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Design and Participants: This follow-up study of the Engagement of Patients with Advanced Cancer trial (2013-2015) used data from 9.4 years after the first patient was enrolled to evaluate the association of an intervention among patients with stage 3/4 or recurrent cancer in the US Veterans Affairs Palo Alto Healthcare System with overall survival and end-of-life healthcare use and costs. The intervention included 6-month lay health worker–led education and support to assist patients with establishing their end-of-life preferences vs usual care. Outcomes were overall survival; death risk; restricted mean survival time; and palliative care, hospice, and acute care use in the final 30 days predeath for participants who died. Analysis (intention to treat) included regression models, log-rank tests, and Kaplan-Meier methodology.
Results: Participants (N=213) were aged mean 69 years (SD=9.1); 99% male; and 1.9% American Indian/Alaska Native, 4.7% Asian Pacific Islander, 5.2% Black, 1.9% Hispanic, 1.9% Hawaiian, and 77% White. There were no clinical or demographic characteristic imbalances at enrollment. As of February 2023, 88% had died. The intervention group had a 25% reduction in death risk (hazard ratio, 0.75; 95% CI=0.56-0.98); more palliative care (44 [50%] vs 35 [35%]) and hospice use (64 [73%] vs 53 [53%]); and lower emergency department use (20 [23%] vs 47 [47%]), hospitalizations (17 [19%] vs 46 [46%]), and total healthcare costs (median=$1,637 [IQR=$383-$9,026] vs $18,520 [$4,790-$50,729]) than control.
Commentary: A lay health worker intervention for advance care planning in this Veterans Affairs–based randomized controlled trial was associated with an unprecedented survival benefit at long-term follow-up. Consistent with prior research, the study also showed a reduction in aggressive care near end of life, lower healthcare costs, and increased utilization of outpatient palliative care and hospice services.3,4 These effects were likely mediated through early integrated palliative care, health behavior modification, and enhanced healthcare engagement beyond cancer care alone. Multicenter validation studies are needed to confirm these results across diverse health systems and other chronic illness populations.
Bottom Line: Advance care planning for advanced cancer not only demonstrates sustained long-term benefits but also may offer a potential survival advantage.
Reviewer: Sonal Admane, MD MPH, The University of Texas MD Anderson Cancer Center, Houston, TX
References:
1. Ferrell BR, Temel JS, Temin S, Smith TJ. Integration of palliative care into standard oncology care: ASCO Clinical Practice Guideline Update Summary. J Oncol Pract. 2017;13(2):119-121. doi:10.1200/JOP.2016.017897.
2. Harle I, Karim S, Raskin W, Hopman WM, Booth CM. Toward improved goals-of-care documentation in advanced cancer: report on the development of a quality improvement initiative. Curr Oncol. 2017;24(6):383-389. doi:10.3747/co.24.3754.
3.Mack JW, Cronin A, Keating NL, et al. Associations between end-of-life discussion characteristics and care received near death: a prospective cohort study. J Clin Oncol. 2012;30(35):4387-4395. doi:10.1200/JCO.2012.43.6055.
4.Desai A, Schneiderman H. Bolstering outpatient advanced care planning and palliative care in oncology: why and how. J Oncol Pract. 2019;15(7):360-362. doi:10.1200/JOP.19.00108.
Source: Patel MI, Agrawal M, Blayney DW, Bundorf MK, Milstein A. Long-term engagement of patients with advanced cancer: results from the EPAC randomized clinical trial. JAMA Oncol. 2024;10(7):905-911. doi:10.1001/jamaoncol.2024.1221.
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