Health care utilization and end-of-life care for older patients with acute myeloid leukemia
See related editorial on pages 2678-80, this issue.
Abstract
BACKGROUND
Health care utilization in older adults (age ≥60 years) with acute myeloid leukemia (AML) has not been well studied.
METHODS
We conducted a retrospective analysis of 330 consecutive older patients who were diagnosed with AML between May 1, 2005 and December 23, 2011, at 2 hospitals in Boston to examine their health care utilization and end-of-life care. Using multivariable logistic and linear regression models adjusting for covariates, we also compared health care utilization between patients who received intensive induction chemotherapy (n = 197; cytarabine/ anthracycline combination) versus nonintensive chemotherapy (n = 133; single-agent therapy).
RESULTS
The median number of hospitalizations for the entire cohort was 4.2 (range, 1-18 hospitalizations). Patients who died spent a mean of 28.3% of their life after diagnosis in the hospital and 13.8% of their life attending outpatient clinic appointments. Although the majority of patients (87.9%) died during the 2-year follow-up period, a minority received palliative care (16.2%) or hospice (23.1%) services. Within 30 days of death, 84.5% of patients were hospitalized, and 61% died in the hospital. Among the patients who died, those who received intensive induction therapy (vs nonintensive therapy) spent 30% more of their life after diagnosis in the hospital (P < .0001) and were less likely to receive hospice services (odds ratio, 0.45; P = .05).
CONCLUSIONS
The current findings highlight the intensity of health care utilization among older patients with AML, regardless of treatment modality. Despite the poor prognosis, palliative care and hospice services are rarely used. Future work should study novel health care delivery models to optimize care throughout the course of illness and at the end of life. Cancer 2015;121:2840-2848. © 2015 American Cancer Society
INTRODUCTION
Older patients (aged ≥60 years) with acute myeloid leukemia (AML) face a life-threatening illness that carries a poor prognosis with a median survival of 8 to 10 months and a long-term disease-free survival rate <10%.1, 2 Factors like poor performance status and comorbidities, biologic parameters such as frequent expression of the multidrug-resistance p-glycoprotein and association with unfavorable karyotypes, and the high proportion of therapy-related disease all contribute to these poor outcomes.1, 3, 4 Surprisingly, studies exploring health care utilization and end-of-life (EOL) care in this population are lacking.5, 6 Data describing patients' receipt of health services, such as the time they spend in the hospital and clinic and their care at the EOL, would allow clinicians to communicate accurate information to their patients about the ramifications of their diagnosis and treatment. Ensuring that patients are well informed about their illness is a key component of patient-centered care, because it provides patients with the vital information they need to plan for the future.7, 8
In addition, various treatment options are available for older patients with AML. There is limited agreement among clinicians regarding the optimal initial treatment, and there are no published data on how these treatment strategies impact patients' health care utilization and EOL care. Treatment options include: 1) intensive chemotherapy using a combination of cytarabine and an anthracycline (“7 + 3” regimen), a regimen commonly used to induce remission in younger adults with AML4, 9; 2) less intensive therapy with low-dose cytarabine or the hypomethylating agents decitabine or azacitidine5, 9-11; 3) clinical trial enrollment9; or 4) supportive care alone.9 Patients who are deemed medically more fit commonly receive intensive therapy (the 7 + 3 regimen) with the hope of attaining complete remission and ultimately undergoing allogeneic hematopoietic stem cell transplantation (HCT), which is potentially curative.1, 6 Older individuals who are not fit for induction therapy often receive less intensive therapy or supportive care alone after discussing the risks and benefits of various options with their oncologists.1, 6
Given the short life expectancy of many older patients with AML and the low likelihood of cure, patients may wish to consider the impact of cancer therapy on their quality of life, including the time spent in the hospital and the medical care received throughout their illness and at the EOL. One randomized study conducted in 1989 compared intensive induction versus supportive care with cytoreductive agents as needed (cytarabine or hydroxurea) in older patients with AML.12 In that study, patients who received intensive induction had a 10-week survival advantage compared with those who received supportive care. It is noteworthy that there were no significant differences in patients' time spent in the hospital or their quality of life between the treatment arms. However, quality of life was assessed based on time spent in the hospital rather than patient-reported measures. Moreover, with the introduction of hypomethylating agents as well as improvements in supportive care measures, it is unclear whether the findings of that study would be replicable in the modern era.
The objective of our study was to describe current health care utilization and EOL care in older patients (aged ≥60 years) with AML. We also sought to examine the impact of the initial treatment strategy (intensive vs nonintensive) on health care utilization and EOL care.
