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Tharakan S, Feld J, Van Hyfte G, Mascarenhas J, Tremblay D. Impact of Facility Type on Survival in Chronic Myelomonocytic Leukemia: A Propensity Score Matched, National Cancer Database Analysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e385-e391.e1. [PMID: 39003100 DOI: 10.1016/j.clml.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Chronic myelomonocytic leukemia (CMML) is a rare and likely underdiagnosed hematologic malignancy. Due to its rarity and nuances in diagnosis, many patients are referred to tertiary referral centers, although many continue to be cared for in the community setting. Given discrepancies in outcomes based on facility type in related myeloid malignancies, we hypothesized that CMML patients treated at academic centers may have improved survival as compared to patients treated at nonacademic centers (NACs). PATIENTS AND METHODS Using the National Cancer Database (NCDB), we identified 6290 patients with CMML and collected data on demographics, comorbidities, treatment, and survival. We also performed a propensity matched analysis to control for baseline differences. RESULTS We found that patients at academic centers had higher median overall survival (OS) (17.7 months vs 14.7 months) and 5-year OS (19.1% vs 15.3%) than patients at NACs. In addition, patients treated at an academic center were also more likely to receive hematopoietic stem cell transplant as compared to those treated at NACs. Time to treatment initiation was overall similar between academic and NACs. CONCLUSION Our study of one of the largest available datasets of CMML patients supports the importance of referring CMML patients to academic centers upon diagnosis to optimize outcomes in this rare hematologic malignancy.
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Affiliation(s)
- Serena Tharakan
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jonathan Feld
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Grace Van Hyfte
- Institute for HealthCare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Douglas Tremblay
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
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Nixon SM, Maze DC, Parry M, Mayo SJ. Shared-Care in Complex Malignant Hematology: An Integrative Review Using the RE-AIM Evaluation Framework. Curr Oncol 2024; 31:5484-5497. [PMID: 39330034 PMCID: PMC11431418 DOI: 10.3390/curroncol31090406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2024] [Revised: 08/29/2024] [Accepted: 09/12/2024] [Indexed: 09/28/2024] Open
Abstract
Complex malignant hematology (CMH) shared-care programs have been established to support patients with access to care closer to home. This integrative review examined what is known about CMH shared-care using the RE-AIM evaluation framework. We searched five electronic databases for articles published until 16 January 2024. Articles were included if they were qualitative or quantitative studies, reviews or discussion papers, and reported on an experience with shared-care (defined as a reciprocal, ongoing patient-sharing relationship between a specialist centre and community hospital) for patients with hematological malignancies, and examined one or more aspects of the RE-AIM framework. The search yielded 6523 articles; 10 articles describing eight shared-care experiences. Indicators of reach were reported for 65% of the programs, and emphasized some patient eligibility criteria. Effectiveness indicators were reported for 28% of programs, and suggested favourable survival outcomes within a shared-care model; however, health system impact and quality of life studies were lacking. Indicators of adoption and implementation were reported for 56% and 42% of programs, respectively, and emphasized multidisciplinary teams, infrastructure support, and communication strategies. Maintenance was not reported. Common elements contribute to the implementation of existing CMH shared-care programs; however, a formal evaluation remains an area of need.
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Affiliation(s)
- Shannon M. Nixon
- Princess Margaret Cancer Centre, Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Dawn C. Maze
- Princess Margaret Cancer Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Monica Parry
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Samantha J. Mayo
- Princess Margaret Cancer Centre, Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada;
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3
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Sivendran S, McNaughton C, Briguglio A, Webb JA, LeBlanc TW, Lattanzio-Hale A, Horst M, Wilson W, Newport K. Implementation of a Novel Pathway to Integrate Palliative and Oncology Care for Patients With Acute Myeloid Leukemia in a Community Hospital. JCO Oncol Pract 2024:OP2400456. [PMID: 39250734 DOI: 10.1200/op-24-00456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/30/2024] [Accepted: 08/13/2024] [Indexed: 09/11/2024] Open
Abstract
PURPOSE Historically, patients with hematologic malignancies are referred to palliative care less often and later in the disease trajectory than those with solid tumors. Recent evidence demonstrates the benefit of early, integrated inpatient palliative care (PC) for patients with acute myeloid leukemia (AML) receiving chemotherapy at academic centers. The current study evaluated the feasibility of implementing standardized early palliative care services (PCS) during hospitalization for AML treatment in a community setting. METHODS Starting June 2018, automated consultations for PCS were incorporated into clinical pathways to encourage early, integrated services for patients receiving chemotherapy for AML with an expected hospital stay of 4-6 weeks. Expectations were established that consultations would be performed within 72 hours of request; patients would have two visits per week by a palliative care clinician and at least one visit by a member of the interdisciplinary team. To measure the feasibility of this intervention, data on number of patients who received palliative care consultation and time to palliative care consultation were compared with institutional historical controls. RESULTS On the basis of retrospective chart review, the postintervention group (n = 21) had greater PCS compared with historical controls (n = 28; 95% v 36%). The average number of PC team member visits per patient was significantly greater after the intervention: PC clinicians (1.04-8.05, P < .001), chaplains (1.3-3.3, P = .0085), and social workers (1.0-4.3, P < .001). Of those patients who received PCS, 74% had their initial palliative medicine consultation within 3 days of a clinician's order and 100% within 4 days. CONCLUSION We have demonstrated the feasibility of implementing standardized integration of PCS for patients with AML hospitalized for treatment in a community setting.
