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Title Value of palliative care in newly diagnosed cancer The value of palliative care in newly diagnosed cancer
Full text https://hdl.handle.net/1842/39270; http://dx.doi.org/10.7488/era/2521
Date 2022
Author(s) Reid, Eleanor Anderson
Contributor(s) Grant, Liz; Fallon, Marie; Hall, Peter
Abstract INTRODUCTION: Globally, deaths due to non-communicable diseases are on the rise, with low- and middleincome countries (LMICs) particularly affected. Palliative care (PC) reduces pain and suffering for patients with incurable disease, and in high income settings, also reduces costs at the end of life. In LMICs there is a gap in access to PC as well as underpinning research to support its implementation. In Ethiopia, cancers constitute a rising proportion of recorded NCDs. We therefore designed a feasibility study to better understand the initiation of home-based, early, routine addition of palliative care PC for patients with newly diagnosed cancer, patient reported outcomes, and costs in Addis Ababa, Ethiopia. METHODS: A feasibility single-blind randomized controlled trial of standard cancer care versus standard cancer care plus early routine addition of Palliative Care in newly diagnosed cancer patients was designed. The cancer care delivered represents the standard of cancer care in this location, including medication stock outs and preferential treatment given to those patients with a higher likelihood of therapeutic response. The palliative care intervention was home-based and delivered by Hospice Ethiopia nurses, according to local standard palliative care practices. Given the risk of bias in assigning patients with poor prognosis preferentially to the PC arm, blinding was critical to ensure homogeneity in our sample population across study arms. This was achieved by delivering the PC intervention in patient homes as opposed to in Oncology clinic, which also aligns with the standard practice of PC at Hospice Ethiopia. Follow-up was at 8 weeks plus or minus 4 weeks and at 12 weeks plus or minus 4 weeks per the treating, blinded Oncologist's discretion, and standard practices. Outcomes of interest were three-fold: (1)feasibility with a focus on implementation and practicality, (2)patient reported outcomes as measured by the African Palliative Care Association Palliative Outcome Scale, A and (3)Costs and consequences, comprising patient-reported and hospital-generated costs was conducted for those patients who completed all three study visits. RESULTS: Ninety-five adult patients with newly diagnosed cancer were randomised to receive standard cancer care or standard cancer care plus PC. The mean age was 49.5 years and 66% of the population was female. Twenty-seven patients completed all three study visits and of these, 20 charts were available for adjudication in the cost consequence analysis. While there were few barriers to recruitment of study subjects due to the large number of patients seeking care for newly diagnosed cancers, retention was a challenge for the following reasons: death, technical difficulties reaching patient by mobile phone for follow- up, patients moving from the city back to the countryside, limited death reports. Study sample characteristics reflect the pragmatic nature of the study: the preferential selection of patients thought to have a good chance of therapeutic response to chemotherapeutics, as well as a high percentage of patients with advanced disease (91.4% with Stage III or IV disease). In both study arms there were significant improvements in patient reported outcomes over the course of the study. Mean total healthcare costs to the patient, pooled from both arms, were 40,430 Ethiopian birr (979 USD); mean palliative care costs to Hospice Ethiopia were 765 Ethiopian birr (19 USD) per subject. Those receiving standard cancer care reported higher out of pocket payments for medical care and increased lost wages of an informal caregiver. Those receiving standard cancer care reported higher out of pocket payments for medical care and increased lost wages of an informal caregiver. Out-ofix pocket payments for medical care and lost wages were multiple times an average yearly salary in Ethiopia (70 USD) at 5810 Ethiopian birr (140.8 USD) and 74900 Ethiopian birr (1814.9 USD). By the third study visit, healthcare-generated costs, units of healthcare utilization and mortality had all increased. CONCLUSION: Despite the limitations and challenges of conducting an RCT in what became a particularly challenging environment and time, our results suggest that it is feasible to conduct an RCT of early routine addition of PC for patients with cancer in Ethiopia. Patient retention was the biggest challenge faced and is also a major limiting factor. The preferential selection of those patients thought to have a good chance at therapeutic response further limits the applicability of our results to other populations. The effect of PC on patient reported outcomes may have been minimized by adaptations due to the COVID-19 pandemic which required a shift to phone follow-up as opposed to the planned in-person visits. Finally, the overall significant improvement in patient-reported outcomes without between group differences and inability to reject the null hypothesis actually reflects the acceptability of the PC intervention and specifically, that between study planning and roll-out, there was an increase in analgesia prescribed to all patients with cancer in this clinic. The study revealed opportunities to improve care for those with advanced cancer diagnoses while informing future, larger research on the health economics of PC in Ethiopia and other similar settings. The study provides important information on feasibility which can inform the design of a larger implementation study. Crucial to progress in PC provision is continued engagement with healthcare decision-makers and funders regarding the health economics, delivery strategies and improved patient reported outcomes fostered by PC, as it is likely that PC is a resource-sparing and poverty-reducing strategy.
Subject(s) n/a
Language en
Publisher The University of Edinburgh
Type of publication Thesis or Dissertation; Doctoral; PhD Doctor of Philosophy
Format application/pdf
Repository Edinburgh - University of Edinburgh
Added to C-A: 2022-07-04;10:41:16