Rugno, F.C., Paiva, B.S., & Paiva, C.E. (2014). Early integration of palliative care facilitates the discontinuation of anticancer treatment in women with advanced breast or gynecologic cancers. Gynecologic Oncology, 135, 249–254.

To evaluate quality of life, anxiety, depression, and provider-patient communication in patients with breast and gynecologic cancers with advanced disease stopping active treatment based on the care model used (integrated [ICM] compared to traditional [TCM])

Patients who had received anticancer treatment that was discontinued and were followed up only in the palliative care unit were recruited. Consented patients were evaluated by a treating physician using the Communication Assessment Protocol (CAP). The patients then completed the CAP. The CAP was aimed at determining the degree to which patients had been informed about the reality of their diseases. Patients were categorized for group placement for study comparisons. Those who had been evaluated at least once for palliative care were placed in the ICM model (included PC commitment team and active cancer treatment). Those with no prior consult were placed in the TCM model. Patients in both groups completed study assessments.

• N = 87
• MEDIAN AGE = 56 years (range = 24–83 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Advanced breast and gynecologic cancers with monastic disease or inoperable recurrences; patients with uncomfortable and uncontrolled symptoms were excluded from study participation
• OTHER KEY SAMPLE CHARACTERISTICS: Gynecologic diseases included cancers of the endometrium, ovary, uterine cervix, and vulva/vagina. Subjects were told that once they enrolled in the study, they would not receive additional anticancer treatment. There were no neuropsychiatric problems, major cognitive impairments, or uncomfortable symptoms impairing questionnaire completion.

• SITE: Single-site
• SETTING TYPE: Not specified
• LOCATION: Sao Paulo, Brazil

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Prospective, descriptive, two-group comparison

• Hospital Anxiety and Depression Scale (HADS)
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Karnofsky Performance Status
• Communication assessment protocol

KPS scores ranged from 30–90 (median = 50). Previous treatment included up to eight different lines of systemic palliative treatment (mean = 2.7). There were no group differences between the two care models. The ICM care group had higher global health (p = 0.022), emotional functioning (p = 0.034), and social functioning (p = 0.018), and it had lower insomnia scores (p = 0.027) compared to the TCM group. A smaller proportion of those in the ICM group demonstrated HADS scores at a level indicating clinically relevant anxiety (HADS ≥ 11, p = 0.018). There was no correlation with the number of consultations with the palliative care team. The ICM group experienced significantly fewer communication problems (p = 0.004). The ICM group received less chemotherapy in the last six weeks compared to the TCM (p = 0.001). There was no significant difference between groups in fatigue, anorexia, constipation, pain, or diarrhea. Multivariate analyses showed increased prognostic factors for survival in the ICM group.

Early palliative care may improve quality of life and reduce insomnia and symptoms of anxiety in patients at the end-of-life phase of care.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: Patients with significant symptoms were excluded from the study, so the sample was biased from the beginning toward individuals with less symptom distress. This factor could be expected to bias study results.

This study sought to show that offering appropriate and timely palliative care using the ICM model can reduce symptom burden during the transition into advanced disease and death. This study provided little support because of study design flaws. There was limited research on the effects of early palliative care. Additional research is needed to test this model in the United States and focus on integration into practice.