Study: Engagement of Patients with Advanced Cancer (EPAC)

When patients with cancer discuss their care preferences with their clinicians and loved ones, they often have better experiences with their care and receive care that matches their wishes. Most patients, however, do not have an opportunity to have these important discussions with their clinicians for a lot of different reasons.


The goal of the Engagement of Patients with Advanced Cancer is to understand if a lay health worker, non-clinical personnel with specific skills-based training, can promote discussions between patients and their cancer care clinicians regarding their preferences for care.


We enrolled Veterans at the Veterans Affairs Palo Alto Health Care System who were newly diagnosed with Stage 3 and 4 cancer and cancers that had progressed or recurred into the study.


We randomized Veterans to the intervention group or a usual oncology group. A lay health worker was assigned to patients in the intervention group and assisted with the following for 6 months: 1) goals of care principles, 2) establishing care preferences, 3) identifying a surrogate decision-maker, 4) filing an advance directive, and 5) how to proactively discuss care preferences with oncology doctors and nurses.


A total of 213 Veterans were randomized in the study.  Veterans in the intervention as compared to the Veterans who received usual cancer care experienced

-Improvements in discussions of their care preferences with their clinicians
-Improvements in Advance Directive discussions and documentation
-Improvements in Hospice Use
-Lower emergency department use
-Lower hospital use
-Lower total health care costs


The information gathered during the study can help Veterans, VA facilities, clinicians, and policymakers improve discussions regarding patients' care preferences and improve cancer outcomes, especially at the end-of-life.



The Engagement of Patients with Advanced Cancer is an intervention that utilizes well-trained lay health coaches to engage patients and their families in goals of care and shared decision-making after a diagnosis of advanced cancer.


The objective of this study was to determine whether a lay health worker program can increase documentation of patients' care preferences after cancer diagnosis.


Stanford School of Medicine

Can someone with no medical training improve the quality of life for a terminally ill cancer patient? And will that have any impact on health care costs?