Stepped Palliative Care: A Scalable Alternative to Early Palliative Care in Advanced Cancer?

Early palliative care, shown to improve quality of life (QOL) and survival, is recommended for patients with advanced cancer, yet implementation is challenging due to limited resources. In this multicenter, nonblinded, noninferiority trial, 507 adults with advanced lung cancer diagnosed within the prior 12 weeks were randomized to receive early or stepped palliative care.

Early care involved outpatient visits every 4 weeks and inpatient palliative care during hospital admissions. Stepped care involved an initial outpatient visit and subsequent visits only with specific events (cancer progression, treatment toxicity, discontinuation of therapy) or after hospitalization; in addition, patients were stepped up to visits every 4 weeks if they had a ≥10-point decrease from baseline on a QOL measure assessed every 6 weeks (Functional Assessment of Cancer Therapy – Lung [FACT-L]; 0–136-point scale).

By 24 weeks, the stepped-care group had significantly fewer palliative care visits than the early-care group (mean, 4.7 vs. 2.4; P<0.001). QOL at week 24 (the primary outcome) was noninferior in the stepped-care group compared with the early-care group (adjusted mean FACT-L score, 100.6 vs. 97.8; P<.001 for noninferiority). Depression symptoms, use of coping strategies, understanding of prognosis, and communication about end-of-life care did not differ between groups. However, hospice use was less in the stepped-care group than the early-care group (adjusted mean days, 19.5 vs. 34.6; P=0.91 for noninferiority).