Factors Associated with Early Referral to Palliative Care in Outpatients with Advanced Cancer

Background: Although timely palliative care is recommended for patients with advanced cancer, referrals to palliative care services are often late. Objectives: To identify factors associated with early referral to an oncology palliative care clinic and to describe symptom severity according to timing of referral. Design: We conducted a retrospective review of 337 patients with advanced cancer referred to outpatient palliative care at a comprehensive cancer center. We gathered data related to patient demographics, diagnosis, and referral. Timing of referral was categorized as early (>12 months before death), intermediate (6-12 months before death), or late (<6 months before death). Ordinal logistic regression was used to determine factors related to referral timing, and the Kruskal-Wallis test to determine symptom severity in each referral timing category. Results: Of the 337 patients, 232 (69%) referrals were late, 60 (18%) intermediate, and 45 (13%) early. On multivariable analysis, earlier referral was associated with earlier primary cancer diagnosis (p=0.004), and referral for pain and symptom management (p=0.001). Patients who were referred late had worse overall Edmonton Symptom Assessment System distress scores, as well as worse tiredness, nausea, drowsiness, appetite, and wellbeing (all p0.001). Severity of pain, shortness of breath, anxiety, and depression did not differ based on time of referral. Conclusions: A longer disease course and referral for symptom management were associated with earlier referral, whereas overall symptom burden was higher for late referrals. Further research is required on combining symptom screening with timely referral to improve symptom management in advanced cancer.