Prospective Cohort Study Depending on the Use of Palliative Care for Advanced Stage of Cancer Patients

Patients with advanced cancer report physical, emotional, social and economic problems that may be due to the cancer itself or its treatment. Previous studies have shown the benefit of early palliative care in oncology. However, many Korean patients tend to start palliative care late even in general hospital. Because of the late start of palliative care, the burden of medical expenses increases, on the other hand, the quality of life of terminally ill patients decrease.

In this study, the use of palliative care in advanced cancer patients will be evaluated by a prospective cohort study. The goals of this study are as follow:

First, the clinical, psycho-social, and cognitive factors affecting quality of life, decision making, and hospital utilization (palliative medical team medical treatment, hospice and medical care) of patients with advanced stage cancer will be investigated.

Second, this study will explore the effects of age-specific characteristics on quality of life and care.

Third, an index, which reflects age-specific characteristics and predicts the time and content of terminal care will be developed. Improvements on the quality of life and care of patients with advanced stage of cancer or metastatic cancer are expected to establish effective terminal care strategies through this study.

The patients' symptom and quality of life, choice of medical care, advance care planning and caregiver's burden of care will be evaluated every 3 months after confirming the willingness to use palliative care for cancer patients. 3 months after the death, a caregiver evaluation will be conducted and hospice use, medical expenses will be analyzed.

• Early palliative care (Behavioral): Palliative Care Team provide a self-learning booklet, medical treatment and consultation about Advance Care Planning with chemotherapy by oncologist.
• Routine hospice care (Behavioral): Palliative Care Team provide a routine hospice care the same as other patients who doesn't participate this study after the chemotherapy is totally terminated

Primary outcomes

• Change from baseline Overall QOL of EORTC QLQ - Core 15 at 6 months items [Baseline, 3 months, 6 months]: to measure quality of life of adult patients developed by European Organisation for Research and Treatment of Cancer for Palliative Care

Secondary outcomes

• Patients survival and Physicians Orders for Life Sustaining Treatment (POLST) documentation [Baseline, 3 months, 6 months]: Patients survival and POLST(Physician Order for Life-Sustaining Treatment) documentation whether patients survive during the study period and write POLST documentation (Since POLST has no legal form in Korea, it is based on the format of each institution.)
• Patient Health Questionnaire-9 [Baseline, 3 months, 6 months]: "Patient Health Questionnaire-9 items" is used as assessment tool to measure depression of both patients and their caregivers by completing the questionnaire.
• Decision Conflict Scale [Baseline, 6 months]: "Decision Conflict Scale" is used as assessment tool to measure a level of decision conflict in treatment of both patients and their caregivers by completing the questionnaire.
• Understanding the illness [Baseline, 3 months, 6 months]: to measure the awareness of patients' status of prognosis in both patients and caregivers through two questions in the questionnaire. The first question is about the idea of the possibility of curing the patient's disease and asks patients thought about whether treatment is available for cure and prolong survival. The second question concerns the life expectancy of the patient.
• Self-reported Health Status [Baseline, 3 months, 6 months]: to measure the perceived holistic health status(physical, mental, social, spiritual and general) in both patients and caregivers. caregivers (The patient is asked to answer the perceived health status into five stages.)
• KG-7(The Korean Cancer Study Group Geriatric Score) [Baseline, 3 months, 6 months]: To measure Daily functional skills in elderly only in 65-year or order patients.
• Medical cost in KRW/person/month [3 months, 6 months]: Direct medical cost will be collected through National Health Insurance Corporation and Indirect cost will be collected by caregiver's questionnaire. In addition, "EuroQoL 5 Dimensions 5 Levels (EQ-5D-5L)" tool will be included in the patient's questionnaire to measure the condition of patients at the same time.
• Utilization of healthcare services [3 months, 6 months]: In order to analyze the cost effectiveness, investigate the frequency of use of early palliative care programs, the use of life-sustaining treatment and hospicee, and the use of complementary and alternative medicine(CAM). CAM include Chinese medicine, aromatherapy, diet, and yoga, etc.
• Preference of Advance care and Palliative care [3 months, 6 months]: to assess the patient's awareness of advanced care planning and willingness to construct advanced care planning. The preference for palliative care is divided according to the life expectancy. Investigate the preference of palliative care in each case - if the life expectancy is within a year, within a few months, or within a few weeks.
• Mcgill Quality of Life (MQOL) [Baseline, 3 months, 6 months]: To measure mental, social, spiritual quality of life of both patients and caregivers
• Pediatric Quality of Life Inventory [Baseline, 3 months, 6 months]: "Pediatric Quality of Life Inventory(Peds QL)" will be used as assessment tool for QOL among pediatric patients.

Sex: All

\[Adult Patients\]

Inclusion Criteria:

* 19 years of age or older and diagnosed as cancer older than 19 years of age
* Stage 4 of advanced Breast Cancer, Colon cancer, gastric cancer, pancreatobiliary cancer, lung cancer, Liver Cancer or Malignant hematologic neoplasm
* Patients under one of the following status : 1) under the standard chemotherapy, 2) interrupted state of standard chemotherapy, 3) under the additional chemotherapy after standard chemotherapy, 4) terminating state of any chemotherapy yet expected to be survive more than 6 months.
* who understand the purpose and method of the study and sign with informed consent form.

Exclusion Criteria:

* who are unable to participate due to poor cognitive capacity
* who cannot read or understand Korean language
* who are unable to complete surveys due to physical conditions

\[Pediatric Patients\]

Inclusion Criteria:

* Who was diagnosed as pediatric cancer between 0-18 years of age.
* Younger than 30 years of age
* Patients under one of the following status : 1)recurrence after 2nd standard chemotherapy or without remission in leukemia, 2) recurrence after stem cell transplantation, 3) diagnosed as the cancer of poor prognosis : ATRT, glioblastoma multiforme, brainstem glioma etc.
* Patients or their proxy understand the purpose and method of the study and sign with informed consent form.

Exclusion Criteria:

* Parents of patient are unable to participate due to poor cognitive capacity
* Parents of patient do not have legal responsibility or rights of the patient
* Parents of patients cannot speak, read or understand Korean language

• Results publication: Yun JY, Jung JY, Keam B, Lee NR, Kang JH, Kim YJ, Shim HJ, Jung KH, Koh SJ, Ryu H, Yoo SH, Kang E, Yun YH. Depression, performance status, and discontinued treatment mediate an association of curability belief with prognosis in advanced cancer patients. Sci Rep. 2024 Nov 24;14(1):29098. doi: 10.1038/s41598-024-80687-6. PMID 39582048

• Young Ho Yun, MD-PhD, Principal investigator, Seoul National University Hospital