End-of-life care for older AML patients relapsing after allogeneic stem cell transplant at a dedicated cancer center

Abstract

Older patients with acute myelogenous leukemia (AML) are at increased risk for mortality and morbidity. While allogeneic stem cell transplantation may provide cure in some patients, many still relapse after transplant and are then left with limited therapeutic options and poor survival. Moreover, the quality of the end-of-life care for these patients has not been previously reported. We describe here the end-of-life experience of a cohort of 72 older patients with AML who relapsed after first allogeneic stem cell transplant at our dedicated cancer center. Despite a median overall survival of only 4 months, we find a high level of primary palliative care delivered by transplant/leukemia physicians through goals of care discussions and/or advanced care planning and provide evidence for high-quality end-of-life care outcomes, often with concurrent disease-directed therapy. Our results compare favorably with end-of-life care outcomes reported for older AML patients, including those who did not undergo transplant. Given the poor prognosis and unique underlying vulnerabilities in this high-risk patient population, incorporating timely advanced care planning and palliative care delivery while exploring available salvage options may further improve end-of-life care outcomes.

FIGURE 1.

Kaplan-Meier estimate of post-relapse survival stratified by treatment received: supportive care only, low intensity treatment, and high intensity treatment (p<0.001).

FIGURE 2.

Changes in the utilization of quality end-of-life care measures over three time periods, 2001–2010, 2011–2014, and 2015–2017. Each column with standard error bar represents the proportion of patients with indicated outcomes. There was increased use of subspecialty palliative care consultation (PC consult) over time (p=0.029). However, we did not identify significant changes in hospice use, chemotherapy in the last 14 days, hospitalization in the last 30 days, and ICU admission in the last 30 days over time.

FIGURE 3.

Changes in the utilization of quality end-of-life care measures over different treatments after relapse: support care only, low intensity treatment, and high intensity treatment. Each column with standard error bar represents the proportion of patients with indicated outcomes. We did not identify significant changes in hospice use, chemotherapy in the last 14 days, hospitalization in the last 30 days, and ICU admission in the last 30 days over different treatments after relapse.