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Original Investigation
December 17, 2020

Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia: A Randomized Clinical Trial

Author Affiliations
  • 1Massachusetts General Hospital, Boston
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Duke University School of Medicine, Durham, North Carolina
  • 4University of Wisconsin, Madison
  • 5University of Pennsylvania, Philadelphia
  • 6Ohio State University, Columbus
JAMA Oncol. 2021;7(2):238-245. doi:10.1001/jamaoncol.2020.6343
Key Points

Question  What is the effect of integrated palliative and oncology care (IPC) on patient-reported and end-of-life (EOL) outcomes for patients with acute myeloid leukemia (AML)?

Findings  In this randomized clinical trial of 160 adults with AML, IPC improved patient-reported quality of life, as well as depression, anxiety, and posttraumatic stress symptoms during intensive chemotherapy and for up to 24 weeks. Among patients who died, those receiving IPC were more likely to have reported discussing their EOL care preferences and less likely to have received chemotherapy near the EOL.

Meaning  For patients with AML, IPC led to substantial improvements in quality of life, psychological distress, and EOL care, and should be considered a new standard of care for this population.

Abstract

Importance  Patients 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 Participants  We 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 Measures  Patients 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.

Results  Of 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 Relevance  In 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.

Trial Registration  ClinicalTrials.gov Identifier: NCT02975869

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    1 Comment for this article
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    Effectiveness of integrated palliative and oncology care for patients with acute myeloid leukemia
    Tomoyuki Kawada, MD | Nippon Medical School
    El-Jawahri et al. evaluated the effect of integrated palliative and oncology care (IPC) on patient-reported quality of life (QOL) in patients with acute myeloid leukemia (AML) (1). IPC led to the improvements in QOL, psychological distress, and end of life care, and the authors recommended IPC as a standard of care for patients with AML. I greatly appreciate their trials for exploring improvement in care of cancer patients, and I want to discuss the effectiveness of IPC.

    The same authors previously conducted a randomized clinical trial to evaluate the effect of IPC on patient- and caregiver-reported outcomes during hospitalization
    for hematopoietic stem cell transplantation (HCT) and 3 months after transplantation (2). Although the use of IPC resulted in a smaller decrease in quality of life 2 weeks after transplantation, intervention patients had higher QOL scores and less depression symptoms at 3 months after HCT. In contrast, anxiety, fatigue, or symptom burden presented no significant advantage. Furthermore, caregivers of patients in the intervention group reported no change in QOL or anxiety but had a smaller increase in depression after 2 weeks of HCT. This report presents the need for evaluating QOL and mental symptoms in patients and caregivers with special reference to intervals from the treatment. Anyway, appropriate methods of IPC should be established in patients with malignancy. I suppose that prognosis might also be influenced by IPC.


    References
    1. El-Jawahri A, LeBlanc TW, Kavanaugh A, et al. Effectiveness of Integrated Palliative and Oncology Care for Patients With Acute Myeloid Leukemia: A Randomized Clinical Trial. JAMA Oncol 2020 Dec 17. doi: 10.1001/jamaoncol.2020.6343
    2. El-Jawahri A, LeBlanc T, VanDusen H, et al. Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation: A Randomized Clinical Trial. JAMA 2016;316(20):2094-2103.
    CONFLICT OF INTEREST: None Reported
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