management of cancer symptoms and treatment side effects; (4) teaching and coaching; (5) facilitating continuity of care and navigating the system; (6) decision making and advocacy; and (7) professional practice and leadership (CANO/ACIO, 2019).

In North America, although EPC has been an accepted practice for many years, problems remain in integrating it into standard oncology care (Bakitas et al., 2010). Some of the challenges are reportedly related to healthcare professionals’ lack of training in general palliative care and the various facets involved (e.g., death, loss, grieving) (Aline et al., 2019; Hawley, 2017). Other studies suggest that healthcare professionals may underestimate or disregard some of the physical, psychosocial and spiritual symptoms experienced by patients who would benefit from an EPC approach (Beernaert et al., 2014). A lack of understanding of the prognosis and treatment objectives, either by patients or clinicians, also stands as an obstacle to referring patients to palliative care (Addicott, 2012; Yoong et al., 2013). Additionally, the literature indicates that palliative care referrals by medical teams are often made too late, i.e., within a mere 30 to 60 days of a patient’s death (Bauman et al., 2014; Osta et al., 2008). Hui et al. (2018) suggest integrating EPC sooner in the trajectory, within three months of a diagnosis of advanced cancer in patients with a life expectancy of less than one year. Integrating EPC would appear to be an ongoing and sizeable challenge at every point along the oncology care continuum.

Despite these recommendations to integrate EPC for patients with untreatable or advanced cancer, getting EPC-supportive clinical projects off the ground seems to present a challenge. There appears to be a widespread lack of understanding about the nature and benefits of EPC integration in comparison to standard oncology care (Hui et al., 2018). A rapid review of the available literature was conducted as part of a master’s-level research project to respond to an oncology nursing team’s questions about embracing an EPC approach. In an effort to better inform clinical practices, this rapid review will aim to synthesize and outline the benefits of EPC interventions and describe their characteristics.

METHOD

A rapid review of the literature was undertaken, in line with the recommendations of the National Collaborating Centre for Methods and Tools (2017). This method makes it possible to conduct a brief overview of the available scientific evidence to inform decisions on the part of healthcare professionals and policymakers (National Collaborating Centre for Methods and Tools/Centre de collaboration nationale des méthodes et outils, 2017). The process consists of four steps: (1) formulating a research question; (2) identifying relevant studies based on established inclusion and exclusion criteria; (3) assessing the quality of the selected studies; and (4) drafting a summary of the findings.

In order to formulate the research question (Step 1), AF met with a group of 20 nurse navigators working in a cancer program run by a university hospital centre in greater Montreal, Canada, in 2019. The meeting lasted a total of 90 minutes. AF kept notes in a logbook. Nurses had questions about some of the problems they faced in their practice (e.g., benefits of EPC interventions, the models for delivering palliative care by a mobile team). The meeting revealed a pressing need to compile data on existing interventions integrating EPC into oncology practice. The purpose of the present rapid review is to answer the following research question: (1) What are the characteristics of EPC interventions, and how are these interventions introduced? This was followed by a documenting strategy (Step 2), developed by AF and validated by a librarian with experience in health sciences, using the key words and descriptors palliative care, early palliative care integration, palliative care integration, cancer and oncology in the CINAHL and PubMed databases. A manual search was also conducted in Google Scholar as well as in the references cited in the selected papers. The criteria used were the following: (1) be written in English or French and be published between 2010 and 2019; (2) be a randomized controlled trial (RCT); (3) explicitly address oncology care; (4) provide a detailed description of the early palliative care intervention; and (5) discuss the benefits and drawbacks of such an approach. The titles and abstracts were examined based on the inclusion criteria, and the full texts that were eligible were read. Studies addressing the pediatric population and conference abstracts were excluded. Figure 1 presents the study selection flow chart.

Figure 1.

Figure 1

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Flow Chart

During Step 3, the quality of the RCTs was assessed by AF using the CONSORT scale (Schulz et al., 2010). Data were then extracted by AF using Excel software (specifically, the names of the authors, the year of publication, the target population, the nature of the intervention, the scales used and the study findings). The data were then summarized and tabulated using descriptive statistics. The summary was presented to the group of nurse navigators at the end of the project (Step 4).

