Effect of early palliative care: complex intervention and complex results – Authors' reply

We would like to thank Ishiki and colleagues for their comments. They note that the primary outcome solely focused on the difference of overall quality of life (QOL) scores between both groups at 12 weeks. As stated in our article, 1 Vanbutsele G Pardon K Van Belle S et al. Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trial. Lancet Oncol. 2018; 19: 394-404 Summary Full Text Full Text PDF PubMed Scopus (220) Google Scholar the effect of intervention on the primary outcome and other outcomes was assessed by multivariate regression analyses adjusted for baseline scores. Baseline scores were, therefore, taken into account: for the same baseline score (59·7) in both groups, the usual care group scored 7·6 points lower on QOL at 12 weeks compared with that of the early palliative care group. They also correctly note that the number of consultations in the early palliative care group was smaller than anticipated. As was mentioned, one reason is that some patients did not have planned hospital visits by 18 weeks and we did not demand additional hospital visits of patients merely for our study. Other reasons contributing to the smaller number of consultations were the refusal or, sometimes, the death of the patient. Ishiki and colleagues also suggested that the lower QOL score in the usual care group might be due to the disappointment of patients for not receiving early palliative care. However, a study 2 Zimmermann C Swami N Kryzanowska M et al. Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ. 2016; 188: 217-227 Crossref PubMed Scopus (212) Google Scholar of early palliative care showed that patients often described feeling frightened when palliative care is introduced, with these perceptions changing after the trial in patients receiving early palliative care, but not in patients receiving usual care. 2 Zimmermann C Swami N Kryzanowska M et al. Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ. 2016; 188: 217-227 Crossref PubMed Scopus (212) Google Scholar Ishiki and colleagues also note that treating oncologists might have refrained from consulting the palliative care team for participants in the usual care group. As stated in our article, a crossover effect cannot be excluded; staff members were not masked to patient allocation to the intervention or control groups. The design of our trial did not exclude referral to the palliative care team in the usual care group and 18% of participants were referred by 18 weeks. Effect of early palliative care: complex intervention and complex resultsWe applaud the work done by Vanbutsele and colleagues1 using a highly complex palliative care intervention. However, the results are difficult to interpret, because of multiple confounders. Here, we present a couple of discussion points regarding this. Full-Text PDF Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trialThe findings of this study show that a model of early and systematic integration of palliative care in oncological care increases the quality of life of patients with advanced cancer. Our findings also show that early and systematic integration of palliative care is more beneficial for patients with advanced cancer than palliative care consultations offered on demand, even when psychosocial support has already been offered. Through integration of care, oncologists and specialised palliative care teams should work together to enhance the quality of life of patients with advanced cancer. Full-Text PDF