Examining the impact of specialty palliative care consultation in patients with metastatic pancreatic cancer: evaluating use at an NCI designated cancer center

Metastatic pancreatic ductal adenocarcinoma (PDAC) is characterized by a high mortality rate and significant symptom burden (1). Despite advances in treatment options, the prognosis remains poor, with a median survival of less than one year (2). The complexity and aggressiveness of this disease necessitates a holistic approach to patient care, integrating both cancer treatment approaches and palliative strategies (3). Early consultation to specialty palliative care in solid cancers has been shown to increase survival, enhance quality of life, optimize symptom management, and reduce aggressive end-of-life (EOL) interventions (4). However, the utilization patterns and specific impacts of palliative care in patients with metastatic PDAC require further exploration. Our study aimed to evaluate the timing, setting, and EOL outcomes associated with specialty palliative care consultation among patients with metastatic PDAC treated at a National Cancer Institute (NCI)-designated cancer center.

We conducted a retrospective analysis of patients diagnosed with metastatic PDAC and treated from January 2012 to December 2021. We compared the baseline demographic features of patients who received palliative care consultation with those who did not. Primary outcomes included time from diagnosis to palliative care referral with early referral defined as consultation within 30 days of diagnosis (5), site of referral (inpatient vs. outpatient), chemotherapy use in the last 30 days of life, Do Not Resuscitate (DNR) code status at EOL, and hospice referral rates. Impact of demographics on referral rates was also analyzed. Chi-square tests and independent sample t-tests were conducted to assess for differences in patient demographics between palliative care and non-palliative care groups. All statistical tests were two-sided; a P value of <0.05 was considered significant. Statistical analyses were performed using SPSS version 29.0.

Among 168 identified patients, 125 (74.4%) received specialty palliative care consultation. Patients who received palliative care were significantly younger 63±10.1 vs. 73±8.8 years (P<0.001). There was no significant difference in other baseline characteristics including sex, race, ethnicity, insurance, performance status, and primary language spoken between the two groups (Table 1).

There was a median time of 145 days [interquartile range (IQR) 37–347 days] from diagnosis of metastatic disease to the first palliative care visit for those referred. Early palliative care consultation was observed in 23 (18.4%) patients. There was no significant difference in baseline characteristics between patients who received early consultation vs. those who did not. A total of 45 (36.0%) patients received specialty palliative care exclusively within the last 30 days of life. A total of 78 (62.4%) patients received their first palliative care encounter in the inpatient setting and 47 (37.6%) were first seen in the outpatient setting.

Patients who received specialty palliative care demonstrated a higher likelihood of having a DNR code status at the EOL (68.8% vs. 27.9%, P<0.001) and were more likely to be referred to hospice (65.6% vs. 30.2%, P<0.001). Furthermore, among the 104 deceased patients, those who received specialty palliative care were less likely to undergo chemotherapy in the last 30 days of life (31% vs. 55%, P=0.044).

Our study highlights several critical implications for the care of patients with metastatic PDAC. First, patients who received specialty palliative care consultation received more comfort-directed treatment at EOL. For our study, we defined comfort-directed care at EOL using three key criteria: (I) referral to hospice services at EOL, (II) absence of toxic chemotherapy administration within the last 30 days preceding death, and (III) documented orders for “Do Not Resuscitate” (DNR) or “Do Not Intubate” (DNI) at the EOL. This aligns with observations from other retrospective and prospective studies (6). Research has consistently demonstrated that aggressive care near death is correlated with poorer quality of life for patients and more challenging bereavement adjustment for their caregivers (7). In contrast, comfort-directed care at EOL can improve quality of life and may in fact be associated with goal concordant care.

