Bischoff, K., Weinberg, V., & Rabow, M.W. (2013). Palliative and oncologic co-management: Symptom management for outpatients with cancer. Supportive Care in Cancer, 21, 3031–3037.

To assess the association between palliative care management, symptoms, and quality of life

Clinical records of patients referred for outpatient palliative care who had follow-up visits within 120 days of initial referral were included. Retrospective analysis of clinical data was done.

• N = 266
• MEAN AGE = 57.2 years (SD = 13.8 years)
• MALES: 46%, FEMALES: 54%
• KEY DISEASE CHARACTERISTICS: 59% had metastatic disease. Multiple cancer sites were included, and 68% were on active treatment. Median time since diagnosis was 17 months. Mean time of follow-up after initial visit was 41 days.

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: California

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

• Retrospective, descriptive

• Edmonton Symptom Assessment Scale

At the time of initial visit, average symptom scores were 2.9–5.8 (10-point scale). At the first follow-up visit, there was an average 0.67-point improvement in pain (p < .001), a 0.67-point improvement in fatigue (p < .001), a 0.94-point improvement in depression (p < .001), and a 0.89-point improvement in anxiety (p < .001). At least 50% of patients reported a greater than one-point improvement in symptoms by the first follow-up visit, and 16%–25% reported a one-point or greater worsening of symptoms. Among 142 patients who had a second follow-up visit, there was continued significant improvement from baseline symptom scores. Patients on active treatment had less improvement in fatigue than others (p = .02).

Most patients who continued follow-up by palliative care demonstrated improvement in pain, fatigue, anxiety, and depression.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (sample characteristics)
• Other limitations/explanation: The study only included those patients referred who had follow-up visits in the palliative care clinic. It is possible that at least some of those who did not come back for another visit did not have symptom improvement, so results may be overestimated. The opposite also is possible. There was a lot of variability in the timing of follow-ups. A single symptom measure was used repeatedly; it is possible that the study had threats to validity because of testing effect and patient expectations. It is not known if oncologic providers made any changes in medications for symptom management, as palliative care follow-up visits were relatively infrequent.

Palliative care, with attention to symptom management, has been shown to be effective in reducing symptom severity for the majority of patients. It is not clear, however, if formal palliative care services result in better outcomes than attention to symptom management in general. It would be expected that, whether provided by oncology or palliative care providers, focused attention on symptom management would result in improvement of symptoms. The optimum frequency of follow-up and timing for optimal symptom control has not been determined.