Randomized Trial of a Palliative Care Intervention to Improve End-of-Life Care Discussions in Patients With Metastatic Breast Cancer

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Joseph A. Greer Massachusetts General Hospital,
Harvard Medical School, and

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Beverly Moy Massachusetts General Hospital,
Harvard Medical School, and

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Areej El-Jawahri Massachusetts General Hospital,
Harvard Medical School, and

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Vicki A. Jackson Massachusetts General Hospital,
Harvard Medical School, and

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Mihir Kamdar Massachusetts General Hospital,
Harvard Medical School, and

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Juliet Jacobsen Massachusetts General Hospital,
Harvard Medical School, and

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Charlotta Lindvall Harvard Medical School, and
Dana-Farber Cancer Institute, Boston, Massachusetts;

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Jennifer A. Shin Massachusetts General Hospital,
Harvard Medical School, and

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Simone Rinaldi Massachusetts General Hospital,
Harvard Medical School, and

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Heather A. Carlson Massachusetts General Hospital,
Harvard Medical School, and

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Angela Sousa Massachusetts General Hospital,
Harvard Medical School, and

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Emily R. Gallagher Massachusetts General Hospital,

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Zhigang Li University of Florida, Gainesville, Florida;

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Samantha Moran Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts;

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Magaret Ruddy University of Massachusetts Medical School, Worcester, Massachusetts;

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Maya V. Anand University of Rochester School of Medicine and Dentistry, Rochester, New York; and

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Julia E. Carp Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania.

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Jennifer S. Temel Massachusetts General Hospital,
Harvard Medical School, and

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Background: Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population. Patients and Methods: Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization. Results: The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21–7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10–14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms. Conclusions: This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories.

ClinicalTrials.gov identifier: NCT02730858

Submitted November 25, 2020; final revision received April 4, 2021; accepted for publication April 5, 2021.

Author contributions: Study concept and design: Greer, Moy, Temel. Data curation: Gallagher, Moran, Ruddy, Anand, Carp. Data analysis: Greer, El-Jawahri, Lindvall, Li, Temel. Data interpretation: Greer, Moy, El-Jawahri, Jackson, Kamdar, Jacobsen, Lindvall, Shin, Rinaldi, Carlson, Souza, Li, Temel. Manuscript preparation—original draft: Greer, El-Jawahri, Temel. Manuscript preparation—review and editing: Moy, Jackson, Kamdar, Jacobsen, Lindvall, Shin, Rinaldi, Carlson, Souza, Gallagher, Li, Moran, Ruddy, Anand, Carp.

Disclosures: Dr. Greer has disclosed receiving grant/research support from Blue Note Therapeutics and receiving royalties from Springer (Humana Press). The remaining authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: This work was supported by funding from NCCN/Pfizer Independent Grants for Learning & Change (PI: J.S. Temel).

Correspondence: Joseph A. Greer, PhD, Massachusetts General Hospital, Yawkey Center, Suite 10B, 55 Fruit Street, Boston, MA 02114. Email: jgreer2@mgh.harvard.edu

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