According to findings from a study published in the Journal of the American Medical Association Network, stepped palliative care is an effective method of providing palliative care to patients with advanced lung cancer while also enhancing their quality of life.

The authors wrote, “Despite the evidence for early palliative care improving outcomes, it has not been widely implemented in part due to palliative care workforce limitations.”

The researchers conducted a randomized, nonblinded, noninferiority trial of stepped versus early palliative care with the primary objective of assessing a stepped-care model to deliver less resource-intensive and more patient-centered palliative care for patients with advanced cancer. The trial was conducted between February 12, 2018, and December 15, 2022, at three medical centers and included 507 patients diagnosed with advanced-stage lung cancer. Researchers enrolled adult patients diagnosed with either small cell lung cancer, non–small cell lung cancer, or mesothelioma within 12 weeks of not being treated with curative intent.

In the study, a stepped palliative care (SPC) approach was employed with Step 1 of the intervention involving an initial palliative care visit within 4 weeks of enrollment, with subsequent visits resulting from changes in cancer treatment or hospitalization. During Step 1, patients were administered a measure of quality of life (QoL; Functional Assessment of Cancer Therapy–Lung [FACT-L]; range, 0-136, with higher scores indicating better QoL) every 6 weeks, and those with a 10-point or more significant decline from baseline were advanced to meet with the palliative care clinician every 4 weeks (intervention Step 2). Patients allocated to early palliative care had palliative care visits every 4 weeks after enrollment.

The authors noted that by Week 24, the mean number of palliative care visits (n = 2.4) for SPC was reduced by 2.3 visits versus early palliative care (4.7; 95% CI, –2.7 to –2.8; P <.001) by Week 24. At Week 24, FACT-L scores were noninferior for stepped palliative care patients among those receiving early palliative care by Week 24 (100.6 vs. 97.8, respectively; lower 1-sided 95% confidence limit, –0.1; P <.001), and the rate of end-of-life care communication was non-inferior as well. Noninferiority was not demonstrated for days in hospice, with an adjusted mean between SPC of 19.5 days versus 34.6 days in early palliative care.

Based on their findings, the authors concluded, “A stepped-care model, with palliative care visits occurring only at key points in patients’ cancer trajectories and using a decrement in QoL to trigger more intensive palliative care exposure, resulted in fewer palliative care visits without diminishing the benefits for patients’ QoL. While stepped palliative care was associated with fewer days in hospice, it is a more scalable way to deliver early palliative care to enhance patient-reported outcomes.”

In a press release, lead author Jennifer Temel stated, “Palliative care interventions are delivered by specially trained palliative care physicians and advanced practitioners. Stepped care starts with low-frequency visits, and when conditions worsen (e.g., change in cancer trajectory, hospital admission), patients step up to more frequent visits. This improves the utilization of resources. Stepped palliative care enables more efficient use of resources and fewer office visits for patients compared to monthly office visits.”

Dr. Temel added, “Patients with advanced cancer have poor quality of life, depression, and anxiety; and distress related to prognostic uncertainty and lack of coping skills. Early palliative care is an evidence-based strategy that improves coping and satisfaction with cancer care. Our study shows that stepped palliative care is an effective and scalable way to deliver early palliative care and improve patients’ quality of life.”

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