Multi-site randomized trial of a collaborative palliative and oncology care model for patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) receiving non-intensive therapy.
Authors: El-Jawahri Areej , Kavanaugh Alison , Greer Joseph A. , Jackson Vicki , Gustin Jillian , Mims Alice S. , Cook Albert , LeBlanc Thomas William , Choe Joanna , Reynolds Mathew , Fathi Amir Tahmasb , Hobbs Gabriela , Brunner Andrew Mark , Temel Jennifer S. 
Published: June 2024

LBA6508 Background: Patients with AML and high-risk MDS receiving non-intensive chemotherapy have substantial quality of life (QOL) impairments and often do not engage in timely discussions with their clinicians about their end-of-life (EOL) care preferences. Yet interventions to optimize EOL care delivery and QOL for this population are lacking. Methods: We conducted a multi-site randomized clinical trial of a collaborative palliative and oncology care model compared to usual care in 115 adult patients with AML and high-risk MDS receiving non-intensive therapy at two tertiary care academic hospitals. Patients with a new diagnosis or relapse/ refractory disease were eligible to participate within 30 days of initiating therapy. Patients assigned to the intervention met with a palliative care clinician monthly in the outpatient setting and a minimum of twice weekly during every hospital admission. Patients assigned to usual care were seen by palliative care only upon request. We used Natural Language Processing methods to interrogate the Electronic Health Record (EHR) with a validated algorithm to collect documented EOL care preferences. The primary outcome was to compare time from documentation of EOL care preferences to death between the study arms. Secondary outcomes obtained from the EHR include rates of documentation of EOL care preferences, hospitalization, and hospice utilization at the EOL. Patient-reported secondary outcomes include discussions with clinicians about EOL care preferences, QOL (Functional Assessment of Cancer Therapy – Leukemia), and psychological distress (Hospital Anxiety and Depression Scale) at 3 months after enrollment. Results: We enrolled 51.8% (115/222) of eligible patients. The rate of documented EOL care discussions in the EHR was higher among intervention patients vs. usual care (96.5% vs. 68.4%, P<0.001). Overall, 61.7% (71/115) of patients died, and those receiving the intervention had a longer time from documentation of EOL care preferences to death (41 days vs. 1.5 days, P<0.001). Intervention patients were more likely to report discussing their EOL care preferences with their clinicians (56.9% vs. 14.0%, P<0.001), and less likely to be hospitalized in the last 30 days of life (70.6% vs. 91.9%, P=0.031). There was no difference in hospice utilization at the EOL. At 3 months, patients assigned to the intervention reported better QOL (138.6 vs. 125.5, P=0.010), but no difference in depression or anxiety symptoms compared to those assigned to usual care. Conclusions: Palliative care significantly improved rates of discussion and documentation of EOL care preferences, reduced hospitalization at the EOL, and improved QOL in patients with AML and high-risk MDS. Clinical trial information: NCT03310918 .