Implementing Palliative and Supportive Care in Liver Cancer: A phase III cluster based randomised controlled trial of symptom assessment supported by a clinical care pathway versus usual care to improve palliative care symptoms in adult patients attending ambulatory hepatocellular carcinoma clinics

Abstract

Hepatocellular carcinoma (HCC) is the 7th most frequency occurring cancer, and the second most common cause of cancer related mortality. Current hepatology guideline recommendations for palliative and supportive care (PSC) in HCC focuses on patients who have no treatment options. This thesis assesses the current evidence base for implementation of palliative and supportive care in HCC, identifying gaps in the literature and contrasts with the established evidence other malignancies. Using qualitative methods, the attitudes and perceptions of healthcare professionals demonstrated a willingness to refer patients with HCC to early PSC but was hampered by uncertainty of which patients would benefit from this intervention which has been reflected in the guidelines. A phase III cluster based randomised controlled trial of early PSC care supported by symptom measure versus standard care was developed in hepatology outpatient clinics. An interim analysis of the study after 30 months demonstrated a high symptom burden in patients with HCC with significant heterogeneity in presenting symptoms. Traditional markers of symptom burden such as disease stage and age did not appear to correlate with the participants results. The thesis examines the primary outcome of reduction in symptom burden associated with PSC care intervention and the secondary outcome in mortality. Despite being underpowered for the interim analysis, there was a statistically significant improvement in patients symptom burden with early PSC compared to those under standard care. Additionally, due to the long survival time of participants in the study, there was no worsening or improving mortality benefit in the interim analysis. This thesis provides novel information on the implementation of PSC in HCC which has the clinical applicability to help reduce the symptom burden in patients with HCC.