Main findings/results of the study
This study of 34 STS patients admitted for specialised palliative care intervention clearly demonstrates the effectiveness of these interventions documented by a standardised palliative base assessment. In detail, our patients experienced a significant reduction of pain, an improvement of symptom burden measured by the MIDOS symptom score and a decreased stress level. Therefore, our analysis demonstrates that specialised palliative care intervention leads to significant symptom relief and is useful for patients with advanced STS.
The importance and effectiveness of palliative care interventions have been shown for multiple oncologic diseases and are increasingly accepted [
19‐
21]. Notably, the early integration of palliative care leads to an OS benefit which was first shown by Temel et al. in advanced lung cancer [
22,
23]. In a variety of advanced cancer diseases integration of palliative care has a significant impact on patient outcome, quality of care, length of hospital stay and hospital costs [
20]. Additionally, the involvement of a specialised palliative care team reduces acute care hospital treatments [
24] and leads to a less aggressive therapeutic approach during end-of-life care as well as to higher levels of satisfaction among patients and their relatives [
23]. Consequently, the early inclusion of palliative care within the first 8 weeks after the diagnosis of advanced cancer disease is now part of national and international clinical practice guidelines [
25,
26].
Palliative care in an outpatient setting focusses on coping and support, symptom control, decision-making and future planning [
27]. In general, reasons for admittance to an inpatient palliative care unit are symptom management, support for distressed families, or care for the imminently dying patient [
20]. There are little data directly comparing community- and hospital-based palliative care. Generally, patients requiring a hospital stay often have a higher symptom burden, or a faster disease progression limiting the necessary transitions in their homes. In the inpatient setting, a decrease of symptom burden can often be enabled faster. For instance, an optimisation of the opioid medication requires frequent clinical feedback, which cannot always be realised in the outpatient setting.
So far, only limited data are available on the specific challenges of palliative care interventions in the context of STS. Similarities can be found comparing our patients to other well-defined cohorts with different oncologic diseases receiving specialised palliative care intervention, especially when being integrated early into the therapeutic schedule [
9,
23,
24,
28]. Patients with advanced STS are known to require multidisciplinary approaches due to the aggressiveness of the heterogeneous diseases and the high occurrence of a severe symptom burden [
6]. Additionally, treatment of advanced and metastasised STS often includes repeated surgical interventions, which may be associated with complications and/or mutilating procedures. Furthermore, the majority of therapeutic approaches in advanced or metastatic STS comprises of chemotherapy and/or radiotherapy, possibly resulting in diverse side effects. STS often occurs at a younger age, leading to explicitly challenging therapeutic demands. Especially in younger patients, maintenance and/or recovery of abilities regarding activities of daily living (ADL) is very important. Pain, weakness and fatigue have been the predominant indications for admission in our cohort. Nevertheless, the median NRS for acute pain at admission was not very high (median 3). In our experience, patients with chronic pain often underestimate their actual pain level referring to the NRS. Accordingly, the mental burden of pain may not directly correlate with the respective pain level. Presumably, the majority of patients would retrospectively estimate their acute pain level on admission higher than they did in the situation of admission itself. Thus, the documented pain level within the previous 24 h was significantly higher in most cases (median 5).
Our data compare well to Gough et al. on patients with advanced STS, who have documented pain, fatigue and sleep disturbances as the most frequent symptoms [
6]. To our knowledge, there are no published data concerning an early integration of palliative care in patients with sarcoma. Even though we aim to integrate palliative care early in the course of disease of our patients, some patients were admitted late (median disease duration until first admission 24 months, maximum 125 months), had aggressive disease or unfortunately died throughout the repeated palliative care interventions. These circumstances can partially explain why 25% of patients died before they were discharged. Another reason for this high percentage might be a less aggressive anti-tumour therapeutic approach in those patients.
Published literature covering an end-of-life setting describes symptoms like dyspnea and fever more predominantly than in our study. Our analysis also does not entirely compare to other early palliative care interventions, which are most often realised in an outpatient and/or community-based setting [
9,
27,
29].
Strength and weaknesses/limitations of the study
Our study is limited by the sample size of 34 patients and the known restrictions of single-centre evaluation. Furthermore, for many of theinterventions data was incomplete. This was in part due to theself-assessment of some outcomes by the patients, a high symptom burden and a sometimes occuring communication barrier. Information about e.g. the pain level, which is simple to assess with the NRS, was available for all interventions. In contrast, information about more complex questions such as MIDOS and the distress thermometer was less often complete. Additionally, there were obviously no follow-up data about the deceased patients at discharge. To evaluate the benefit of the intervention for these patients, follow-up assessments could have been done earlier during the stay.
Besides the cohort size of our study, the heterogeneity of sarcomas as well as the retrospective character of our analysis make universal conclusions difficult, and in accordance our data should be validated prospectively and in a larger patient cohort.
However, even though the optimal assessment for QoL in patients with STS is not yet defined, and despite our small patient population, we could show clinically relevant effects and we still consider our data as profoundly useful as published information on these patients remains sparse. Our study emphasises the importance of palliative care intervention in advanced oncologic disease, specifically in STS patients, and even gives further evidence to support the earlier integration of palliative care intervention in STS patients. Therefore, we recommend an early integration of palliative care measurement in the first 8 weeks, according to ASCO clinical practice guidelines [
25].
Some of our patients showed pain relief optimised without any change in medication. Besides the amelioration achieved by causal treatment of the pain source, other essential factors are influencing the pain level. For instance, an intensified individual support structure including psychooncologic counselling, music therapy and a reduction of psychosocial stress level, in general, may also influence the pain intensity in the individual patient.
BMI was only evaluable in a tiny subset of patients (n
i = 5,9%). In general, the administration of parenteral nutrition might be considered in patients with a survival of more than some weeks, only [
26]. Despite the small sample size, in n
i = 4 (8%) patients, we found a discrete gain of body weight by optimisation of antiemetic treatment and/or appetite increase as well as the provision of high caloric nutrition if indicated.
What this study adds
To our knowledge, this is the first report in STS patients analysing hospital-based palliative care intervention, which does not focus on end-of-life care, but on palliative care intervention throughout the entire course of the disease.