Symptom screening with Targeted Early Palliative care (STEP) for patients with advanced cancer: a pilot trial
Innovative Approaches to Care Delivery, Public Health, and Equity, Diversity & Inclusion
Our novel intervention called STEP (Symptom screening with Targeted Early Palliative care) uses routine symptom screening to increase access to outpatient palliative care services for patients with advanced cancer experiencing moderate to high symptom burden. Since symptom screening is mandated by Cancer Care Ontario at all provincial cancer centres, STEP is transferable to all Ontario cancer centres. As well, international cancer guidelines recommend both routine symptom screening and early access to outpatient palliative cancer care. Thus our trial supports and provides evidence for these international recommendations.
Due to the success of this feasibility trial, we were able to secure funding from the Canadian Institutes of Health Research to conduct a randomized controlled trial of STEP versus usual cancer care. Unfortunately, this trial was halted prematurely due to the COVID-19 pandemic; however, we are now planning a further trial of STEP2 incorporating virtual palliative care.
Objectives/Methodology: Studies have shown that receiving early palliative care (EPC) improves outcomes in patients with advanced cancer, but most patients do not have timely access to outpatient palliative care. We developed a new system, called STEP (Symptom screening with Targeted Early Palliative care), to identify patients with the greatest need for palliative care (i.e., those with severe symptoms) for triage by a nurse and referral to a palliative care clinic (PCC). We conducted a pilot trial of STEP with feasibility criteria including accrual of at least 100 patients in 12 months, completion of at least 70% of symptom screens for at least 70% of visits, and at least 60% of screen-positive patients meeting with the palliative care team.
Results/Outcomes: Between Nov 2016 and Jan 2018, 116 patients were enrolled and results showed this intervention is feasible. For patients with low symptom burden at baseline, patient-reported measures of quality of life (QoL), mood, and symptom control were significantly better than for those reporting moderate-high symptoms (all P<.0001) and remained stable over time. Among participants reporting moderate to high symptoms, depression and symptom control improved over time for those who attended the PCC and worsened for those who did not (P<.01 for trend over time), even correcting for baseline symptom control; there was no difference in QoL or satisfaction with care.
Conclusion: STEP is feasible in outpatients with advanced cancer and can identify those who benefit from targeted EPC.
Challenges: Some patients declined visits to the palliative care clinic, despite reporting moderate to high symptoms. Future interventions will need to incorporate further explanation/reassurance about outpatient palliative care.
Next steps: We have received further funding from AMS Healthcare to continue to study STEP, incorporating virtual palliative care (STEP2).
Zimmermann C, Pope A, Hannon B, Krzyzanowska MK, Rodin G, Li M, Howell D, Knox JJ, Leighl NB, Sridhar S, Oza AM, Prince R, Lheureux S, Hansen AR, Rydall A, Chow B, Herx L, Booth CM, Dudgeon D, Dhani N, Liu G, Bedard PL, Mathews J, Swami N, Le LW. Phase II Trial of Symptom Screening With Targeted Early Palliative Care for Patients With Advanced Cancer. J Natl Compr Canc Netw. 2021 Sep 7;20(4):361-370.e3. doi: 10.6004/jnccn.2020.7803. PMID: 34492632.
Zimmermann C, Pope A, Hannon B, Bedard PL, Rodin G, Dhani N, Li M, Herx L, Krzyzanowska MK, Howell D, Knox JJ, Leighl NB, Sridhar S, Oza AM, Lheureux S, Booth CM, Liu G, Castro JA, Swami N, Sue-A-Quan R, Rydall A, Le LW. Symptom screening with Targeted Early Palliative care (STEP) versus usual care for patients with advanced cancer: a mixed methods study. Support Care Cancer. 2023 Jun 21;31(7):404. doi: 10.1007/s00520-023-07870-9. PMID: 37341839.