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Affiliation(s)
- Shanthi Sivendran
- Penn Medicine Lancaster General Health Ann B Barshinger Cancer Institute, Lancaster, PA
- American Cancer Society, Lancaster, PA
| | - Caitlyn McNaughton
- Penn Medicine Lancaster General Health Ann B Barshinger Cancer Institute, Lancaster, PA
| | - Avery Briguglio
- Penn Medicine Lancaster General Data Science and Biostatistics, Lancaster, PA
- Penn State University College of Medicine Section of Palliative Care, Hershey, PA
| | - Jason A Webb
- Section of Palliative Care, Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | | | | | - Michael Horst
- Penn Medicine Lancaster General Data Science and Biostatistics, Lancaster, PA
| | - Wendy Wilson
- Penn Medicine Lancaster General Palliative Care, Lancaster, PA
| | - Kristina Newport
- Penn State University College of Medicine Section of Palliative Care, Hershey, PA
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Al-Juhaishi T, Dela Cruz S, Gupta R, Keiffer G, Morrison VA, Shapira I, Woods A, Norsworthy K, de Claro RA, Theoret MR, Garg R, Pulte ED. Treatment of Acute Myeloid Leukemia in the Community Setting. Oncologist 2024; 29:801-805. [PMID: 39159003 PMCID: PMC11379644 DOI: 10.1093/oncolo/oyae051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 02/22/2024] [Indexed: 08/21/2024] Open
Abstract
The treatment landscape for acute myeloid leukemia (AML) is rapidly changing. Many new agents and lower-intensity regimens have been approved and can be safely used by hematologists and oncologists in both academic and community settings. The US Food and Drug Administration (FDA) held a virtual symposium on AML treatment in the community in November 2022. Several members of the FDA, along with practicing hematologists and oncologists in both academic and community settings, participated in the symposium. The goal of the symposium was to discuss challenges and opportunities in the treatment of patients with AML in community oncology settings. A summary of these discussions and key considerations are presented here.
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Affiliation(s)
- Taha Al-Juhaishi
- Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | | | - Rohan Gupta
- The Center for Cancer and Blood Disorders, Fort Worth, TX, USA
| | - Gina Keiffer
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vicki A Morrison
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN, USA
| | | | - Ashley Woods
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Kelly Norsworthy
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Romeo Angelo de Claro
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Marc R Theoret
- Oncology Center of Excellence, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Ravin Garg
- Maryland Oncology and Hematology, Annapolis, MD, USA
| | - Elizabeth Dianne Pulte
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
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Mangan BL, DuMontier C, Hopkins JO, Abel GA, McCurdy SR. Tailoring Therapy in Older Adults With Hematologic Malignancies. Am Soc Clin Oncol Educ Book 2024; 44:e432220. [PMID: 38788182 DOI: 10.1200/edbk_432220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Hematologic malignancies most often present in the sixth or seventh decade of life. Even so, many older adults may be unable to tolerate standard chemotherapy or require supplementary care or dose adjustments to do so. Both in community and academic centers, geriatric assessment (GA) can be used to improve the care of older adults with blood cancers. For example, hematologic oncologists can use GA to guide treatment selection, adjusting for patient frailty and goals, as well as prompt initiation of enhanced supportive care. After initial therapy, GA can improve the identification of older adults with aggressive myeloid malignancies who would benefit from hematopoietic cell transplantation (HCT), inform shared decision making, as well as allow transplanters to tailor conditioning regimen, donor selection, graft-versus-host disease prophylaxis, and pre- and post-HCT treatments. As in HCT, GA can improve the care of older patients with relapsed lymphoma or multiple myeloma eligible for chimeric antigen receptor-T therapy, identifying patients at higher risk for toxicity and providing a baseline for subsequent neurocognitive testing. Here, we review the data supporting GA for the care of older adults with blood cancers, from the community to the academic center. In addition, we explore future directions to optimize outcomes for older adults with hematologic malignancies.
