Shifting to outpatient management of acute myeloid leukemia: a prospective experience

Savoie, Mary Lynn; Nevil, T. J.; Song, Kevin; Forrest, Donna L.; Hogge, Donna E.; Nantel, Stephen H.; Shepherd, John; Smith, Clay; Sutherland, Heather J.; Toze, Cynthia L.; Lavoie, Julye C.

doi:10.1093/annonc/mdl011

Cited by 50 publications

(52 citation statements)

References 23 publications

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“…4 Formal evidence for this recommendation is lacking, despite evidence of a graft-versusleukemia effect in AML. At initial diagnosis of high-risk AML, alloSCT seems no better than chemotherapy only.…”

Section: 11mentioning

confidence: 99%

“…At initial diagnosis of high-risk AML, alloSCT seems no better than chemotherapy only. 4 Therefore, the need for alloSCT in relapsed AML may be questioned, at least as a general recommendation.…”

Section: 11mentioning

confidence: 99%

“…[3][4][5][6] There is little published data of the safety of this approach in centers with limited resources. Domiciliary management of low risk febrile neutropenia with oral antibiotics relies on an efficient health care infrastructure, where patients would be immediately admitted if their condition deteriorates.…”

mentioning

confidence: 99%

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Early discharge from hospital after consolidation chemotherapy in acute myeloid leukemia in remission: febrile neutropenic episodes and their outcome in a resource poor setting

Naithani¹,

Kumar²,

Mahapatra³

et al. 2008

Haematologica

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Early discharge from hospital after consolidation chemotherapy in acute myeloid leukemia in remission: febrile neutropenic episodes and their outcome in a resource poor settingTreatment of acute myeloid leukemia (AML) involves administration of myelosuppressive chemotherapy administered after admittance to hospital.1 Admission to intensive nursing care units till bone marrow recovery leads to prolonged hospital stay. Quality of life and health care issues have made many cancer centers change to outpatient care even during high-risk phases of disease. 2-6In India most patients belong to poor socioeconomic backgrounds. There is an acute shortage of hospital beds.Early discharge after myelosuppressive therapy would promote better use of hospital resources, but the safety of this approach in these patients has not been established. We present our experience of the feasibility and safety of early discharge of patients with acute myeloid leukemia after consolidation chemotherapy.All patients were induced with standard '3+7' chemotherapy using a peripherally inserted central venous (PICC) line. After documentation of complete remission (CR) consolidation chemotherapy with 3 cycles of high dose cytarabine was given.Eighty-three consecutive episodes of neutropenia after consolidation chemotherapy in 28 acute myeloid leukemia patients in remission were included in the study. Patients were divided into 2 groups.Group 1. Outpatients. These consisted of patients discharged after the chemotherapy was completed to their own homes or temporary residential facilities, which did not have any medical, or home visit facilities. Criteria for inclusion were: (a) no fever or infection; (b) location of residence nearby; (c) ability to come to hospital within one hour if fever developed or condition deteriorated. They had telephone access to the study team.Group 2. Inpatients. These were patients who remained in hospital after high dose Ara C (HiDAC) chemotherapy till recovery of neutrophil counts. The criteria of inclusion were: (a) inability to move to a residential place as specified under group 1 or (b) severe infective course during earlier chemotherapy.All patients were given the following supportive therapy: prophylactic ciprofloxacin 500 mg twice daily and fluconazole 200 mg/day and simple instructions concerning hygiene. Blood counts were monitored twice a week for Outpatients and on alternate days for Inpatients. Outpatients were seen at least once a week in the outpatient department (OPD). Blood and platelet transfusion support was given in the day care center. Patients who developed fever were administered granulocyte colony stimulating factor (G-CSF). Fever was considered present if the temperature measured orally was ≥38°C on two occasions at least four hours apart during a 24-hour period or was ≥38.5°C on a single occasion. Neutropenia was defined as an absolute neutrophil count (ANC) of <0.5×10 9 /L. 7All Outpatients who developed fever were admitted and administered IV antibiotics. First line antibiotics included pipera...

