SpringerLink
Log in

Symptom screening with Targeted Early Palliative care (STEP) versus usual care for patients with advanced cancer: a mixed methods study

  • Research
  • Published:
Supportive Care in Cancer Aims and scope Submit manuscript

Abstract

Purpose

Although early palliative care is recommended, resource limitations prevent its routine implementation. We report on the preliminary findings of a mixed methods study involving a randomized controlled trial (RCT) of Symptom screening with Targeted Early Palliative care (STEP) and qualitative interviews.

Methods

Adults with advanced solid tumors and an oncologist-estimated prognosis of 6–36 months were randomized to STEP or symptom screening alone. STEP involved symptom screening at each outpatient oncology visit; moderate to severe scores triggered an email to a palliative care nurse, who offered referral to in-person outpatient palliative care. Patient-reported outcomes of quality of life (FACT-G7; primary outcome), depression (PHQ-9), symptom control (ESAS-r-CS), and satisfaction with care (FAMCARE P-16) were measured at baseline and 2, 4, and 6 months. Semi-structured interviews were conducted with a subset of participants.

Results

From Aug/2019 to Mar/2020 (trial halted due to COVID-19 pandemic), 69 participants were randomized to STEP (n = 33) or usual care (n = 36). At 6 months, 45% of STEP arm patients and 17% of screening alone participants had received palliative care (p = 0.009). Nonsignificant differences for all outcomes favored STEP: difference in change scores for FACT-G7 = 1.67 (95% CI: −1.43, 4.77); ESAS-r-CS = −5.51 (−14.29, 3.27); FAMCARE P-16 = 4.10 (−0.31, 8.51); PHQ-9 = −2.41 (−5.02, 0.20). Sixteen patients completed qualitative interviews, describing symptom screening as helpful to initiate communication; triggered referral as initially jarring but ultimately beneficial; and referral to palliative care as timely.

Conclusion

Despite lack of power for this halted trial, preliminary results favored STEP and qualitative results demonstrated acceptability. Findings will inform an RCT of combined in-person and virtual STEP.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The data of this study are available from the corresponding author upon reasonable request.

References

  1. Ferrell BR, Temel JS, Temin S, Alesi ER, Balboni TA, Basch EM et al (2017) Integration of palliative care into standard oncology care: American society of clinical oncology clinical practice guideline update. J Clin Oncol 35(1):96–112. https://doi.org/10.1200/JCO.2016.70.1474

    Article  PubMed  Google Scholar 

  2. Jordan K, Aapro M, Kaasa S, Ripamonti CI, Scotte F, Strasser F et al (2018) European Society for Medical Oncology (ESMO) position paper on supportive and palliative care. Ann Oncol 29(1):36–43. https://doi.org/10.1093/annonc/mdx757

    Article  CAS  PubMed  Google Scholar 

  3. Zimmermann C, Swami N, Krzyzanowska M, Hannon B, Leighl N, Oza A et al (2014) Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. The Lancet 383(9930):1721–1730. https://doi.org/10.1016/s0140-6736(13)62416-2

    Article  Google Scholar 

  4. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA et al (2010) Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 363(8):733–742. https://doi.org/10.1056/NEJMoa1000678

    Article  CAS  PubMed  Google Scholar 

  5. Temel JS, Greer JA, El-Jawahri A, Pirl WF, Park ER, Jackson VA et al (2017) Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol 35(8):834–841. https://doi.org/10.1200/JCO.2016.70.5046

    Article  PubMed  Google Scholar 

  6. Vanbutsele G, Pardon K, Van Belle S, Surmont V, De Laat M, Colman R et al (2018) Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trial. Lancet Oncol 19(3):394–404. https://doi.org/10.1016/S1470-2045(18)30060-3

    Article  PubMed  Google Scholar 

  7. Maltoni M, Scarpi E, Dall'Agata M, Zagonel V, Berte R, Ferrari D et al (2016) Systematic versus on-demand early palliative care: results from a multicentre, randomised clinical trial. Eur J Cancer 65:61–68. https://doi.org/10.1016/j.ejca.2016.06.007

    Article  PubMed  Google Scholar 

  8. Bakitas M, Lyons KD, Hegel MT, Balan S, Brokaw FC, Seville J et al (2009) Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the project ENABLE II randomized controlled trial. JAMA 302(7):741–749. https://doi.org/10.1001/jama.2009.1198

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Lupu D (2010) American Academy of H, Palliative Medicine Workforce Task F. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage 40(6):899–911. https://doi.org/10.1016/j.jpainsymman.2010.07.004