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Affiliation(s)
- Brendan L Mangan
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA
| | - Clark DuMontier
- Brigham and Women's Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Gregory A Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Shannon R McCurdy
- Division of Hematology-Oncology/Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Male HJ, Lin TL. The approach of HMA plus VEN with or without BMT for all patients with AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:186-191. [PMID: 38066860 PMCID: PMC10727071 DOI: 10.1182/hematology.2023000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Treatment options for acute myeloid leukemia (AML) have expanded over the last 5 years. New regimens are increasing the options for patients who previously may not have been offered any antineoplastic therapy. The use of the hypomethylating agent (HMA) decitabine or azacitidine combined with the BCL2 inhibitor venetoclax (HMA-VEN) has improved overall survival in an older and unfit population compared to HMA therapy alone. Delivering these regimens outside academic centers allows more patients with AML to be treated, though support and collaboration with allogeneic stem cell transplant (SCT) centers should still be considered to determine eligibility and promptly initiate a donor search for potential transplant candidates. Expanding the use of HMA-VEN to younger and fit patients who are also candidates for intensive chemotherapy (IC) is being studied prospectively and is not recommended at this time outside of a clinical trial. Retrospective studies suggest populations that may benefit from HMA-VEN over IC, but this is not yet confirmed prospectively. Utilizing HMA-VEN prior to allogeneic SCT is also under investigation, and some retrospective data show feasibility and the ability to achieve measurable residual disease negativity pretransplant. Upcoming prospective randomized clinical trials aim to answer the comparability or superiority of HMA-VEN vs IC in fit populations and its potential use as a standard pretransplant induction regimen.
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Affiliation(s)
- Heather J Male
- University of Kansas Medical Center, Division of Hematologic Malignancies and Cellular Therapeutics, Kansas City, KS
| | - Tara L Lin
- University of Kansas Medical Center, Division of Hematologic Malignancies and Cellular Therapeutics, Kansas City, KS
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Genç EE, Saraç İS, Arslan H, Eşkazan AE. Diagnostic and Treatment Obstacles in Acute Myeloid Leukemia: Social, Operational, and Financial. Oncol Ther 2023:10.1007/s40487-023-00229-4. [PMID: 37178373 PMCID: PMC10182356 DOI: 10.1007/s40487-023-00229-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/06/2023] [Indexed: 05/15/2023] Open
Abstract
Acute myeloid leukemia (AML) can affect individuals of all ages, but is more common in older adults. It has been estimated that AML accounted for 1% of all newly diagnosed cancers in the USA in 2022. The diagnostic process varies depending on the presenting symptoms and the healthcare facility that patients attend at diagnosis. The treatment process is long and prone to complications, requiring experienced medical professionals and appropriate infrastructure. Treatment of the disease did not change greatly over the years until 2017 when targeted therapies were licensed. The treatment of AML is associated with significant direct economic costs. A number of obstacles originating both from individual patients and the healthcare system may be encountered during the diagnosis and treatment of the disease, which may negatively impact the optimal management of the disease process. In this article, we focus primarily on the social, operational, and financial obstacles including the corona virus disease 2019 (COVID-19) pandemic experienced during the diagnosis and treatment of AML.
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Affiliation(s)
- Emine Eylem Genç
- Department of Hematology, Tekirdağ Dr. Ismail Fehmi Cumalıoğlu State Hospital, Tekirdağ, Turkey
| | - İrem Sena Saraç
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Hayrunnisa Arslan
- Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Department of Internal Medicine, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Fatih, Istanbul, Turkey.
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Rosenblum RE, Ormond E, Smith CW, Bilderback AL, Altieri Dunn SC, Buchanan D, Geramita EM, Rossetti JM, Bhatnagar M, Arnold RM. Institution of Standardized Consultation Criteria to Increase Early Palliative Care Utilization in Older Patients With Acute Leukemia. JCO Oncol Pract 2023; 19:e161-e166. [PMID: 36170636 DOI: 10.1200/op.22.00269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Older patients with acute leukemia (AL) have a high symptom burden and poor prognosis. Although integration of palliative care (PC) with oncologic care has been shown to improve quality-of-life and end-of-life care in patients with AL, the malignant hematologists at our tertiary care hospital make limited use of PC services and do so late in the disease course. Using the Plan-Do-Study-Act (PDSA) methodology, we aimed to increase early PC utilization by older patients with newly diagnosed AL. METHODS We instituted the following standardized criteria to trigger inpatient PC consultation: (1) age 70 years and older and (2) new AL diagnosis within 8 weeks. PC consultations were tracked during sequential PDSA cycles in 2021 and compared with baseline rates in 2019. We also assessed the frequency of subsequent PC encounters in patients who received a triggered inpatient PC consult. RESULTS The baseline PC consultation rate before our intervention was 55%. This increased to 77% and 80% during PDSA cycles 1 and 2, respectively. The median time from diagnosis to first PC consult decreased from 49 days to 7 days. Among patients who received a triggered PC consult, 43% had no subsequent inpatient or outpatient PC encounter after discharge. CONCLUSION Although standardized PC consultation criteria led to earlier PC consultation in older patients with AL, it did not result in sustained PC follow-up throughout the disease trajectory. Future PDSA cycles will focus on identifying strategies to maintain the integration of PC with oncologic care over time, particularly in the ambulatory setting.