MATERIALS AND METHODS
Study Design
We conducted a retrospective analysis of all patients aged ≥60 years who had a diagnosis of AML and received treatment at the Dana-Farber Cancer Institute or Massachusetts General Hospital between May 1, 2005 and December 31, 2011. Patients were categorized according to whether they received either intensive induction therapy (n = 197) or nonintensive therapy (n = 133) at the time of diagnosis. We defined intensive induction as receiving the standard “7 + 3” regimen with a combination of cytarabine and an anthracycline or a modification of this regimen on a clinical trial with other agents added to the 7 + 3 backbone. We defined nonintensive therapy as the receipt of hypomethylating agents, low-dose cytarabine, or single-agent therapy on a clinical trial. Single agents that were included as nonintensive therapy were: SNS595 (a topoisomerase II inhibitor), heat-shock protein 90 (HSP90) inhibitor, panobinostat (a histone deacetylase inhibitor), cloretazine, lenalidomide, NEDD-8 activating enzyme inhibitor, sorafenib, PKC-412 inhibitor, and bortezomib. We excluded patients with a diagnosis of acute promyelocytic leukemia and who only attended a 1-time consultation. Because 1 of our objectives was to compare health care utilization and EOL care among those receiving intensive induction versus nonintensive therapy, we excluded patients who received supportive care alone and those who received nonintensive therapy but subsequently received the 7 + 3 regimen.
We identified the eligible cohort using the Dana-Farber Cancer Institute and Massachusetts General Hospital Leukemia Clinical Research Information Systems database, which includes all patients with acute leukemia seen at these institutions. We then conducted a comprehensive chart review to obtain information regarding patients' demographics, comorbidities (as measured by the Sorror comorbidity index),13 Eastern Cooperative Oncology Group (ECOG) performance status, AML cytogenetics and molecular profile, subsequent consolidation therapy, and health services utilization and care at the EOL. We used the European LeukemiaNet risk-stratification recommendations to classify disease risk.4, 14
Health Services Utilization and EOL Care
We obtained information regarding frequency of hospitalizations and clinic visits, hospital length of stay, palliative care consultations, and intensive care unit (ICU) admissions from the electronic medical record. For patients who had died by December 31, 2013 (a minimum of 2-year follow-up), we determined the number of days spent hospitalized and the number of days patients visited the outpatient clinic. We then calculated the percentage of life spent in the hospital (inpatient days/total survival days × 100%), the percentage of life spent in the outpatient clinic (outpatient clinic visit days/total survival days × 100%), and the percentage of life spent outside the hospital or clinic. We measured total survival days from the date of AML diagnosis. Each clinic visit was calculated as 1 full survival day. Seventy of 330 patients (21.2%) were missing data on the time spent in clinic, because they were concurrently receiving care both locally and at our institutions. We conducted all analyses using observed data without imputation for missing data.
We determined patients' place of death, cause of death, hospice utilization, and length of stay in hospice using the electronic medical record and the Social Security Death Index. We also determined whether patients were hospitalized (yes vs no), received chemotherapy (yes vs no), or were admitted to the ICU (yes vs no) within 30 days of death.
Statistical Methods
We used descriptive statistics to summarize patient and disease characteristics of all study patients stratified according to initial treatment strategy. We used chi-square tests or 2-sample t tests, as appropriate, to compare demographic and clinical characteristics between patients who received intensive induction therapy and those who received nonintensive therapy.
We used Kaplan-Meier survival analysis to estimate overall survival and the log-rank test to assess the univariate association between induction strategy and overall survival. By using multivariable Cox proportional hazards regression analysis, we assessed the independent effect of demographic and clinical variables (including induction strategy used) on overall survival. We calculated overall survival from the time of diagnosis, with patients censored at the date last known alive. The model included the following covariates: age, sex, marital status, education, Sorror comorbidity index, ECOG performance status, AML risk stratification, and the receipt of allogeneic HCT.