    Article  PubMed  Google Scholar 

  10. Sleeman KE, de Brito M, Etkind S, Nkhoma K, Guo P, Higginson IJ et al (2019) The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions. Lancet Glob Health 7(7):e883–ee92. https://doi.org/10.1016/S2214-109X(19)30172-X

    Article  PubMed  PubMed Central  Google Scholar 

  11. Hui D, Hannon BL, Zimmermann C, Bruera E (2018) Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. CA Cancer J Clin 68(5):356–376. https://doi.org/10.3322/caac.21490

    Article  PubMed  PubMed Central  Google Scholar 

  12. Vogt J, Beyer F, Sistermanns J, Kuon J, Kahl C, Alt-Ep** B et al (2021) Symptom burden and palliative care needs of patients with incurable cancer at diagnosis and during the disease course. Oncologist 26(6):e1058–e1e65. https://doi.org/10.1002/onco.13751

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Rodin R, Swami N, Pope A, Hui D, Hannon B, Le LW et al (2022) Impact of early palliative care according to baseline symptom severity: secondary analysis of a cluster-randomized controlled trial in patients with advanced cancer. Cancer Med 11(8):1869–1878. https://doi.org/10.1002/cam4.4565

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zimmermann C, Pope A, Hannon B, Krzyzanowska MK, Rodin G, Li M et al (2021) Phase II Trial of Symptom screening with Targeted Early Palliative care for patients with advanced cancer. J Natl Compr Canc Netw 20(4):361–70.e3. https://doi.org/10.6004/jnccn.2020.7803

    Article  PubMed  Google Scholar 

  15. Creswell JW, Plano Clark VL (2018) Designing and conducting mixed methods research, 3rd edn. Sage Publications, Thousand Oaks, CA

    Google Scholar 

  16. Alcalde J, Hannon B, Zimmermann C (2023) Mixed Methods research. In: Higginson IJ, Costantini M, Preston NJ, Currow DC, Bruera E, Larkin PJ (eds) Research methods in palliative care, 2nd edn. Oxford University Press. In press

  17. Farquhar MC, Ewing G, Booth S (2011) Using mixed methods to develop and evaluate complex interventions in palliative care research. Palliat Med 25(8):748–757. https://doi.org/10.1177/0269216311417919

    Article  PubMed  Google Scholar 

  18. Curry L, Nunez-Smith M (2015) Mixed methods in health sciences research: a practical primer. In:Thousand Oaks. SAGE Publications, Inc., California. https://doi.org/10.4135/9781483390659https://methods.sagepub.com/book/mixed-methods-in-health-sciences-research-a-practical-primer

    Book  Google Scholar 

  19. Oken MM, Creech RH, Tormey DC, Horton J, Davis TE, McFadden ET et al (1982) Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 5(6):649–655

    Article  CAS  PubMed  Google Scholar 

  20. Katzman R, Brown T, Fuld P, Peck A, Schechter R, Schimmel H (1983) Validation of a short orientation-memory-concentration test of cognitive impairment. Am J Psychiatry 140(6):734–739. https://doi.org/10.1176/ajp.140.6.734

    Article  CAS  PubMed  Google Scholar 

  21. Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F (2011) A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients. J Pain Symptom Manage 41(2):456–468. https://doi.org/10.1016/j.jpainsymman.2010.04.020

    Article  PubMed  Google Scholar 

  22. Dudgeon D, King S, Howell D, Green E, Gilbert J, Hughes E et al (2012) Cancer Care Ontario's experience with implementation of routine physical and psychological symptom distress screening. Psychooncology 21(4):357–364. https://doi.org/10.1002/pon.1918

    Article  PubMed  Google Scholar 

  23. Pereira J, Green E, Molloy S, Dudgeon D, Howell D, Krzyzanowska MK et al (2014) Population-based standardized symptom screening: Cancer Care Ontario's Edmonton Symptom Assessment System and performance status initiatives. J Oncol Pract 10(3):212–214. https://doi.org/10.1200/JOP.2014.001390

    Article  PubMed  Google Scholar 

  24. Follwell M, Burman D, Le LW, Wakimoto K, Seccareccia D, Bryson J et al (2009) Phase II study of an outpatient palliative care intervention in patients with metastatic cancer. J Clin Oncol 27(2):206–213. https://doi.org/10.1200/JCO.2008.17.7568

    Article  PubMed  Google Scholar 

  25. Ontario CC: managing symptoms, Side Effects & Well-Being. https://www.cancercareontario.ca/en/symptom-management. Accessed December 18 2022.