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Affiliation(s)
- Rachel E Rosenblum
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ellen Ormond
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Crystal W Smith
- The Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Dan Buchanan
- Clinical Analytics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emily M Geramita
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - James M Rossetti
- Division of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mamta Bhatnagar
- Palliative and Supportive Care Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Robert M Arnold
- Palliative and Supportive Care Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
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Benton C, Grunwald MR, Safah H, Kasner M. Co-management strategies for acute myeloid leukemia patients in the community setting. Front Oncol 2022; 12:1060912. [PMID: 36578924 PMCID: PMC9791081 DOI: 10.3389/fonc.2022.1060912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
The treatment landscape for acute myeloid leukemia (AML) has changed substantially in recent years. The introduction of newer therapies, including oral agents, less myelosuppressive agents, and parenteral regimens suitable for outpatient administration, has made it feasible for select patients to receive therapy in the outpatient setting and in community practices. Thorough patient evaluation (including molecular testing), planned supportive care (eg, transfusion support, antimicrobial prophylaxis), and vigilant patient monitoring (for tumor lysis syndrome and adverse events) by a multidisciplinary team are required for successful management of patients both in the community and at specialized leukemia centers. Some patients are unable or unwilling to travel to larger academic centers for treatment, and treatment of AML in the community setting may have potential advantages compared to less conveniently located academic/leukemia centers. This includes reduction of financial hardship for patients and their families and often better opportunities for family/caregiver support. Additionally, partnership between community practices and academic/leukemia centers is often crucial to optimizing AML management for many patients, as collaboration may facilitate access to additional expertise and trials, multidisciplinary teams for supportive care, easier transition to hematopoietic cell transplantation, and access to sophisticated molecular testing. In this review, we discuss AML treatment and management in the community setting, available therapies, and circumstances in which a referral to and co-management with an academic/leukemia center is more strongly recommended.
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Affiliation(s)
- Christopher Benton
- Rocky Mountain Cancer Centers, US Oncology Network, Denver, CO, United States
| | - Michael R. Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | - Hana Safah
- Tulane Cancer Center, Tulane University School of Medicine, New Orleans, LA, United States
| | - Margaret Kasner
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States,*Correspondence: Margaret Kasner,
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Geriatric assessment predicts non-fatal toxicities and survival for intensively treated older adults with AML. Blood 2022; 139:1646-1658. [PMID: 35007323 DOI: 10.1182/blood.2021013671] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/13/2021] [Indexed: 11/20/2022] Open
Abstract
Given a few prospective studies with conflicting results, we investigated the prognostic value of multi-parameter geriatric assessment (GA) domains on tolerance and outcomes after intensive chemotherapy in older adults with acute myeloid leukemia (AML). Newly diagnosed AML aged over 60 years who received intensive chemotherapy consisting of cytarabine and idarubicin (n=105) were enrolled prospectively. Pretreatment GA included evaluations for social and nutritional support, cognition, depression, distress, and physical function. The median age was 64 years (range, 60-75), and 93% had an Eastern Cooperative Oncology Group score <2. Between 32.4% and 69.5% of patients met the criteria for impairment for each domain of GA. Physical impairment by the Short Physical Performance Battery (SPPB) and cognitive dysfunction by the Mini-Mental State Examination in the Korean version of the CERAD Assessment Packet (MMSE-KC) were significantly associated with non-fatal toxicities, including grade III-IV infections (SPPB, P=0.024; MMSE-KC, P=0.044), acute renal failure (SPPB, P=0.013), and/or prolonged hospitalization (³40 days) during induction chemotherapy (MMSE-KC, P=0.005). Reduced physical function by SPPB and depressive symptoms by the Korean version of the short form of geriatric depression scales (SGDS-K) were significantly associated with inferior survival (SPPB, P=0.027; SGDS-K, P=0.048). Gait speed or sit-and-stand speed was the single powerful tool to predict survival outcomes. Notably, the addition of SPPB and SGDS-K, gait speed and SGDS-K, or sit-and-stand speed and SGDS-K significantly improved the power of existing survival prediction models. In conclusion, GA improved risk stratification for treatment decisions and may inform interventions to improve outcomes for older adults with AML. This study was registered at the Clinical Research Information Service (KCT0002172).
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