Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada.
Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada.
Oncologist. 2021 Apr;26(4):332-340. doi: 10.1002/onco.13625. Epub 2021 Jan 2.
Evidence from randomized controlled trials has demonstrated benefits in quality of life outcomes from early palliative care concurrent with standard oncology care in patients with advanced cancer. We hypothesized that there would be earlier referral to outpatient palliative care at a comprehensive cancer center following this evidence.
Administrative databases were reviewed for two cohorts of patients: the pre-evidence cohort was seen in outpatient palliative care between June and November 2006, and the post-evidence cohort was seen between June and November 2015. Timing of referral was categorized, according to time from referral to death, as early (>12 months), intermediate (>6 months to 12 months), and late (≤6 months from referral to death). Univariable and multivariable ordinal logistic regression analyses were used to determine demographic and medical factors associated with timing of referral.
Late referrals decreased from 68.8% pre-evidence to 44.8% post-evidence; early referrals increased from 13.4% to 31.1% (p < .0001). The median time from palliative care referral to death increased from 3.5 to 7.0 months (p < .0001); time from diagnosis to referral was also reduced (p < .05). On multivariable regression analysis, earlier referral to palliative care was associated with post-evidence group (p < .0001), adjusting for shorter time since diagnosis (p < .0001), referral for pain and symptom management (p = .002), and patient sex (p = .04). Late referrals were reduced to <50% in the breast, gynecological, genitourinary, lung, and gastrointestinal tumor sites.
Following robust evidence from trials supporting early palliative care for patients with advanced cancer, patients were referred substantially earlier to outpatient palliative care.
Following published evidence demonstrating the benefit of early referral to palliative care for patients with advanced cancer, there was a substantial increase in early referrals to outpatient palliative care at a comprehensive cancer center. The increase in early referrals occurred mainly in tumor sites that have been included in trials of early palliative care. These results indicate that oncologists' referral practices can change if positive consequences of earlier referral are demonstrated. Future research should focus on demonstrating benefits of early palliative care for tumor sites that have tended to be omitted from early palliative care trials.
随机对照试验的证据表明，在晚期癌症患者中，早期姑息治疗与标准肿瘤治疗同时进行，可以提高生活质量。我们假设，在这一证据之后，综合癌症中心的患者会更早地被转介到门诊姑息治疗。
我们对两个患者队列的行政数据库进行了审查：预证据队列是在 2006 年 6 月至 11 月期间在门诊姑息治疗中接受治疗的，后证据队列是在 2015 年 6 月至 11 月期间接受治疗的。根据从转介到死亡的时间，将转介时间分为早期（>12 个月）、中期（>6 个月至 12 个月）和晚期（≤6 个月）。采用单变量和多变量有序逻辑回归分析来确定与转介时间相关的人口统计学和医学因素。
晚期转介从预证据的 68.8%下降到后证据的 44.8%；早期转介从 13.4%增加到 31.1%（p<0.0001）。从姑息治疗转介到死亡的中位数时间从 3.5 个月增加到 7.0 个月（p<0.0001）；从诊断到转介的时间也缩短了（p<0.05）。在多变量回归分析中，与后证据组相比，更早地转介到姑息治疗（p<0.0001），调整后诊断时间较短（p<0.0001）、因疼痛和症状管理而转介（p=0.002）和患者性别（p=0.04）。在乳腺癌、妇科、泌尿生殖系统、肺癌和胃肠道肿瘤部位，晚期转介减少到<50%。
在试验中支持对晚期癌症患者进行早期姑息治疗的有力证据之后，患者被更早地转介到门诊姑息治疗。
在发表的证据表明，对晚期癌症患者进行早期姑息治疗的益处之后，综合癌症中心的门诊姑息治疗的早期转介显著增加。早期转介的增加主要发生在已经被纳入早期姑息治疗试验的肿瘤部位。这些结果表明，如果证明早期转介的积极后果，肿瘤学家的转介实践可以改变。未来的研究应该集中在证明早期姑息治疗对那些往往被排除在早期姑息治疗试验之外的肿瘤部位的益处。