RESULTS

Of the 28 papers identified, only five RCTs met the selection criteria. Of these, three were conducted in the United States, one in Belgium and one in Italy. All five involved participants of 18 years of age and older (up to 84 years of age). In the majority of the studies, the average age of the participants was 65 years of age. Participants had advanced cancer (Bakitas et al., 2015; Vanbutsele et al., 2018), pancreatic cancer (Maltoni et al., 2016), or gastrointestinal and/or lung cancer (Temel et al., 2010; Temel et al., 2016). Participants’ life expectancy in the five RCTs varied between two months and two years. Table 1 summarizes the characteristics of the selected studies.

Table 1.

Characteristics of the RCTs Included

Authors/Country Population Nature of Intervention Scales Limitations
Bakitas et al. (2015) – U.S. (n = 207) participants; advanced cancer; ≥ 18 years; 6 months < LE > 24 months Monthly individual consultation by phone (PCN) FACIT-Pal; CES-D – Participants belatedly assigned a PCN had their consultation earlier than scheduled, which may have reduced the efficacy of the intervention.
– Participants assigned usual oncology care had received palliative care in the same facility where the RCT was conducted.
Maltoni et al. (2016) – Italy (n = 207) participants; inoperable pancreatic cancer; ≥ 18 years; LE > 2 months Individual consultation (interdisciplinary team) every 2 to 4 weeks FACT-Hep; HADS; TOI – Selection bias: the centre where the intervention took place is an accredited palliative care facility.
– Unblinded RCT: participants were informed of the content of the intervention.
– Intervention administered by an MD rather than a palliative care team.
Temel et al. (2016) – U.S. (n = 350) participants; gastrointestinal and/or lung cancer; ≥ 18 years; LE > 2 months Monthly consultation (PCN + MD) for 1 year and/or until patient’s death FACIT-G; PHQ-9; HADS – More than a third of the participants receiving standard oncology care had already received palliative care on an outpatient basis, which may have hindered the efficacy of the intervention.
– Participants and members of the care team were not blinded.
Temel et al. (2010) – U.S. (n = 151) participants; lung cancer; ≥ 18 years Monthly consultation (palliative care team) TOI; FACT-L; PHQ-9 – This was a single-centre trial, thereby limiting the generalizability of the results.
– Clinicians and patients were not blinded and were informed of the content of the intervention.
– A minority of the control group had received palliative care, which may bias the final outcomes.
Vanbutsele et al. (2018) – Belgium (n = 186) participants; advanced cancer; ≥ 18 years; LE > 1 year Monthly individual consultation (MD + PCN) for 1 year QLQ-C30; MQOL; HADS; PHQ-9 – Some measures were selected by random chance (type 1 error).
– Lack of compliance with the research protocol: consultations held less frequently.
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Legend: CES-D: Center for Epidemiologic Studies – Depression scale; FACIT-Pal: Functional Assessment of Chronic Illness – Palliative Care; FACT-G: Functional Assessment of Chronic Illness Therapy – General; FACT-Hep: Functional Assessment of Cancer Therapy – Hepatobiliary; FACT-L: Functional Assessment of Cancer Therapy – Lung; HADS: Hospital Anxiety and Depression Scale; LE: life expectancy; MD: physician; MQOL: McGill Quality of Life Questionnaire; PCN: palliative care nurse; PHQ-9: Patient Health Questionnaire; QLQ-C30: Quality of Life Questionnaire; TOI: Trial Outcome Index.

Analysis of the data collected from these RCTs showed a favourable effect of EPC interventions compared to standard oncology care, namely with regard to improvements in quality of life (4/5), symptoms of anxiety and depression (2/5), and overall survival rate (1/5). The five RCTs included in this rapid review are deemed to vary in quality from low to moderate. The presentation of the study elements appears to be adequate and consistent with RCT standards (i.e., in terms of scientific context, research objectives and hypothesis, methodology and randomization, discussion and conclusions). Although all of the RCTs reported a favourable effect from the integration of EPC into standard oncology care, certain limitations must be considered. The level of evidence and the magnitude of the effect for each of the parameters assessed (i.e., quality of life, symptoms of anxiety and depression, and overall survival rate) vary from low to moderate. Table 2 shows the effect of EPC intervention for each study.

Table 2.

