Summary
An integrated palliative and oncology care model for acute myeloid leukemia (AML) patients undergoing intensive chemotherapy resulted in substantial improvements in patients’ quality of life (QOL), psychological distress, and end-of-life (EOL) care. These findings, presented at the ASCO 2020 Annual Meeting, suggest that palliative care should be considered a new standard of care for patients with AML (Abstract 12000).
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Original Article
Integrating Palliative Care Into AML Treatment Improves Quality of Life
Oncology Times
By Catlin Nalley
An integrated palliative and oncology care model for acute myeloid leukemia (AML) patients undergoing intensive chemotherapy resulted in substantial improvements in patients’ quality of life (QOL), psychological distress, and end-of-life (EOL) care. These findings, presented at the ASCO 2020 Annual Meeting, suggest that palliative care should be considered a new standard of care for patients with AML (Abstract 12000).
“Patients with AML face an abrupt, life-threatening illness that often requires a prolonged 4-6 week hospitalization where they receive intensive induction chemotherapy,” noted study author Areej El-Jawahri, MD, an oncologist at Massachusetts General Hospital. “During this intensive chemotherapy hospitalization, patients experience marked physical and psychological symptoms that persist through their illness course.
“We also know that there is a critical need to optimize end-of-life care for patients with AML as they often receive intensive treatments at the end of life,” she continued. “However, interventions to improve quality of life, reduce psychological distress, and optimize end-of-life care for patients with AML are lacking. We know that specialty palliative care can improve a wide range of patient-reported outcomes for patients with advanced solid tumors.”
The researchers previously showed that palliative care can improve quality of life and reduce psychological distress for patients with hematological malignancies hospitalized for stem cell transplantation, which, El-Jawahri noted, is a similar prolonged 3-4 week hospitalization through the intensive chemotherapy experience of those with AML.
Despite evidence of its value, oncologists rarely consult palliative care for patients with AML, according to El-Jawahri. “So, we asked the question, can the involvement of palliative care improve the experience and outcomes of this patient population? To answer this question, we conducted a multistate randomized clinical trial of 160 patients with high-risk AML admitted to receive intensive chemotherapy.”
Methods
Researchers examined the impact of integrated palliative and oncology care on QOL, mood, post-traumatic stress (PTSD) symptoms, and EOL outcomes in patients with AML. They conducted a randomized trial of integrated palliative and oncology care (n=86) versus usual oncology care (n=74) for AML patients undergoing intensive chemotherapy.
Patients who received the intervention met with a palliative care clinician at least twice weekly during their initial chemotherapy hospitalization, according to El-Jawahri. “Of note, they also met with palliative care clinicians at least twice weekly during all subsequent hospitalization.
“The intervention did not entail any outpatient palliative care follow-up,” she explained. “Patients randomized to usual care received standard leukemia care. They were also permitted to see palliative care upon consultation upon the request of their leukemia clinician.”
Eligible patients included those who were hospitalized with high-risk AML receiving intensive chemotherapy. High-risk AML was defined as newly diagnosed patients who were 60 years of age or older, patients with an underlying hematological disorder or therapy-related AML, and those with relapsed or primary refractory AML, El-Jawahri outlined. Intensive chemotherapy was defined as the receipt of 7 + 3 regimen or other similar chemotherapy regimens requiring a prolonged 3-6 week hospitalization.
Patients completed the Functional Assessment of Cancer Therapy-Leukemia, the Hospital Anxiety and Depression Scale, and the PTSD Checklist to assess their QOL, mood, and PTSD symptoms at baseline and then weeks 2, 4, 12, and 24. QOL at week-2 was the primary endpoint. To assess the effect of the intervention on patient-reported outcomes, researchers used analysis of covariance and mixed linear effect models, controlling for baseline scores.
Results
Between January 2017 and July 2019, 160 patients were enrolled. The researchers reported a data completion rate of more than 90 percent at week 2. At week 24, El-Jawahri noted that approximately 65 percent of participants had completed patient-reported outcomes. The majority of missing data was due to patients dying during the illness course or worsening disease.
“We asked our palliative care clinicians to report back to us the focus of their visits during intensive chemotherapy hospitalization using a standard REDCap survey,” El-Jawahri explained. “Palliative care focused predominantly on establishing rapport with patients and families, addressing symptoms, and helping patients cope most effectively with their illness during the intensive chemotherapy hospitalization.”
Symptoms addressed by palliative care clinicians, included pain, nausea, fatigue, diarrhea, constipation, and psychological concerns. During subsequent hospitalizations, palliative care providers reported similar themes regarding symptom management and coping as well as a greater focus on illness understanding, patient goals and expectations, treatment decision-making, and advanced care planning.
At week 2, data showed that, compared to those receiving usual care, intervention patients reported better QOL and lower depression, anxiety, and PTSD symptoms. The impact of the intervention continued up to week 24 for QOL, depression, anxiety, and PTSD symptoms, according to the study authors.
“We had about 87 patients who died at 6-month follow-up,” noted El-Jawahri. “Participants randomized to the intervention group were more likely to discuss end-of-life care wishes with their clinicians and they were also less likely to receive chemotherapy in the last 30 days of life. We noted no differences in hospitalization at the end of life or hospice utilization between the two groups.”
These findings showcase the benefits integrated palliative and oncology care among AML patients. “We saw that the palliative care intervention led to a sustained improvement in quality of life and psychological distress 6 months after initiating chemotherapy in this population,” said El-Jawahri.
Limitations of the study include that it was performed at tertiary care academic centers with a lack of racial and ethnic diversity, which can limit the generalizability of the findings. Additionally, El-Jawahri noted, study staff, patients, and clinicians could not be blinded to the intervention and there is a potential for cross-contamination.
“In conclusion, palliative care should be considered a new standard of care for patients with AML,” El-Jawahri stated. “Future studies should focus on the implementation and dissemination of this care model across care settings for this population. And we do need comparative effectiveness trials to compare specialty palliative care versus primary palliative care for patients with AML.”
Catlin Nalley is a contributing writer.