  26. Mah K, Swami N, Le LW, Chow R, Hannon BL, Rodin G et al (2020) Validation of the 7-item Functional Assessment of Cancer Therapy-General (FACT-G7) as a short measure of quality of life in patients with advanced cancer. Cancer 126(16):3750–3757. https://doi.org/10.1002/cncr.32981

    Article  PubMed  Google Scholar 

  27. Hannon B, Dyck M, Pope A, Swami N, Banerjee S, Mak E et al (2015) Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer. J Pain Symptom Manage 49(5):945–952. https://doi.org/10.1016/j.jpainsymman.2014.10.013

    Article  PubMed  Google Scholar 

  28. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Zimmerman M (2012) Symptom severity and guideline-based treatment recommendations for depressed patients: implications of DSM-5's potential recommendation of the PHQ-9 as the measure of choice for depression severity. Psychother Psychosom 81(6):329–332. https://doi.org/10.1159/000342262

    Article  PubMed  Google Scholar 

  30. Yanez B, Pearman T, Lis CG, Beaumont JL, Cella D (2013) The FACT-G7: a rapid version of the functional assessment of cancer therapy-general (FACT-G) for monitoring symptoms and concerns in oncology practice and research. Ann Oncol 24(4):1073–1078. https://doi.org/10.1093/annonc/mds539

    Article  CAS  PubMed  Google Scholar 

  31. Lo C, Burman D, Rodin G, Zimmermann C (2009) Measuring patient satisfaction in oncology palliative care: psychometric properties of the FAMCARE-patient scale. Qual Life Res 18(6):747–752. https://doi.org/10.1007/s11136-009-9494-y

    Article  PubMed  Google Scholar 

  32. Guyatt GH, Osoba D, Wu AW, Wyrwich KW, Norman GR (2002) Clinical significance consensus meeting G. Methods to explain the clinical significance of health status measures. Mayo Clin Proc 77(4):371–383. https://doi.org/10.4065/77.4.371

    Article  PubMed  Google Scholar 

  33. Ringash J, O'Sullivan B, Bezjak A, Redelmeier DA (2007) Interpreting clinically significant changes in patient-reported outcomes. Cancer 110(1):196–202. https://doi.org/10.1002/cncr.22799

    Article  PubMed  Google Scholar 

  34. Sandelowski M (2000) Whatever happened to qualitative description? Res Nurs Health 23(4):334–340. https://doi.org/10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g

    Article  CAS  PubMed  Google Scholar 

  35. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3(2):77–101. https://doi.org/10.1191/1478088706qp063oa

    Article  Google Scholar 

  36. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–383. https://doi.org/10.1016/0021-9681(87)90171-8

    Article  CAS  PubMed  Google Scholar 

  37. Hannon B, Swami N, Pope A, Leighl N, Rodin G, Krzyzanowska M et al (2016) Early Palliative care and its role in oncology: a qualitative study. Oncologist 21(11):1387–1395. https://doi.org/10.1634/theoncologist.2016-0176

    Article  PubMed  PubMed Central  Google Scholar 

  38. Hannon B, Swami N, Rodin G, Pope A, Zimmermann C. Experiences of patients and caregivers with early palliative care: a qualitative study. Palliat Med 2016;31(1):72-81.  https://doi.org/10.1177/0269216316649126.

  39. Zimmermann C, Swami N, Krzyzanowska M, Leighl N, Rydall A, Rodin G et al (2016) Perceptions of palliative care among patients with advanced cancer and their caregivers. CMAJ 188(10):E217–Ee27. https://doi.org/10.1503/cmaj.151171

    Article  PubMed  PubMed Central  Google Scholar 

  40. Hannon B, Mak E, Al Awamer A, Banerjee S, Blake C, Kaya E et al (2021) Palliative care provision at a tertiary cancer center during a global pandemic. Support Care Cancer 29(5):2501–2507. https://doi.org/10.1007/s00520-020-05767-5

    Article  PubMed  Google Scholar 

  41. Tasneem S, Kim A, Bagheri A, Lebret J (2019) Telemedicine video visits for patients receiving palliative care: a qualitative study. Am J Hosp Palliat Care 36(9):789–794. https://doi.org/10.1177/1049909119846843

    Article  PubMed  Google Scholar 

  42. Eastman P, Dowd A, White J, Carter J, Ely M (2021) Telehealth: rapid adoption in community palliative care due to COVID-19: patient and professional evaluation. BMJ Support Palliat Care. https://doi.org/10.1136/bmjspcare-2021-002987

Download references

Acknowledgements

Camilla Zimmermann is supported by the Harold and Shirley Lederman Chair in Psychosocial Oncology and Palliative Care, a joint Chair among the University of Toronto, Princess Margaret Cancer Centre/University Health Network and the Princess Margaret Cancer Foundation. The authors thank the patients who participated in this study, the medical oncologists who referred patients to this study, and the clinical and administrative staff of the palliative care team at the Princess Margaret Cancer Centre for their facilitation of this research.

