Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia

Abstract

IMPORTANCEPatients with acute myeloid leukemia (AML) receiving intensive chemotherapy experience substantial decline in their quality of life (QOL) and mood during their hospitalization for induction chemotherapy and often receive aggressive care at the end of life (EOL). However, the role of specialty palliative care for improving the QOL and care for this population is currently unknown.OBJECTIVE To assess the effect of integrated palliative and oncology care (IPC) on patient-reported and EOL outcomes in patients with AML. DESIGN, SETTING, AND PARTICIPANTSWe conducted a multisite randomized clinical trial of IPC (n = 86) vs usual care (UC) (n = 74) for patients with AML undergoing intensive chemotherapy. Data were collected from January 2017 through July 2019 at 4 tertiary care academic hospitals in the United States.INTERVENTIONS Patients assigned to IPC were seen by palliative care clinicians at least twice per week during their initial and subsequent hospitalizations. MAIN OUTCOMES AND MEASURESPatients completed the 44-item Functional Assessment of Cancer Therapy-Leukemia scale (score range, 0-176) to assess QOL; the 14-item Hospital Anxiety and Depression Scale (HADS), with subscales assessing symptoms of anxiety and depression (score range, 0-21); and the PTSD Checklist-Civilian version to assess posttraumatic stress disorder (PTSD) symptoms (score range, 17-85) at baseline and weeks 2, 4, 12, and 24. The primary end point was QOL at week 2. We used analysis of covariance adjusting and mixed linear effect models to evaluate patient-reported outcomes. We used Fisher exact test to compare patient-reported discussion of EOL care preferences and receipt of chemotherapy in the last 30 days of life. RESULTSOf 235 eligible patients, 160 (68.1%) were enrolled; of the 160 participants, the median (range) age was 64.4 (19.7-80.1) years, and 64 (40.0%) were women. Compared with those receiving UC, IPC participants reported better QOL (adjusted mean score, 107.59 vs 116.45; P = .04), and lower depression (adjusted mean score, 7.20 vs 5.68; P = .02), anxiety (adjusted mean score, 5.94 vs 4.53; P = .02), and PTSD symptoms (adjusted mean score, 31.69 vs 27.79; P = .01) at week 2. Intervention effects were sustained to week 24 for QOL (β, 2.35; 95% CI, 0.02-4.68; P = .048), depression (β, −0.42; 95% CI, −0.82 to −0.02; P = .04), anxiety (β, −0.38; 95% CI, −0.75 to −0.01; P = .04), and PTSD symptoms (β, −1.43; 95% CI, −2.34 to −0.54; P = .002). Among patients who died, those receiving IPC were more likely than those receiving UC to report discussing EOL care preferences (21 of 28 [75.0%] vs 12 of 30 [40.0%]; P = .01) and less likely to receive chemotherapy near EOL (15 of 43 [34.9%] vs 27 of 41 [65.9%]; P = .01). CONCLUSIONS AND RELEVANCEIn this randomized clinical trial of patients with AML, IPC led to substantial improvements in QOL, psychological distress, and EOL care. Palliative care should be considered a new standard of care for patients with AML.

Palliative care of patients with haematological malignancies: strategies to overcome difficulties via integrated care

“…15,16 Data from randomised controlled trials suggest the integration of a palliative care approach with some treatments with curative intent, such as HSCT 17 and induction chemo therapy in patients with acute myeloid leukaemia. 18 This is in line with the WHO definition of palliative care: to address patients with lifethreatening disease, not only those with incurable disease. 19 With a median age at diagnosis of about 70 years, most haematological malignancies have an ageassociated increase in incidence and mortality.…”

Children and adolescents with hematologic cancers deserve better end‐of‐life care

“…Indeed, one recent randomized control trial among adults with acute myeloid leukemia demonstrated that integrating palliative care was associated not only with decreased receipt of chemotherapy at the EOL but also with substantial improvements in patient-reported quality of life and decreases in psychological distress. 21 Though not randomized, numerous pediatric studies have also conclusively demonstrated that palliative care can positively affect how they live, right until the very end. 22 Children with hematologic cancer deserve to benefit from palliative care as much as anyone else.…”

Posttraumatic stress disorder symptoms in patients with acute myeloid leukemia

“…This was a secondary analysis of data from 160 hospitalized patients with AML who were enrolled in a multisite, nonblinded, randomized palliative care intervention trial at Massachusetts General Hospital (Boston, Massachusetts), Duke University Medical Center (Durham, North Carolina), the Hospital of the University of Pennsylvania (Philadelphia, Pennsylvania), and Ohio State University (Columbus, Ohio) between January 2017 and July 2019 14 . The study was approved by the Institutional Review Boards at all participating sites.…”