Second, palliative care is still more utilized among patients with advanced PDAC in inpatient settings and late in the trajectory of illness often when patients are hospitalized for uncontrolled symptoms and/or progression of cancer. In this study, a substantial number of patients (36.0%) received the first palliative care consultation within the last 30 days of death. This observation expands the current literature (8). While our retrospective study did not allow for an assessment of the reasons behind late palliative care consultation, we hypothesize based on clinical practice that several factors, including patient, system, and caregiver-related elements, may be associated with this phenomenon (3). Patient misconceptions, such as the notion that palliative care exclusively focuses on EOL care or that accepting palliative care means forgoing curative treatments, can contribute to delayed referrals or resistance to referral uptake (9). Power dynamics between healthcare providers, trust issues, desire to maintain control over patient care, and a lack of trust in the expertise of palliative care providers are significant factors that also hinder timely referrals (10). While inpatient palliative care is invaluable, providing early referral to outpatient services has been demonstrated to improve patient and caregiver outcomes and is also associated with decreased healthcare utilization at the EOL (5). Identifying ways to move these referrals more upstream, particularly among patients who are at higher risk, is crucial to improve cancer care delivery.

Third, patients seen by palliative care in our cohort were younger, which contrasts with observations from other studies (8). One possible rationale for this difference could be the presence of distinct and heightened psychosocial hurdles associated with illness among younger patients, prompting clinicians and or patients to seek early involvement with palliative care services. Our study has several limitations. This was a single center study, limiting generalizability. The data spanned 10 years, during which the practice patterns, the recognition of palliative care and in the institutional culture likely evolved and could not be accounted for. Due to its retrospective design, we were unable to analyze the factors and barriers that may contribute to the reduced utilization of palliative care services.

In conclusion, our study provides compelling evidence for the benefits of specialty palliative care consultation in patients with metastatic PDAC. By reducing aggressive end-of-life interventions, palliative care plays a vital role in the providing value concordant treatment. Future efforts should focus on overcoming barriers to early palliative care referral and expanding outpatient palliative care services. Additionally, further studies should explore how the structure and frequency of palliative care follow up, including how often patients are seen and what triggers the follow-up, influence outcomes. Investigating models of follow-up care could provide insights into optimizing palliative care delivery and improving patient outcomes.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://apm.amegroups.com/article/view/10.21037/apm-24-121/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-24-121/coif). C.B.S. reports that he received speaker’s fees from GSK and is on Advisory Board for Elevance Health. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Rahib L, Smith BD, Aizenberg R, et al. Projecting cancer incidence and deaths to 2030: the unexpected burden of thyroid, liver, and pancreas cancers in the United States. Cancer Res 2014;74:2913-21. [Crossref] [PubMed]
2. Von Hoff DD, Ervin T, Arena FP, et al. Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med 2013;369:1691-703. [Crossref] [PubMed]
3. Moffat GT, Epstein AS, O'Reilly EM. Pancreatic cancer-A disease in need: Optimizing and integrating supportive care. Cancer 2019;125:3927-35. [Crossref] [PubMed]
4. Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:1721-30. [Crossref] [PubMed]
5. Sohal DP, Mangu PB, Khorana AA, et al. Metastatic Pancreatic Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016;34:2784-96. [Crossref] [PubMed]
6. Maltoni M, Scarpi E, Dall'Agata M, et al. Systematic versus on-demand early palliative care: A randomised clinical trial assessing quality of care and treatment aggressiveness near the end of life. Eur J Cancer 2016;69:110-8. [Crossref] [PubMed]
7. Wright AA, Zhang B, Ray A, et al. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 2008;300:1665-73. [Crossref] [PubMed]
8. Bhulani N, Gupta A, Gao A, et al. Palliative care and end-of-life health care utilization in elderly patients with pancreatic cancer. J Gastrointest Oncol 2018;9:495-502. [Crossref] [PubMed]
9. Flieger SP, Chui K, Koch-Weser S. Lack of Awareness and Common Misconceptions About Palliative Care Among Adults: Insights from a National Survey. J Gen Intern Med 2020;35:2059-64. [Crossref] [PubMed]
10. Salins N, Ghoshal A, Hughes S, et al. How views of oncologists and haematologists impacts palliative care referral: a systematic review. BMC Palliat Care 2020;19:175. [Crossref] [PubMed]