We used descriptive statistics to describe health care utilization and EOL care for all patients in this cohort. To compare health care utilization and EOL care between patients who received intensive induction versus nonintensive therapy in the univariate analysis, we used a Fisher exact test or a 2-sample t test, as appropriate, depending on the outcome of interest. By using multivariable logistic regression models, we examined the association between initial treatment strategy and the binary outcomes of interest (yes vs no: palliative care consultation, ICU admission, receipt of chemotherapy, hospitalization, ICU admissions within 30 days of death, hospice use, and length of stay in hospice ≤7 days). We used multivariable linear regression models to examine associations between the initial treatment strategy and continuous outcomes of interest (total number of hospitalizations, percentage survival spent in the hospital, percentage survival spent in the clinic, and percentage survival spent outside the hospital or clinic). We included the following covariates in the multivariable linear and logistic regression models: age, sex, marital status, education, Sorror comorbidity index, ECOG performance status, AML risk stratification,4, 14 and the receipt of allogeneic HCT. We chose these covariates given their potential role as confounders, because they are associated with both the treatment (intensive vs nonintensive) and the outcome of interest (health care utilization). These covariates are also commonly controlled for in multivariable analyses comparing intensive versus nonintensive therapy. All reported P values are 2-sided, and P values < .05 are considered statistically significant.
RESULTS
Patients Characteristics
Table 1 depicts the clinical characteristics of all patients (n = 330) included in this study. The median age of the cohort was 70 years, and 42% had high-risk disease.4, 14 Compared with the patients who received nonintensive therapy, those who received intensive induction were more likely to be younger (median age, 66.3 years vs 75.2 years; P < .0001), more educated (postgraduate education, 18.3% vs 6%; P = .04), had fewer comorbidities (median Sorror comorbidity score, 1.7 vs 2.2; P = .02), and had a better performance status (0.77 vs 1.0; P < .0001).
| No. of Patients (%) | ||||
|---|---|---|---|---|
| Variable | All Patients, n = 330 | Intensive Chemotherapy, n = 197 | Nonintensive Chemotherapy, n = 133 | Pa |
| Age: Mean ± SD | 69.9 ± 6.8 | 66.3 ± 4.6 | 75.2 ± 6.2 | < .0001 |
| Male gender | 195 (59.1) | 110 (55.8) | 85 (63.9) | .14 |
| White race | 321 (97.3) | 190 (96.4) | 131 (98.5) | .47 |
| Marital status | .05 | |||
| Single | 36 (10.9) | 22 (11.2) | 14 (10.5) | |
| Married | 243 (73.6) | 147 (74.6) | 96 (72.2) | |
| Divorced | 26 (7.9) | 19 (9.6) | 7 (5.3) | |
| Widow | 25 (7.6) | 9 (4.6) | 16 (12) | |
| Education | .04 | |||
| ≤High school | 136 (41.2) | 75 (38.1) | 61 (45.9) | |
| College | 150 (45.5) | 86 (43.7) | 64 (48.1) | |
| Postgraduate | 44 (13.3) | 36 (18.3) | 8 (6) | |
| Therapy-related disease | 48 (14.6) | 29 (14.7) | 19 (14.3) | .91 |
| Comorbidity index: Mean ± SD | 1.9 ± 1.8 | 1.7 ± 1.6 | 2.2 ± 2.1 | .02 |
| Disease risk | .40 | |||
| Favorable | 25 (7.6) | 18 (9.1) | 7 (5.3) | |
| Intermediate risk | 165 (50) | 99 (50.3) | 66 (49.6) | |
| High risk | 140 (42.4) | 80 (24.2) | 60 (45.1) | |
| ECOG PS: Mean ± SD | 0.88 ± 0.56 | 0.77 ± 0.55 | 1.0 ± 0.55 | < .0001 |
| Achieved complete remission | 171 (51.8) | 140 (71.1) | 31 (23.3) | < .0001 |
| Underwent allogeneic HCT | 109 (33) | 102 (51.8) | 7 (5.3) | < .0001 |
| Median survival [95%CI], d | 340 [280-391] | 390 [309-487] | 255 [198-354] | < .0001 |
- Abbreviations: ECOG PS, Eastern Cooperative Oncology Group performance status; HCT, hematopoietic stem cell transplantation; SD, standard deviation.
- a P values in boldface are statistically significant.
The median survival for the entire cohort was 340 days (95% confidence interval [CI], 280-391 days). Patients who received intensive induction were more likely to achieve complete remission (71.1% vs 22.3%; P < .0001) and to undergo allogeneic HCT (51.8% vs 5.3%; P < .0001). In the unadjusted analysis, the median survival for patients who received intensive induction was 390 days (95% CI, 309-487 days), and it was 255 days (95% CI, 198-354 days) for those who received nonintensive therapy (P = .0003). In multivariable analyses, there was no significant difference in overall survival between patients who received intensive induction versus nonintensive therapy (hazard ratio, 1.36; 95% CI, 0.98-1.87; P = .06). Undergoing allogeneic HCT was associated with better overall survival (hazard ratio, 0.30; 95% CI, 0.21-0.41; P < .0001).
