Few patients with early-stage lung cancer receive palliative care despite severe symptoms; however, patients with stage I to III lung cancer and comorbid COPD with a worsening symptom burden are more likely to receive palliative care, according to study findings published in the Journal of Pain and Symptom Management.
Patients with COPD who have lung cancer may have greater palliative care needs due to a greater symptom burden. Investigators thus assessed patients with lung cancer, comparing those with and without COPD with respect to their receipt of timely palliative care and their level of symptom burden.
Investigators conducted a retrospective, population-based cohort study in Ontario, Canada, using health administrative databases and cancer registries to identify adults at least 18 years of age diagnosed with lung cancer from January 2009 through March 2019. Patients were followed through March 2020 or until death, whichever came first.
Patients who received palliative care in the 5 years prior to lung cancer diagnosis (index date), or those diagnosed with lung cancer upon death were excluded. Receipt of palliative care was determined through physician billing codes.
COPD impacts the receipt of palliative care and symptom burden for patients with early-stage lung cancer.
The study included almost 75,000 patients with lung cancer; of those, 48% had available symptom data; 50% had COPD at lung cancer diagnosis; and 51% were diagnosed with stage IV lung cancer. Median follow-up was 329 days (interquartile range, 89-1275 days). Of the patients studied, 81% received palliative care during the study period. Most patients with stage III (65%) or stage IV (90%) received palliative care within 1 year of diagnosis. The investigators noted 18% of patients with stage I and 38% of patients with stage II received palliative care within 1 year of diagnosis.
A total of 62,495 deaths occurred within the study period, with 63% within the first year following diagnosis.
The investigators found that in those with stage I, II, and III lung cancer, the provision of palliative care was more common in those with COPD vs those without (adjusted hazard ratio [aHR]stage I, 1.05; aHRstage II, 1.31; aHRstage III, 1.22); among patients with stage IV lung cancer, there was no difference between the COPD and non-COPD cohorts (aHRstage IV, 1.02; 95% CI, 1.00-1.04).
Severe symptoms were reported by most patients (84%) and symptom burden was worsened with COPD, especially among patients with early-stage disease. The investigators noted few patients with early-stage disease received palliative care despite severe symptoms, although those with COPD were more likely to receive palliative care (stage I with COPD [23%]; stage I no COPD [18%]; standard mean difference, 0.12).
The first visit location for receiving palliative care was a secondary outcome of interest in this study. The researchers found that 44% of such visits took place in an outpatient setting and 30% in the hospital setting; notably, this was consistent for patients in all lung cancer stages.
More patients with COPD vs without had severe respiratory symptoms in stage I (81% vs 70%) as well as more severe nonrespiratory symptoms including depression, anxiety, pain, and tiredness. Results were similar for patients with stage II. Among patients with stage III, more patients with COPD reported severe tiredness, shortness of breath, and drowsiness. Among patients with stage IV, only shortness of breath was reported as more severe among patients with COPD.
Study limitations include lack of accounting for both the severity of COPD and certain types of palliative care, such as radiation and psychosocial support.
“COPD impacts the receipt of palliative care and symptom burden for patients with early-stage lung cancer,” investigators concluded. They stated, “Many patients with severe symptoms did not receive palliative care, suggesting unmet needs among this vulnerable population.”