Improving advance care planning for patients receiving chimeric antigen receptor T-cell therapy with lymphoma and myeloma.
Authors: Gaulin Charles , Cervoni-Curet Frances Natalia , Lionel Anath Christopher , Hawkins Misha , Ahmed Sairah , Becnel Melody R. , Rodriguez Maria Alma 
Published: September 2024

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Background:
Advance care planning (ACP) enhances patient autonomy by creating a written record of their preferences for future medical care. Despite inclusion of ACP in cancer care guidelines, ACP documentation rates in oncology remain low. Patients who receive chimeric antigen receptor T-cell therapy (CAR T) for non-Hodgkin lymphoma (NHL) and multiple myeloma (MM) are often heavily pre-treated and at risk of potentially serious adverse events. As a result, our departmental policy has recommended ACP documentation prior to CAR T since 2022. The outpatient setting is the ideal setting for ACP as it involves the primary stakeholders of the patient-doctor relationship and allows for multiple opportunities to address goals of care. We therefore sought to evaluate existing outpatient ACP documentation rates and implement a pilot strategy to increase outpatient ACP documentation rates prior to CAR T at our center.
Methods:
Patients treated with commercial CAR T for NHL/MM between Oct 1, 2023-Dec 31, 2023 (pre-intervention, retrospective) and between Feb 5, 2024-Apr 5, 2024 (post-intervention, prospective) at The University of Texas MD Anderson Cancer Center were identified. An ACP reminder sent via email by the CAR T coordinator to the outpatient oncology team prior to CAR T was implemented. The proportion of patients with ACP documentation generated using our center’s Epic SmartBlock within 30 days prior to CAR T was measured. This project was approved by the Quality Improvement Assessment Board (QIAB# 1177).
Results:
A total of 55 consecutive patients were identified (Table). Of the 34 treated pre-intervention, 17 (50%) had ACP documentation prior to CAR T. Of the 21 treated post-intervention, 18 (86%) had ACP documentation prior to CAR T. ACP documentation rates were generally comparable across disease type. ACP documentation rates progressively increased over the study period, peaking at 91% four weeks post-intervention, and were sustained. These metrics surpassed our predetermined pilot goal rate of 60%.
Conclusions:
Incorporating an ACP documentation reminder within our commercial CAR T coordination workflow led to a significant improvement in outpatient ACP documentation rates prior to CAR T for NHL/MM. An expansion study in patients treated with bispecific T-cell engagers is planned, with broader rollout within our entire hematologic malignancy group in the future. Additional data will be collected to evaluate the relationship between ACP documentation rates and immune effector cell therapy-related outcomes/resource utilization. Input from key stakeholders to identify additional barriers to ACP is also planned.

Patient characteristics.

Pre-interventionn=34
Post-interventionn=21

Median age (years, range)
63 (35-87)
67 (48-83)

Male gender (%)
27 (79)
14 (67)

NHL (%)
20 (59)
18 (86)

MM (%)
14 (41)
3 (14)

ACP documentation (%)
17 (50)
18 (86)