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06/30/2022

Liz Meszaros, Deputy Managing Editor, BreakingMED™

Reviewed by: Vandana G. Abramson, MD, Associate Professor of Medicine, Vanderbilt University Medical Center

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Take Away:

  1. In patients with newly diagnosed advanced cancers, receiving a community health worker-led intervention plus usual care reduced the use of acute care compared with the receipt of usual care only.

  2. Researchers concluded that such an intervention may be an effective way to reduce the use of acute care and improve documentation of advance care planning, palliative care, and hospice use, in these patients as well as improve their overall mental and emotional health.

In patients with newly diagnosed advanced cancers, a little extra care on the community level may go a long way toward improving advance care planning and symptom management and reducing the unnecessary use of acute care, according to a recent study published in JAMA Oncology.

"National guidelines recommend advance care planning (ACP) and symptom management for patients with advanced stages of cancer, yet a minority receive such care. This deficiency leads to lack of prognostic awareness and undertreated symptoms, which result in avoidable acute care use, care that differs from patients’ preferences, and psychological and physical distress. Although ACP and proactive symptom management can reduce acute care use and improve patient experiences, multilevel barriers inhibit delivery of such care. These include limited clinician time, lack of reimbursement, and cancer and palliative care workforce shortages," wrote Manali I. Patel, MD, MPH, MS, of Stanford University School of Medicine, California, and fellow researchers.

To counter this, they developed a strategy that included trained community health workers (CHWs) to help patients with advance care planning and proactively screening for symptoms.

"Supportive cancer care interventions led by CHWs remain relatively uncommon in the U.S. While some interventions integrate CHWs into delivery of ACP for veterans, Medicare beneficiaries, and Latinx adults, less frequently are CHWs integrated into proactive cancer symptom screening, and none to our knowledge integrate CHWs into both ACP and proactive cancer symptom screening in community settings," noted Patel and colleagues.

To study such an intervention, they randomized 128 patients with newly diagnosed advanced or recurrent solid and hematologic cancers to usual care plus a 6-month community health worker-led intervention or usual care alone. Patients were a median of 67 years old, 47.7% were women, 67.2% White, 18.0% Hispanic/Latino, 8.6% Asian, and 3.9% Black. Nearly one-third were Medicare recipients, and 59%-62% had private insurance. Most had gastrointestinal cancers (31%-45%), followed by thoracic cancers (15%-22%); most were stage IV at diagnosis (75%-77%); and many had undergone chemotherapy (93%-94%), radiation therapy (40%-44%), and surgery (16%-30%). Mean symptom burden ranged from 12.8 to 13.3.

"In this study, we developed and implemented a high-touch, low-cost, technology-independent intervention that integrates CHWs into cancer care soon after an initial or recurrent cancer diagnosis," Patel et al explained.

The intervention was comprised of telephone support that educated patients on goals of care and advance directives, tailored guidance on how to speak with clinical teams and document advance directives, and weekly proactive symptom screenings. Community health workers also engaged in open-ended discussions with patients. Usual care included access to social workers, navigators, palliative care team, mental health specialists, and ancillary services such as yoga classes, support groups, and nutrition counseling.

Use of acute care was the primary outcome, and secondary outcomes were advance care planning documentation, use of supported care, patient-reported outcomes, survival, and use of end-of-life care.

Within 6 months, patients receiving the intervention had a 62% lower risk of using acute care compared with those who received usual care (hazard ratio [HR], 0.38; 95% CI, 0.19-0.76). At 12 months, they also had a 17% lower odds of using acute care (odds ratio [OR], 0.83; 95% CI, 2.85-18.13), four times the odds of palliative care (OR, 4.46; 95% CI, 1.88-10.55), almost twice the odds of hospice (OR, 1.83; 95% CI, 1.16-2.88), and almost twice the odds of improved mental and emotional health, measured from the time of study enrollment to 6 and 12 months after enrollment (OR, 1.82; 95% CI, 1.03-3.28 and OR, 2.20; 95% CI, 1.04-4.65, respectively).

Patel et al noted, "There were no statistically significant differences in the odds of ED use (OR, 0.84; 95% CI, 0.70-1.00) or hospitalizations (OR, 0.85; 95% CI, 0.71-1.02); however, the intervention group had fewer mean ED visits per participant (RR, 0.45; 95% CI, 0.33-0.62) and fewer mean hospitalizations per participant (RR, 0.50; 95% CI, 0.36-0.70)."

Mortality was not significantly different between the groups—50.0% of those in the intervention group died versus 40.6% in the usual care group. Further, in the month before death, fewer interventional care patients used acute care compared with those receiving usual care (0% versus 23.1%, respectively).

"The combined approach in the current study is innovative, as is the application of the intervention to improve health care use and patient-reported outcomes for patients with advanced cancer," wrote Ana I. Tergas, MD, MPH, of the City of Hope Comprehensive Cancer Center Duarte, California, in her accompanying editorial.

"Overall, the current study provides strong support for CHW-led approaches to improve advance care planning and symptom management and reduce unnecessary acute care use among patients with cancer. While questions remain regarding the widescale implementation of such an approach, it is exciting to consider that this approach may shift the paradigm of care not only for patients with advanced cancer but also possibly for other patient populations that are faced with similar challenges," Tergas concluded.

Study limitations include the limited generalizability of the results due to few Black patients and that it was conducted in a single community clinic, failure to obtain claims data, long patient accrual time, the need for longer follow up, and that P values were not adjusted for secondary analyses because they were considered exploratory by the researchers.