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Early palliative intervention: effects on patient care satisfaction in advanced cancer
  1. Kenneth Mah1,
  2. Nadia Swami1,
  3. Brenda O'Connor1,2,
  4. Breffni Hannon1,2,3,
  5. Gary Rodin1,4,5 and
  6. Camilla Zimmermann1,2,3,4,5
  1. 1Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
  2. 2Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  3. 3Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Princess Margaret Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
  5. 5Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Camilla Zimmermann, Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada; camilla.zimmermann{at}


Objective In a cluster-randomised controlled trial of early palliative care (EPC) in advanced cancer, EPC was robustly associated with increased patient satisfaction with care. The present study evaluated mediational mechanisms underlying this EPC effect, including improved physical and psychological symptoms and quality of life, as well as relationships with healthcare providers and preparation for end of life.

Method Participants with advanced cancer (n=461) completed measures at baseline and then monthly to 4 months. Mediational analyses, using a robust bootstrapping approach, focused on 3-month and 4-month follow-up data.

Results At 3 months, EPC decreased psychological symptoms, which resulted in greater satisfaction either directly (βindirect effect=0.05) or through greater quality of life (βindirect effect=0.02). At 4 months, EPC increased satisfaction through improved quality of life (βindirect effect=0.08). Physical symptom management showed no significant mediational effects at either time point. Better relationships with healthcare providers consistently mediated the EPC effect on patient satisfaction at 3 and 4 months, directly (βindirect effect=0.13–0.16) and through reduced psychological symptoms and/or improved quality of life (βindirect effect=0.00–0.02). At 4 months, improved preparation for end-of-life mediated EPC effects on satisfaction by enhancing quality of life (βindirect effect=0.01) or by reducing psychological symptoms and thereby increasing quality of life (βindirect effect=0.02).

Conclusion EPC increases satisfaction with care in advanced cancer by attending effectively to patients’ emotional distress and quality of life, enhancing collaborative relationships with healthcare providers, and addressing concerns about preparation for end-of-life.

Trial registration number NCT01248624

  • cancer
  • quality of life
  • supportive care
  • psychological distress
  • mediation analysis
  • palliative care
  • patient satisfaction

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  • Contributors CZ is the principal investigator of the parent EPC trial and acquired its funding. NS, BH, GR and CZ collaborated in the conception and design of the parent EPC trial. KM developed the current study concept and design, and CZ contributed to its design. NS monitored the parent EPC trial and collected and cleaned data. KM completed data analysis and interpreted the data, wrote the initial draft of this manuscript, and revised the manuscript. CZ also contributed to data interpretation and manuscript writing. NS, BO, BH, GR and CZ reviewed manuscript drafts and provided feedback and final approval.

  • Funding The parent trial was supported by the Canadian Cancer Society (grant #017257, #020509; CZ) and by the Ontario Ministry of Health and Long Term Care, and the current study was partly supported by the Canadian Institutes of Health Research (grant #152996; CZ). CZ is also supported by the Rose Family Chair in Supportive Care, Faculty of Medicine, University of Toronto.

  • Disclaimer The funders of the original trial played no role in the study design, data collection and analysis, data interpretation, or writing of this report.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval University Health Network Research Ethics Board, protocol number: 06-0525-CE.

  • Data availability statement The data for the findings of this study are available from the corresponding author upon reasonable request.

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