Funding

This study was funded by the Canadian Institutes of Health Research (Grant No. 152996 to Dr. Zimmermann).

Author information

Authors and Affiliations

  1. Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

    Camilla Zimmermann, Ashley Pope, Breffni Hannon, Gary Rodin, Madeline Li, Doris Howell, Jacqueline Alcalde Castro, Nadia Swami, Rachel Sue-A-Quan & Anne Rydall

  2. Princess Margaret Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

    Camilla Zimmermann, Breffni Hannon, Philippe L. Bedard, Gary Rodin, Neesha Dhani, Madeline Li, Monika K. Krzyzanowska, Doris Howell, Jennifer J. Knox, Natasha B. Leighl, Srikala Sridhar, Amit M. Oza, Stephanie Lheureux & Geoffrey Liu

  3. Division of Medical Oncology, Faculty of Medicine, University of Toronto, Toronto, Canada

    Camilla Zimmermann, Philippe L. Bedard, Neesha Dhani, Monika K. Krzyzanowska, Jennifer J. Knox, Natasha B. Leighl, Srikala Sridhar, Amit M. Oza, Stephanie Lheureux & Geoffrey Liu

  4. Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada

    Camilla Zimmermann, Breffni Hannon & Jacqueline Alcalde Castro

  5. Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada

    Camilla Zimmermann, Gary Rodin & Madeline Li

  6. Division of Medical Oncology and Haematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada

    Philippe L. Bedard, Neesha Dhani, Monika K. Krzyzanowska, Jennifer J. Knox, Natasha B. Leighl, Srikala Sridhar, Amit M. Oza, Stephanie Lheureux & Geoffrey Liu

  7. Division of Palliative Medicine, Department of Medicine, Queen’s University, Kingston, Canada

    Leonie Herx

  8. Faculty of Nursing, University of Toronto, Toronto, Canada

    Doris Howell

  9. Division of Medical Oncology, Kingston Health Sciences Centre, Kingston, Canada

    Christopher M. Booth

  10. Department of Oncology, Queen’s University, Kingston, Canada

    Christopher M. Booth

  11. Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Canada

    Christopher M. Booth

  12. Department of Biostatistics, University Health Network, Toronto, Canada

    Lisa W. Le

Authors
  1. Camilla Zimmermann
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ashley Pope
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Breffni Hannon
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Philippe L. Bedard
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Gary Rodin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Neesha Dhani
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Madeline Li
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Leonie Herx
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Monika K. Krzyzanowska
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Doris Howell
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Jennifer J. Knox
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Natasha B. Leighl
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Srikala Sridhar
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Amit M. Oza
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Stephanie Lheureux
    View author publications

    You can also search for this author in PubMed Google Scholar

  16. Christopher M. Booth
    View author publications

    You can also search for this author in PubMed Google Scholar

  17. Geoffrey Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  18. Jacqueline Alcalde Castro
    View author publications

    You can also search for this author in PubMed Google Scholar

  19. Nadia Swami
    View author publications

    You can also search for this author in PubMed Google Scholar

  20. Rachel Sue-A-Quan
    View author publications

    You can also search for this author in PubMed Google Scholar

  21. Anne Rydall
    View author publications

    You can also search for this author in PubMed Google Scholar

  22. Lisa W. Le
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

CZ: conceptualization and design, obtaining funding, interpretation of data, writing and critical revision of the report

AP: acquisition and interpretation of data, critical revision of the report, administrative support

BH: conceptualization and design, interpretation of data and critical revision of the report

PLB, GR, ND, ML, LH, MKK, DH, JJK, NBL, SS, AMO, SL, CMB, GL: interpretation of data and critical revision of the report

JAC: interpretation of data, writing and critical revision of the report

NS: acquisition and interpretation of data, critical revision of the report, administrative support

RSAQ: acquisition and interpretation of data, writing and critical revision of the report

AR: interpretation of data and critical revision of the report

LWL: conceptualization and design, analysis and interpretation of data, critical revision of the report

All authors have provided final approval of the version to be published.

Corresponding author

Correspondence to Camilla Zimmermann.

Ethics declarations

Ethics approval

The study was approved by the University Health Network Research Ethics Board (REB# 19-5007). We certify that the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Competing interests

The authors have no competing interests to declare that are relevant to the content of this article.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

ClinicalTrials.gov Identifier: NCT03987906

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zimmermann, C., Pope, A., Hannon, B. et al. Symptom screening with Targeted Early Palliative care (STEP) versus usual care for patients with advanced cancer: a mixed methods study. Support Care Cancer 31, 404 (2023). https://doi.org/10.1007/s00520-023-07870-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00520-023-07870-9

Keywords

Search

Navigation