Early referral linked to better psychological outcomes

Referring a patient diagnosed with acute myeloid leukemia (AML) to the palliation service at the time grueling therapy begins appears to offer psychological benefits down the road, including improvements in the patients’ perceived quality of life, researchers said at the virtual meeting of the American Society of Clinical Oncology.

At the 2-week time point — a period recognized as most difficult for patients who are in the midst of long-term hospitalization, the quality of life among patients who received the palliation department consultation did not deteriorate, while the patients who received standard of care experienced a decline of 8 points in the FACT-Leukemia scale (P=0.048), reported Areej El-Jawahri, MD, assistant professor of medicine at Harvard Medical School, and associate director of the Massachusetts General Hospital Cancer Center Survivorship Program, Boston.

“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 in her oral presentation online. The in-person meeting, slated for Chicago, was cancelled because of the Covid-19 pandemic.

El-Jawahri, in her pre-recorded presentation, noted that at 24 weeks, the quality of life improved in both arms of the trial, but by 25 points from baseline in patients who received an intervention compared with 10 points in the patients receiving standard care.

“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. And those receiving the intervention were more likely to discuss their end-of-life care preferences with their clinicians and less likely to use chemotherapy in the last month of life,” she said.

“Patients with AML face an abrupt, life threatening illness that often requires a prolonged 4-to-6 weeks hospitalization where they receive intensive induction chemotherapy,” El-Jawahri explained. “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.

“However,” she said, “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.”

She and colleagues enrolled 160 patients in the trial. The patients were diagnosed with high-risk AML and were admitted to receive intensive chemotherapy. Patients were randomized to receive integrated palliative and oncology care versus usual care. Those patients receiving the intervention met with palliative care clinicians at least twice weekly during their initial chemotherapy hospitalization and also met with palliative care clinicians at least twice weekly during all subsequent hospitalization.

The control arm patients received standard leukemia care. They were also permitted to seek palliative care upon consultation upon request of their leukemia clinician.

The patients in the study were about 64 years old, most were white, and the majority were newly diagnosed with AML.

El-Jawahri suggested, “Palliative care should be considered a new standard of care for patients with AML.”

However, Amber Barnato, MD, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, while congratulating the researchers for finding “an awesome population to study,” expressed concern that the intensive palliation consolation schedule might be expensive to accomplish outside a trial, and while the findings were significant, she suggested the effect size was modest. “I want to know what were the mechanisms of action that led to such marvelous findings,” she said.

Barnato said that the influence on health care utilization may be the strength of where future studies should concentrate.

Samuel Kailes, Contributing Writer, BreakingMED™

El-Jawahri and Barnato disclosed no relevant relationships with industry.

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