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Older patients with AML underutilize end-of-life care
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Older patients with acute myeloid leukemia seldom received hospice services and palliative care at the end of life, according to the results of a retrospective analysis.
“Older patients (aged ≥ 60 years) with AML face a life-threatening illness that carries a poor prognosis with a median survival of 8 to 10 months and a long-term DFS rate of less than 10%,” Areej R. El-Jawahri, MD, of the department of oncology at Massachusetts General Hospital and the Dana-Farber Cancer Institute in Boston, and colleagues wrote. “Surprisingly, studies exploring health care utilization and end-of-life care in this population are lacking. Data describing patients’ receipt of health services, such as the time they spend in the hospital and clinical and their care at the end of life, would allow clinicians to communicate accurate information to their patients about the ramifications of their diagnosis and treatment.”
El-Jawahri and colleagues evaluated data from 330 older patients (median age, 70 years) diagnosed with AML between 2005 and 2011 in order to identify trends in health care utilization and end of life care, as well as to examine the effects of intensive vs. nonintensive initial treatment strategy on end of life care in this population.
Forty-two percent of the cohort had high-risk disease. Researchers classified patients based upon receipt of intensive (cytarabine/anthracycline; n = 197) and nonintensive (single-agent; n = 133) chemotherapy.
Researchers used electronic medical records to collect data on palliative care consultations, frequency of hospitalizations and clinic appointments, hospitalization duration and ICU admissions. These data were used to calculate the percentage of life spent in the hospital, outpatient clinic and outside the hospital, with total survival days measured from the date of AML diagnosis.
Median survival for the entire population was 340 days (95% CI, 280-391). Complete remission was more common in patients who received intensive chemotherapy (71.1% vs. 22.3%; P < .0001).
Median number of hospitalizations was 4.2 (range, 0-18) across the entire cohort, and 27.9% of patients were admitted to the ICU during their care.
After a minimum of 2 years of follow-up, 87.9% of the patients died. Among those, 28.3% of their lives following diagnosis were spent in the hospital and 13.8% of their post-diagnosis lives were spent in clinic.
Only 14.2% of the entire cohort and 16.2% of patients who died had a palliative care consultation. Median time from receipt of palliative care to death was 7 days (range, 0-364).
Most patients (61%) died while hospitalized, whereas 31% of deaths occurred at home and 8% occurred in a hospice facility. Eighty-four percent of patients who died were hospitalized within 30 days of death. Twenty-two percent of patients who died utilized hospice services, 11.3% of whom remained in hospice for less than 7 days.
In the multivariable analysis, patients treated with intensive chemotherapy were more likely to be admitted to the ICU (OR = 3.59; 95% CI, 1.74-7.41). Intensive chemotherapy resulted in a 30% increase in hospitalization (P < .0001) but a 9% decrease in clinic visits (P = .0001) among patients who died. Intensive chemotherapy also was linked to an underutilization of hospice services (OR = 0.45; 95% CI, 0.2-1) and hospice stays of less than 7 days (OR = 2.96; 95% CI, 1.03-8.52).
The researchers acknowledged the possibility for selection bias and the relatively small and geographically limited cohort as limitations of their study.
“Clinicians must engage in an honest discussion with patients regarding the best way to incorporate the pursuit of curative therapy into the decision-making process when cure is only a realistic possibility for a minority of older patients with AML,” El-Jawahri and colleagues concluded. “It is noteworthy that our findings highlight the need for developing supportive care interventions to improve quality of life and care for patients with AML throughout the course of their illness, during hospitalization and at the [end of life].”
Mikkael A. Sekeres
It is important that physicians be transparent with older patients and recommend the most necessary and least harmful treatment options, Mikkael A. Sekeres, MD, MS, and Aaron T. Gerds, MD, MS, both of Cleveland Clinic, wrote in an accompanying editorial.
“We should better prepare our older adults with AML for the difficult realities of their disease, adjusting our optimism about the potential benefits of induction chemotherapy, and practice under the assumption that our patients will relapse or that our therapy will fail them,” Sekeres and Gerds wrote. “We will only be wrong less than 10% of the time, and it is a mistake our patients will thank us for. Our patients and their families will then be ready for the health care burden they are about to endure and will be much more open to the suggestion of palliative approaches or hospice when the time comes, recognizing it as part of the natural course of events.” – by Cameron Kelsall
Disclosure: El-Jawahri reports no relevant financial disclosures. Sekeres reports personal fees from Amgen, Boehringer-Ingelheim and Celgene Corporation. Gerds reports personal fees from AstraZeneca and Roche and a New Investigator Award from the American Society for Blood and Marrow Transplantation. Please see the full study for a list of all other researchers’ relevant financial disclosures.
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