There have been remarkable improvements in treatments for cancer, but at the time of diagnosis, some patients will still have a reduced life expectancy. Incurable cancer can pose an enormous challenge to the patient, their family, and medical professionals, affecting the patient's quality of life in many ways (Addington-Hall 1995). Interventions tailored to increase the physical and psychological well-being of people with cancer are of utmost importance. Palliative care comprises an "approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual" (WHO 2013). Interdisciplinary care and carer support help to deliver the essential elements of palliative care by managing the patient's quality of life and symptom control (Hui 2013). However, although early access is inherent in the definition of palliative care, usual practice is still limited to the terminal phase of illness.
Description of the condition
With an incident rate of 12.4 million cases in 2008 and eight million deaths in 2010, malignant neoplastic diseases remain one of the leading causes of death worldwide (Boyle 2008; Lozano 2012). Globally, the most common entity and cause of cancer-related mortality is breast cancer in women and lung cancer in men. Cancer incidence has been estimated to increase yearly by 1%, with the growing population worldwide and the demographic shift towards an ageing population in developed countries being the paramount factors for future cancer burden (Boyle 2008).
Despite significant progress in understanding the risk factors of cancer, development of methods for the early identification of some cancers or pre-cancerous diseases, and sound advances in the treatment of many cancers previously deemed fatal, cancer continues to cause the premature death of many patients. At the time of diagnosis, the chances of a curative treatment are often minimal due to advanced disease. The American Cancer Society defines advanced cancer as "cancers that cannot be cured" and metastatic cancer as tumours that "have usually spread from where they started to other parts of the body" (American Cancer Society 2013). However, not all advanced cancers are metastatic. For example, brain tumours may be considered advanced because they are not curable and are life threatening, even in the absence of metastasis. In addition, the survival rate of patients remains very poor, especially for metastatic lung cancer as well as pancreatic and biliary tract malignancies.
Because of the upcoming death in many of these cases, it is essential to develop appropriate treatment plans for improving survival, while also aiming for a subjectively worthwhile quality of life. Both symptom control and disease-modifying therapy are used in these situations. By often causing a major decline of physical efficiency and persistent chronic pain, advanced cancer regularly puts the physical and psychological integrity of patients at high risk. In many cases, the correct execution of the necessary medical treatments and the daily routine at home demands continuous familial and often additional external support. Symptoms such as fatigue, anorexia, cachexia, confusion, dysphagia, and dyspnoea are independent prognostic factors for predicting life expectancy in patients with recently diagnosed incurable cancer (Trajkovic-Vidakovic 2012). In addition, patients and their carers are concerned with burdensome existential ruminations leading to psychological distress on both sides, with the long-term risk of severe impairments in patients' and carers' physical and psychological health and declining resources of social support (Moser 2013; Singer 1999). Such developments within the family often promote conflicts about the responsibilities regarding decision-making in therapeutic as well as everyday challenges. Economic consequences frequently comprise, for example, a reduction of family income or considerable out-of-pocket medical spending leading to financial hardship for patients and their families (Elkin 2010; Zhang 2009). Due to these strains, professional support gains extraordinary importance in alleviating physical discomfort as well as in contributing to improving the patient's quality of life.
Description of the intervention
The purpose of palliative care lies in the reduction of suffering and improvement in the quality of life for patients and their carers. According to the current National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines, palliative care is generally combined with other therapies (such as chemotherapy or radiotherapy) intended to prolong life or reduce symptoms (Levy 2012). Key components of palliative care are as follows: 1. systematic symptom assessment, 2. pain control and relief of other symptoms, 3. psychosocial care, and 4. support for families (Hui 2013; The WHOQOL Group 1998).
Palliative care is administered either by the collaborating of specialists included in a multidisciplinary palliative care team (doctors, clinical nurse specialists, social workers, chaplains, therapists, and psychologists or psychiatrists) or within the scope of a comprehensive care approach co-ordinated by a health professional (often a nurse). Early palliative care can be delivered in a breadth of settings including community, hospitals, and inpatient hospice units. Community hospice services may also support patients earlier in the day care/outpatient setting. Although a systematic review conducted by Hearn 1998 provided some evidence that specialised palliative care teams contribute to improved outcomes in patients as well as in carers, only one study, thus far, has addressed 'team' effects separately from the general effects of a conventional approach and indicated no consistent differences regarding the benefits of both approaches.
Early palliative care begins at the time of or shortly after the diagnosis of advanced disease (Temel 2010). Compared with palliative care, early palliative care is initiated much earlier in the disease trajectory, and it is not bound to the non-response to curative treatment or evident anticipation of death. A prerequisite for patients' readiness for palliative care in such an early situation is coherent and empathetic communication of health professionals (de Haes 2005; Dowsett 2000; Meyers 2003; Morrison 2004; Sinclair 2006). The purpose of early palliative care is to outline realistic and attainable goals of treatment (Van Mechelen 2013), and to facilitate patient choices by providing adequate information and assessment of his/her values and preferences with regard to advance care planning (Levy 2012). The underlying idea is that symptoms treated early can be managed more easily, thereby improving the patients' quality of life.
How the intervention might work
With a focus on intensified doctor-patient communication, early palliative care may lead to higher social support and increase the likelihood of the acceptance of the diagnosis and illness severity. These effects, along with the augmented satisfaction of the patient-physician relationship, may improve the patient's openness to symptom control and psychosocial interventions, thereby reducing distress. Reduced distress itself is associated with improved quality of life and consistently associated with survival (Gotay 2008; Irwin 2012; Pinquart 2010). Furthermore, patient and family members undergoing early palliative care are better informed about treatment directives and end-of-life decisions, which promotes the experience of higher self efficacy and a higher sense of control in decisions with respect to their individual values (McClain 2003). On the one hand, better symptom control and psychosocial function could promote better adherence to reasonable treatment plans. On the other hand, palliative care is linked to less aggressive cancer treatment, such as reduced use of questionable chemotherapy and treatment in intensive care units (Earle 2008). This tendency to de-escalate treatment intensity in final, irreversible health conditions, together with the extension of outpatient and community palliative care services, is important to patients as well as to socioeconomics (Lowery 2013; Smith 2003).
Why it is important to do this review
Evidence for the benefits of late palliative care is ambiguous because the time required for establishing the beneficial effects may be too short (El-Jawahri 2011; Gomes 2013; Higginson 2010; Zimmermann 2008). Palliative interventions applied early, around the time of the diagnosis of incurable advanced cancer, may be more favourable to improve symptom and disease management (Levy 2012). Therefore, some investigators consider there is a paradigm shift (Kelley 2010). To date, no systematic review or meta-analysis has been conducted on early palliative care interventions for patients with advanced cancer. This results in both a lack of an overview of interventions applied within this framework as well as uncertainty about the general impact of such interventions on various patient- and carer-related outcomes.