Health Care Utilization in Older Patients With AML
The median number of hospitalizations for the entire cohort was 4.2 (range, 0-18 hospitalizations), and 92 of 330 patients (27.9%) were admitted to the ICU at some point during their care (Table 2). With a minimum 2 years of follow-up, 290 of 330 patients (87.9%) had died. Patients who died spent a mean of 28.3% of their life after diagnosis in the hospital and 13.8% of their life attending outpatient clinic appointments. Overall, patients who died spent a mean of 57.9% of their life after diagnosis outside of the hospital or clinic (Table 2). Only 47 of all 330 patients (14.2%) and 47 of the 290 patients who died (16.2%) had a consult with palliative care. The median time from palliative care consultation to death was 7 days (range, 0-364 days).
| Variable | All Patients,a n = 290 |
|---|---|
| No. of hospitalization: Median ± SD | 4.2 ± 3.0 |
| Percentage of life in hospital: Mean ± SD, % | 28.3 ± 28.2 |
| Percentage of life in clinic: Mean ± SD, % | 13.8 ± 14.7 |
| Percentage of life outside hospital or clinic: Mean ± SD, % | 57.9 ± 33.3 |
| ICU admissions: n (%) | 92 (31.7) |
| Palliative care consults: n (%) | 49 (16.2) |
| Time from palliative care consult to death: Median ± SD, d | 7 ± 58.9 |
- *All patients who died during follow-up.
- Abbreviations: ICU, intensive care unit; SD, standard deviation.
EOL Care Outcomes in Older Patients With AML
Among the patients who died (n = 290), 61% died in the hospital, 31% died at home, and 8% died in a skilled nursing facility or hospice home (Table 3). The main causes of death were: disease (68.6%), infection (13.4%), and treatment-related complications (12.4%). Within 30 days of death, 84.5% of patients were hospitalized, 44.5% had received chemotherapy, and 26.6% were admitted to the ICU. Only 22.1% received hospice services, and 11.3% has a hospice length of stay >7 days.
| Variable | No. of Patients (%) |
|---|---|
| Cause of death | |
| Disease | 199 (68.6) |
| Infection | 39 (13.4) |
| Treatment complications | 36 (12.4) |
| Other | 7 (2.4) |
| Place of death | |
| Home without hospice | 49 (16.9) |
| Hospice, home or facility | 64 (22.1) |
| Hospital | 177 (61) |
| Received hospice services | 67 (23.1) |
| Hospice length of stay >7 d | 12 (6.1) |
| Chemotherapy within 30 d of death | 80 (49.4) |
| Hospitalization within 30 d of death | 144 (88.9) |
| ICU admissions within 30 d of death | 59 (36.4) |
- Abbreviation: ICU, intensive care unit.
Health Care Utilization and EOL Care Based on Initial Treatment Strategy
In the unadjusted analyses, patients who received intensive therapy had more frequent hospitalizations (5.0 vs 3.1; P < .0001) and were more likely to be admitted to the ICU (45.1% vs 14.8%; P < .0001) at some point during their care. Among the patients who died, those who received intensive therapy spent more of their life from diagnosis to death in the hospital (39.9% vs 13.7%; P < .0001) but less of their life in clinic (10.7% vs 17.8%; P < .0001) (Fig. 1A).
Univariable analyses of health services utilization and end-of-life care based on initial treatment strategy are illustrated, including (A) the time spent at home, hospital, and clinic based on initial treatment strategy; (B) the receipt of health services within 30 days of death based on initial treatment, and (C) the place of death. ICU indicates intensive care unit.
In unadjusted analyses examining EOL care within 30 days of death, patients who received intensive induction therapy were more likely to be hospitalized (88.9% vs 78.9%; P = .02), receive chemotherapy (49.4% vs 38.3%; P = .05), and be admitted to the ICU (36.4% vs 14.1%; P < .0001) (Fig. 1B). There were no significant differences in place of death (Fig. 1C), hospice use, or palliative care consults between the 2 groups. However, patients who received intensive induction therapy were less likely to have a hospice length of stay >7 days (6.1% vs 15.8%; P = .004).