RCT Findings

RCT Indicator Quality of Life Symptoms of Anxiety and Depression Overall Survival Rate
Bakitas et al. (2015) Ø Ø +
Maltoni et al. (2016) +* Ø Ø
Temel et al. (2010) +* +* N/A
Temel et al. (2016) +* +* N/A
Vanbutsele et al. (2018) +** Ø +
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+: Significant improvement, with a significance threshold of p ≤ 0.05

*

Significant improvement at 12 weeks post-intervention

**

Significant improvement at 18 months post-intervention

Ø: No significant improvement

N/A: Not applicable, not assessed by the authors

As for the characteristics of EPC interventions, the analysis of the data indicates that all of the interventions in the selected studies involved individual consultations with a healthcare team. Most of these consultations occurred face to face (Maltoni et al., 2016; Temel et al., 2010; Temel et al., 2016; Vanbutsele et al., 2018). The fifth study (Bakitas et al., 2015) focused on a telephone-based EPC approach. The healthcare teams in charge of the delivery of these interventions consisted in an advanced practice nurse (Bakitas et al., 2015), a palliative care physician and nurse (Temel et al., 2016; Vanbutsele et al., 2018), an interdisciplinary team (Maltoni et al., 2016) or a palliative care team (Temel et al., 2010). Monthly consultations were used in all of the EPC interventions (Bakitas et al., 2015; Temel et al., 2010; Temel et al., 2016; Vanbutsele et al., 2018) except one (Maltoni et al., 2016), where follow-up was provided every two to four weeks with each participant in the intervention group.

In terms of the themes addressed or the assessments conducted during the EPC interventions, only two RCTs out of five provided a detailed description of the nature of the intervention (Bakitas et al., 2015; Vanbutsele et al., 2018). These consultations focused on: (1) assessing and managing symptoms (Bakitas et al., 2015; Vanbutsele et al., 2018); (2) assisting in decision-making (Bakitas et al., 2015; Vanbutsele et al., 2018); (3) planning care and referring to other resources (Bakitas et al., 2015; Vanbutsele et al., 2018); (4) solving problems (Bakitas et al., 2015); (5) understanding the disease (Vanbutsele et al., 2018); and (6) adapting to the disease (Vanbutsele et al., 2018).

DISCUSSION

This rapid review summarized the benefits of EPC integration and the specific characteristics of the interventions studied. The results show that EPC interventions may have a beneficial effect on quality of life, symptoms of anxiety and depression, and overall rate of survival. However, these results must be interpreted with caution, given some of the challenges encountered, including the clinical differences in the RCTs studied (e.g., older oncology patients with varying forms of cancer), the methodological differences (e.g., distinct intervention protocols), and the low statistical power and the presence of bias (e.g., type 1 selection bias, type 1 error).

Our findings show that the populations included in the five RCTs covered in this rapid review vary widely. Most of the interventions targeted cases of cancer that were at an advanced stage, that had a life expectancy of less than two years or that affected the lung or digestive system. The results of the analysis also show that the average age of the majority of subjects in the study samples was 65 years of age. This points to the need to conduct further studies with participants across other age groups, including adolescents as well as young adults with cancer who experience unequal access to palliative care services (Canadian Partnership Against Cancer/Partenariat canadien contre le cancer, 2017).

The results also stress that EPC interventions in the majority of RCTs were diverse in terms of frequency (weekly, monthly) and the healthcare professionals involved (physician, nurse). The composition of the healthcare teams varied or were unknown. Moreover, most of the interventions were based primarily on individual consultations with a specialized palliative care team, making it difficult to determine the most suitable interdisciplinary team composition for optimizing the outcomes of EPC interventions. Note that several of the studies included in this rapid review involved palliative care nurses or advanced practice nurses, who often play a pivotal role in ensuring the quality of palliative care provided to patients, as pointed out in George (2016). The study by Hui et al. (2015) indicates that interdisciplinary palliative care teams should, at a minimum, be composed of a physician, a specialized nurse and a professional from the psychosocial team. Further research would nevertheless be required to assess the impact of interdisciplinary teamwork on EPC.

The analysis of the five RCTs did not reveal much about the favourable components of EPC interventions. Only Bakitas et al. (2015) and Vanbutsele et al. (2018) provided details about what their respective interventions entailed. Thomas et al. (2019) and Kleiner et al. (2021) conducted two separate studies to generate data on how EPC interventions are introduced by oncologists and palliative care specialists, and by a palliative care team, respectively. Both studies performed a quantitative and qualitative analysis of the content of EPC interventions. The authors reported that the EPC interventions included such diverse subjects and aspects as assessing and managing symptoms (e.g., physical, psychological, spiritual), helping with decisions (e.g., therapy options, understanding of the prognosis), and exploring personal and social avenues (e.g., values and beliefs, strengths, social networks, support systems). As recommended in Kleiner et al. (2021), additional studies would be useful in formally defining the structure and components of an EPC intervention.

