Palliative care early in the treatment algorithm for patients undergoing prolonged hospitalization for acute myeloid leukemia (AML) offered improvements in patients' quality of life (QoL) and other outcomes, researchers reported.
When compared with standard care, individuals randomly assigned to receive the had statistically significant improvements in QoL, anxiety, depressive symptoms, and symptoms of post-traumatic stress disorder (PTSD), according to Areej El-Jawahri, MD, of Harvard Medical School in Boston. El-Jawahri is also the associate director of the Massachusetts General Hospital Cancer Center Survivorship Program in Boston.
Patients completed the Functional Assessment of Cancer Therapy-Leukemia (FACT-Leukemia), the Hospital Anxiety and Depression Scale, and the PTSD Checklist to assess their QoL, mood, and PTSD symptoms at baseline and weeks 2, 4, 12, and 24, she explained in a presentation at the American Society of Clinical Oncology (ASCO) virtual meeting.
Among 160 patients, those who received the intervention reported better outcomes compared with those receiving usual care at 2 weeks:
- QoL: 107.59 vs 116.45 (P=0.039)
- Lower depression: 7.20 vs 5.68 (P=0.021)
- Anxiety: 5.94 vs 4.53 (P=0.018)
- PTSD symptoms: 31.69 vs 27.79 (P=0.009)
The intervention effects were sustained up to week 24 for QoL (β = 2.35, P=0.048), depression (β = -0.42, P=0.039), anxiety (β = -0.38, P=0.042), and PTSD symptoms (β = -1.43, P=0.002), El-Jawahri and colleagues found. Additionally, patients who received usual care had an 8-point decline (P=0.048) in the FACT-Leukemia score at 2 weeks, El-Jawahri said in her oral pre-recorded presentation.
"We know that week 2 is the time when patients experience the highest symptom burden and the worst quality of life deterioration during the induction chemotherapy hospitalization," she said.
"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," she noted. "And those receiving the intervention were more likely to discuss their end-of-life care [EOL] preferences with their clinicians, and less likely to use chemotherapy in the last month of life."
Specifically, among deceased participants, those receiving the intervention were more likely to report discussing their EOL care preferences with their clinicians (75.0% vs 40.0% usual care patients, P=0.009) and less likely to receive chemotherapy in the last 30 days of life (34.9% vs 65.9%, P=0.008). The authors found no difference in hospice utilization or hospitalization at the EOL.
El-Jawahri explained that patients with AML "face an abrupt, life-threatening illness that often requires a prolonged 4 to 6 weeks of hospitalization where they receive intensive induction chemotherapy. During this intensive chemotherapy hospitalization, patients experience marked physical and psychological symptoms that persist throughout 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."
But she said interventions to improve QoL, reduce psychological distress, and optimize EOL care for patients with AML are lacking, although "we know that specialty palliative care can improve a wide range of patient-reported outcomes for patients with advanced solid tumors," she said.
El-Jawahri and colleagues conducted a multisite randomized clinical trial of patients with high-risk AML admitted to receive intensive chemotherapy. Patients were randomized to receive integrated palliative and oncology care versus usual care.
Those receiving the intervention met with palliative care clinicians at least twice weekly during their initial chemotherapy hospitalization, as well as during all subsequent hospitalization.
Patients randomized to usual care received standard leukemia care. They were also permitted to see palliative care clinicians if requested by their treating physician.
The researchers included hospitalized patients with high-risk AML receiving intensive chemotherapy. Patients with high-risk AML were defined as newly diagnosed patients; patients ages ≥60 years of age; patients with an underlying hematologic disorder or therapy-related AML; and those with relapsed or primary refractory AML. The median age of the study cohort was 64, the majority were white, and most were newly diagnosed with AML.
"Palliative care should be considered a new standard of care for patients with AML. 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," El-Jawahri stated.
ASCO discussant Amber Barnato, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, New Hampshire, commented that "this was an awesome population to study. How fantastic is it to have palliative care consultation right after leukemia diagnosis at a point when patients are receiving induction chemotherapy? This is a vulnerable and symptomatic population, and we all know how difficult it is for palliative care to penetrate some of these leukemia services."
"I want to know what were the mechanisms of action that led to such marvelous findings," she added. Barnato pointed out that the effect size of the palliative care intervention was relatively small, and that the cost of providing the intervention might be high. However, she noted that early palliative care provides more quality to patients than can be quantified.
Disclosures
El-Jawahri and Barnato disclosed no relevant relationships with industry.
Primary Source
American Society of Clinical Oncology
El-Jawahri A, et al "Multisite randomized trial of integrated palliative and oncology care for patients with acute myeloid leukemia (AML)" ASCO 2020; Abstract 12000.