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Section: 11mentioning

confidence: 99%

Section: 11mentioning

confidence: 99%

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Early discharge from hospital after consolidation chemotherapy in acute myeloid leukemia in remission: febrile neutropenic episodes and their outcome in a resource poor setting

Naithani¹,

Kumar²,

Mahapatra³

et al. 2008

Haematologica

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“…Prospective reports have demonstrated the feasibility and safety of outpatient management and early discharge of acute leukemia by inclusion of broad‐spectrum AP 11, 12, 17, 18, 20. According to a Cochrane review 32, AP during severe neutropenia among the present AML cohort was not sufficient to prevent radiologically verified pneumonia.…”

Section: Discussionmentioning

confidence: 83%

“…These infections require intravenous broad‐spectrum antibiotics 1, 4, 6, 10, as well as antibiotic prophylaxis (AP) during neutropenia, which has been shown to improve infection prevention and overall survival 2. Non‐randomized studies show that treatment of acute leukemia can be performed on an outpatient basis, allowing the patient to remain at home while under supervision in the active treatment phase and neutropenia period 11, 12, 13, 14, 15, 16, 17, 18, 19. Though feasible and safe, findings from our outpatient management study for acute leukemia showed that neutropenic fever followed by septicemia and pneumonia are the dominant causes of readmission during outpatient management 20.…”

Section: Introductionmentioning

confidence: 99%

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

et al. 2016

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Long‐lasting neutropenia associated with acute myeloid leukemia (AML) and its treatment gives rise to a high risk of pneumonia. The use of broad‐spectrum antibiotic prophylaxis during outpatient management has not completely protected patients against admission due to infections and neutropenic fever, emphasizing the need to approach infection protection with complementary efforts. In a randomized controlled design, we examined the applicability of patient‐performed daily spirometry [forced expiratory volume in one second (FEV1)] as an early warning tool and explored the effectiveness of positive expiratory pressure (PEP) in preventing pneumonia among 80 AML patients. Twenty‐five incidences of pneumonia were detected among 23 patients (6 interventions, 17 controls), giving a prevalence of 28.75% during 5420 days of observation. We found a significant difference in incidence between intervention versus control group (2.17 per 1000 days vs. 6.52 per 1000 days, P = 0.021, respectively). A cross point at 80‐76% of the personal FEV1 reference value showed high sensitivity and specificity on pneumonia development. Our data demonstrate the feasibility of educating AML patients in their continuous daily measurement of FEV1 and use of PEP. Daily measures of FEV1 may be an important early warning tool for assessment of pulmonary deterioration during critical phases of neutropenia. We suggest that strategic patient education in the use of spirometry and PEP should be part of standard of care for AML patients undergoing induction chemotherapy. Am. J. Hematol. 91:271–276, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.

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Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia

Getz

Szymczak

et al. 2021

JAMA Netw Open

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IMPORTANCE Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications.Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management. OBJECTIVETo evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTSThis cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging from January 2011 to July 2019, although the specific date ranges differed for the individual analyses by design and relative timing. Data were analyzed from August 2019 to February 2020. EXPOSURES Discharge to outpatient vs inpatient neutropenia management. MAIN OUTCOMES AND MEASURESThe primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTSPrimary quantitative analyses included 554 patients (272 [49.1%] girls and 282 [50.9%] boys; mean [SD] age, 8.2 [6.1] years). Bacteremia incidence was not significantly different during outpatient vs inpatient management (67 courses [23.8%] vs 265 courses [29.0%]; adjusted rate ratio, 0.73; 95% CI, 0.56 to 1.06; P = .08). Outpatient management was not associated with delays to the next course compared with inpatient management (mean [SD] 30.7 [12.2] days vs 32.8 [9.7]days; adjusted mean difference, −2.2; 95% CI, −4.1 to −0.2, P = .03). Mortality during intensification II was higher for patients who received outpatient management compared with those who received inpatient management (3 patients [5.4%] vs 1 patient [0.5%]; P = .03), but comparable with inpatient management at other courses (eg, 0 patients vs 5 patients [1.3%] during induction I; P = .59). Among 97 patients evaluated for HRQOL, outcomes did not differ between outpatient and inpatient management (mean [SD] Pediatric Quality of Life Inventory total score, 70.1 [18.9] vs 68.7

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Shifting to outpatient management of acute myeloid leukemia: a prospective experience

Abstract: Outpatient management of AML is safe and feasible using the strategies outlined in this report.

Cited by 50 publications

References 23 publications

Early discharge from hospital after consolidation chemotherapy in acute myeloid leukemia in remission: febrile neutropenic episodes and their outcome in a resource poor setting

Early discharge from hospital after consolidation chemotherapy in acute myeloid leukemia in remission: febrile neutropenic episodes and their outcome in a resource poor setting

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia

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