The findings of this rapid review were shared with oncology nurses as part of a PowerPoint presentation. During a subsequent discussion period, AF and KB answered nurses’ questions and discussed the review’s implications.

Outcomes and outlook

The results of the rapid review imply that it would be beneficial to broach palliative and end-of-life care at an early stage. Although Kleiner et al. (2019) report that the involvement of specialized nurses in palliative care may be brief when EPC is introduced, the study suggests that they quickly form a partnership and forge bonds of trust with the patient and the patient’s family, they evaluate the patient’s understanding of the prognosis, and they focus on the patient’s strengths and coping mechanisms. Nurses in oncology play a critical role in the palliative care trajectory of people with cancer. The Canadian Association of Nurses in Oncology (CANO/ACIO, 2019) indicates that the role of oncology nurses is to provide support and education by demystifying and explaining the purpose of palliative care and the manner in which it is delivered. Nurses also play a central part in the palliative care process, referring their patient to other healthcare professionals and resources as required to optimize their palliative care experience (CANO/ACIO, 2019).

Furthermore, given the close relationship they have with cancer patients, oncology nurses are uniquely placed to debunk EPC-related taboos (Mohammed et al., 2020). Their duties may also include assisting their patient with making decisions about EPC, taking into account any emotional distress that may arise because of the experience (Mohammed et al., 2020). Finally, oncology nurses may engage in advocacy (promotion and protection of their patient’s interests) within the interprofessional oncology team, upholding the benefits of EPC and encouraging its introduction in order to improve quality of life during the end-of-life period (Mohammed et al., 2020). The results of this rapid review suggest that it is important to clarify the nature and composition of EPC interventions. Likewise, it would be helpful to identify which aspects of the intervention yield meaningful results and maximize the benefits stemming from the integration of EPC into the disease trajectory. Given the situation in Canada, where palliative care may be a multisite undertaking (i.e., delivered in the hospital, at home, at a long-term care facility, at a palliative care facility, etc.) (Government of Canada/Gouvernement du Canada, 2019), it seems essential to determine the manner in which each type of setting can provide EPC services efficiently and accessibly to all eligible recipients. Sharing the results of this rapid review with healthcare professionals working with people affected by chronic disease would also appear to be useful moving forward.

Strengths and limitations

To the best of our knowledge, this is the first rapid review of the available literature assessing the benefits and characteristics of early EPC integration. This summary of the existing research provided an opportunity for a group of nurses working in oncology to be made aware of a quick overview of the studies addressing EPC integration compared to standard oncology care. This rapid review may be useful to other healthcare professionals and related parties involved in the delivery of palliative care, allowing them to undertake and develop EPC interventions in oncology. It is important to note that the use of this method appears to have had positive outcomes and to possess the potential to provide nurses with information on recent research findings in a timely manner. In fact, one international survey reports that 70% of rapid reviews can be carried out in less than 12 weeks (Tricco et al., 2016).

Some limitations must be taken into consideration with respect to this rapid review. The approach is highly useful for healthcare professionals and differs from other traditional systematic reviews in terms of timeframes (shorter duration), resources (limited databases) and scientific rigour (reliability of the results) (Khangura et al., 2012). It should therefore be borne in mind at all times that the main purpose of this approach is to summarize the available literature in a succinct and timely way (Khangura et al., 2012).

CONCLUSION

This rapid review summarized key papers assessing the benefits and characteristics of EPC intervention. The results of this exercise indicate that such an approach can improve the quality of life, symptoms of anxiety and depression, and overall survival rate for patients at an advanced stage of cancer. Going forward, it will be important to document the nature of these interventions in more detail and determine the most effective solutions. Further quantitative and qualitative studies would be necessary to substantiate the conclusions stemming from EPC interventions. Lastly, considering that oncology nurses provide care throughout the disease trajectory, including at the EPC stage, it seems important that a conversation be initiated in the near future about palliative care and the needs of patients across all age groups who are facing a terminal prognosis.

ACKNOWLEDGEMENTS

The authors would like to thank the oncology nurse navigators at the Centre hospitalier de l’Université de Montréal (CHUM) integrated cancer centre for their contributions and their help in identifying the research question. We are also grateful for the support of Marie-France Vachon in facilitating the project implementation.

Footnotes

CONFLICTS OF INTEREST

The authors have no conflicts of interest to disclose with regard to the writing or publication of this paper.

FINANCIAL SUPPORT

None

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