Acute Myeloblastic Leukemia in the Elderly: How Could Palliative Care Teams and Hematologists Better Work Together?

Dear Editor:

Impact of early palliative care (PC) has been demonstrated in patients with solid tumors. PC team intervention has been shown to provide a better quality of life, shorter hospitalizations, reduced intensive care admissions, reduced chemotherapy prescription in the last days of life, and prolonged overall survival in metastatic lung cancer. In contrast, patients with hematological malignancies are less likely to benefit from PC, have later palliative services admission, receive more chemotherapy, and have more intensive care unit admissions at the end of life.^1,2 This could be explained by hematologists' difficulties to estimate patients' prognosis, by a different perception of PC as only end-of-life care and by practical barriers to PC referrals or misunderstanding with PC physicians.^3,4

Acute myeloblastic leukemia in the elderly more than 70 (AML70) is an incurable and life-threatening disease when patients cannot receive intensive chemotherapy or allogenic stem cell transplantation because of comorbidities, with an expected overall survival at one year of only 15%–20%. According to World Health Organization definition, AML70 could be considered as a palliative disease. To improve collaboration between PC teams and hematologists, we sought to identify in what extent a PC team could support physicians and AML70. We tried first to describe the AML70 population in terms of disease and treatment characteristics, overall survival, and PC referral. We conducted a retrospective study in our University Hospital including all AML70 (excluding AML3) diagnosed between 2007 and 2013. Survival time was calculated with the use of Kaplan–Meier method.

One hundred fifty-three patients were included, whose disease and treatments characteristics are described in Table 1. AML70 were considered as de novo if myelodysplastic syndrome or chemo/radiotherapy did not precede them. One hundred five of AML70 (69%) received chemotherapies. Hydroxycarbamide and mercaptopurine were considered as “oral chemotherapies.” The median overall survival was 3.2 months, ranging from 1 month (no treatment) to 46 months (intensive chemotherapy). Seventy-four patients (54%) died at the University Hospital. Blood transfusion had been prescribed in the last month of life in 122 patients (84%). A PC team intervention was required in 36 subjects (24%).

We confirmed the poor prognosis of AML70. According to these results, three areas of cooperation between PC teams and hematologists are relevant for several reasons. First, therapeutic issues with patient assessment and decision support, outpatient care, and pathways in transfusion support or end-of-life care. Second, prognostic issues, with anticipation of short-term complications, resource utilization (emergency room, ICU, etc.), and ethical questions about extended life or not. Finally, psychological issues with patients and caregivers' difficulties with the experience of incurability and hematological teams' difficulties with treatment failures and poor prognosis.

Our study has identified AML70 likely to probably benefit from early intervention of a PC team. Roles and supports of a PC team should probably be better explained among hematologists. In addition to clinical research to improve overall survival of this population, further studies are required to assess benefit from PC in AML70 and in other hematological malignancies.