In multivariable analyses (Table 4), patients who received intensive induction therapy were more likely to be admitted to the ICU (odds ratio [OR], 3.59; 95% CI, 1.74-7.41; P = .0005) at some point during their care. Among patients who died, those who received intensive induction versus nonintensive therapy spent 30% more of their life after diagnosis in the hospital (P < .0001) but 9% less in the clinic (P = .0001). Patients who received intensive induction therapy spent 20% less of their life from diagnosis to death out of the hospital and clinic (P < .0001) compared with those who received nonintensive therapy. No differences were noted in hospitalization frequency between the 2 groups.
| Outcomes: Intensive vs Nonintensive Treatment | |||
|---|---|---|---|
| Variable | ß ± SE | OR (95% CI) | Pa |
| Total no. of hospitalizations: ß ± SE | 0.69 ± 0.42 | .10 | |
| Percentage of life spent in the hospital: ß ± SE, % | 30 ± 4 | ≤ .0001 | |
| Percentage of life spent in clinic: ß ± SE, % | −9 ± 2 | .0001 | |
| Percentage of life spent outside hospital or clinic: ß ± SE, % | −20 ± 5 | < .0001 | |
| ICU admissions | 3.59 (1.74-7.41) | .0005 | |
| Palliative care consults | 0.53 (0.23-1.17) | .12 | |
| Hospice utilization | 0.45 (0.20-0.99) | .05 | |
| Hospice LOS ≤7 d | 2.96 (1.03-8.52) | .04 | |
| Chemotherapy within 30 d of death | 1.84 (0.95-3.55) | .07 | |
| Hospitalization within 30 d of death | 1.26 (0.50-3.14) | .62 | |
| ICU admission within 30 d of death | 2.89 (1.3-6.20) | .006 | |
- Abbreviations: CI, confidence interval; ICU, intensive care unit; LOS, length of stay; OR, odds ratio; SE, standard error.
- a P values in boldface are statistically significant.
There were no differences in hospitalizations or receipt of chemotherapy within 30 days of death between the 2 groups in multivariable analyses. However, patients who received intensive induction were more likely to be admitted to the ICU within 30 days of death (OR, 2.89; 95% CI, 1.3-6.2; P = .006), less likely to use hospice services before death (OR, 0.45; 95% CI, 0.2-1.0; P = .05), and more likely to have a hospice length of stay of ≤7 days (OR, 2.96; 95% CI, 1.03-8.52; P = .04).
DISCUSSION
This study depicts the substantial health care burden of AML and the therapy used to treat it on older patients as they navigate their illness and face the EOL. The current data also highlight the intensity of health care utilization at the EOL in this population. Patients in our sample were hospitalized frequently during their illness, and the majority were admitted to the hospital in the last month of life and died in the hospital. Although it has not been studied explicitly in patients with AML, data suggest that the majority of cancer patients and the general public express a strong preference to die at home and minimize time spent in the hospital at the EOL.15, 16 Unfortunately, there are many barriers to achieving this goal in patients with AML, including uncertainty about prognosis, the rapid trajectory of decline at the EOL, the frequency of infectious and bleeding complications, and the intensity of supportive care measures needed—particularly blood product support.17, 18 Our findings highlight the need to develop novel health service delivery models to provide appropriate EOL care for patients with AML, taking into account the specific needs of this population.
Despite the proven benefits of palliative and hospice care for patients with cancer, these services were rarely used in our cohort. Because it has been demonstrated that the early integration of palliative care improves quality of life and symptom burden and decreases health service utilization in patients with solid malignancies,19, 20 a similar strategy may prove valuable in improving quality of life and health care delivery in patients with AML. Early referral to palliative care in this population, with its known high symptom burden21 and relatively short survival,1, 2 can occur concurrently while pursuing curative therapy. Such strategies should be evaluated in future studies, because they would allow the incorporation of supportive care interventions despite the unpredictable illness trajectory. In addition, specialized palliative care models must be developed with proper attention to the special needs of elderly patients with AML, including methods to address their transfusion requirements and frequent complications, such as bleeding and infections.
We observed that only a minority of patients dying of AML used hospice services. Hospice utilization is associated with improvement in patients' quality of life and family caregivers' grief and satisfaction with care.22, 23 The absence of a clear transition between the curative and palliative phases of disease for older patients with AML may hamper the receipt of hospice services.17, 18 In addition, the frequent need for blood product support, which many hospice organizations do not permit because of financial constraints, likely contribute to lower rates of hospice referrals.17, 24 Despite the challenges, studies should determine whether patients with AML and their families receive benefit from an earlier and frequent use of hospice care in part through the adoption of alternative care models.
Our retrospective study was not designed to compare the survival outcomes of intensive versus nonintensive therapy in older patients with AML; indeed, this would be impossible given the high selection biases inherent in such treatment choices. However, our work represents the first study to our knowledge comparing health care utilization and EOL care in older patients with AML who were treated according to various induction strategies. Our results highlight the significant amount of time spent hospitalized or interacting with the health care system after a diagnosis of AML, especially among patients who receive intensive induction therapy. The intensity of health care utilization is likely driven by the nature of the disease and its complications as well as the therapies used to treat it. Patients in our cohort who received intensive induction therapy and ultimately died spent >50% of their life after diagnosis in the hospital or clinic. Although intensive induction offers a minority of patients a potentially curative therapy, patients should also be informed of the likely outcome if a cure is not achieved. This information can enable patients to make decisions that are aligned with their values, and it can be used to design supportive care interventions to improve the quality of life and care of this population.
Several of our findings are consistent with the results from prior studies examining EOL care in patients with hematologic malignancies. In 1 study, patients with hematologic malignancies were more likely like to have hospital admissions and to receive chemotherapy within 30 days of death compared with patients who had solid malignancies.25 In another study, patients with hematologic malignancies were referred late for or never received hospice services.26 We focused on older patients with AML as opposed to a heterogeneous population of patients with hematologic malignancies. Given the drastic differences in illness trajectories for patients with various hematologic malignancies, it is important to examine patients with different hematologic malignancies separately.21
Our study has several important limitations. First, we conducted the study at 2 academic institutions in Boston, thereby limiting the generalizability of our findings to other settings. However, many older patients diagnosed with AML are referred to tertiary care centers for their care given their specialized needs. Thus, our data likely accurately reflect the patterns of care for many older patients with AML who are treated in the United States. Second, comparing health care utilization between patients who received different induction strategies in a retrospective fashion can be challenging because of selection biases and the potential for unmeasured confounders. However, we controlled for known baseline differences between the 2 groups in all of our analyses. In addition, compared with patients who receive intensive induction therapy, those who receive nonintensive therapy are older, less fit, and have more comorbidities, which would bias the results toward higher health care utilization during therapy and at the EOL in this group, contrary to our findings. Third, we were unable to assess the extent to which the intensity of health care utilization in this population was driven by the nature of the disease or the therapy used to treat it. This is an important issue, because our findings should not be used to discourage clinicians from recommending therapy for this disease; rather, they should be incorporated into the discussions with patients when clinicians review treatment options. Finally, patients may have been hospitalized or may have received EOL care at facilities outside of our institutions, which may not have been entirely captured by our medical records.
In conclusion, older patients with AML spend a significant portion of their life after diagnosis in the hospital or clinic. They are also likely to die in the hospital and infrequently use hospice or palliative care services. Although older patients with AML who receive intensive induction therapy are more likely to achieve complete remission and to undergo allogeneic HCT, which is a potentially curative therapy for their disease, they are also more likely to spend time in the hospital and to receive aggressive care at the EOL. Although these findings are important for informed decision making, they must be placed within the context of a larger discussion regarding the potential benefits and harms of treatment for this disease. Clinicians must integrate patients' prognostic and disease risk stratification, as well as their values, into their recommendation about the optimal therapy for each patient. Moreover, although quality-of-life data are limited in this population,27, 28 clinicians must also consider the impact of the various treatments on patients' quality of life when discussing therapeutic options. Finally, clinicians must engage in an honest discussion with patients regarding the best way to incorporate the pursuit of curative therapy into the decision-making process when cure is only a realistic possibility for a minority of older patients with AML. It is noteworthy that our findings highlight the need for developing supportive care interventions to improve quality of life and care for patients with AML throughout the course of their illness, during hospitalizations, and at the EOL.
FUNDING SUPPORT
Dr. El-Jawahri is supported by funds from the National Cancer Institute Federal Share Program (K12) and the National Palliative Care Research Center (NPCRC CDA). Dr. LeBlanc is supported by funds from the NPCRC. Dr. Temel is supported by funds from K24 CA 181253.
CONFLICT OF INTEREST DISCLOSURES
Dr. LeBlanc reports grants from the NPCRC, grants and personal fees (honoraria, <$5K) from Helsinn Therapeutics, grants from Opus Science, and personal fees from Epi-Q (consultant, <$10K), all outside the submitted work; in addition, he services on the Boehringer-Ingelheim advisory board. Dr. Attar reports personal fees as an employee of Agios outside the submitted work. Dr. Temel reports travel funds and institutional funds to conduct research from Helsinn Therapeutics outside the submitted work.
