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Acute myeloid leukemia

Early hospital discharge after intensive induction chemotherapy for adults with acute myeloid leukemia or other high-grade myeloid neoplasm

Leukemia volume 34, pages 635–639 (2020)Cite this article

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Adults typically remain hospitalized after intensive AML-like induction chemotherapy until cytopenias resolve [1, 2]. With declining early death rates [3,4,5], interest in outpatient care immediately after the completion of chemotherapy increases (for review, see [1, 2]) although small early studies reported varying levels of success with this care strategy [6,7,8,9,10,11]. Building on a pilot study of discharging patients within 72 h of completing AML-like (re-)induction chemotherapy (“early hospital discharge” [EHD]) [12], we conducted a phase 2 study in which we examined 107 EHD and 29 medically matched inpatient control patients [13]. While almost 90% of the EHD patients required hospital readmission, early mortality was similar to control patients and costs substantially lower [13]. With this, EHD following AML-like induction chemotherapy has become routine at our institution. Here, we analyzed our EHD experience over the 4-year period since completing the phase 2 trial.

We identified all adults ≥18 years with non-APL AML or other high-grade myeloid neoplasms (≥10% blasts in blood and/or marrow) who received a first cycle of “7 + 3” or a regimen of similar or higher intensity in the hospital. Patients were allocated to the EHD group if discharged within 72 h of completing chemotherapy [12, 13]. The study (“at risk”) period started on the day of initial hospital discharge (for EHD patients) or on the day chemotherapy finished (for control patients). It ended with the earliest of: recovery of absolute neutrophil count ≥500/µL and self-sustained platelet count of ≥20,000/µL [12, 13]; hospital discharge (control patients only); receipt of additional AML-directed chemotherapy; transition to comfort care; initiation of pre-transplant work-up; once 42 days had elapsed, or death. For EHD patients, medical resource utilization calculations excluded the day of initial hospital discharge since patients may have received additional transfusions while still hospitalized. For control patients, these calculations excluded the day chemotherapy ended and, if applicable, the day of hospital discharge. Chemotherapy regimens were categorized as “standard-intensity” (“7 + 3” or “7 + 3”-like therapy) and “high-intensity” (containing cytarabine doses of >1 gram/m2) regimens. Characteristics of EHD patients and inpatient controls were compared with Fisher’s exact and Wilcoxon–Mann–Whitney tests. Outcome analyses accounted for days on study. Linear and logistic regression models were used to evaluate prognostic variables for the proportion of time spent as an inpatient after discharge, hospital readmission, and early death (death within 30 days). Overall survival (measured from study start date) was estimated with the Kaplan–Meier method and compared using log-rank tests. This retrospective analysis was approved by the Fred Hutchinson Cancer Research Center Institutional Review Board.

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References

  1. Walter RB, Taylor LR, Gardner KM, Dorcy KS, Vaughn JE, Estey EH. Outpatient management following intensive induction or salvage chemotherapy for acute myeloid leukemia. Clin Adv Hematol Oncol. 2013;11:571–7.

    PubMed  PubMed Central  Google Scholar 

  2. Vaughn JE, Buckley SA, Walter RB. Outpatient care of patients with acute myeloid leukemia: benefits, barriers, and future considerations. Leuk Res. 2016;45:53–8.

    Article  Google Scholar 

  3. Othus M, Kantarjian H, Petersdorf S, Ravandi F, Godwin J, Cortes J, et al. Declining rates of treatment-related mortality in patients with newly diagnosed AML given ‘intense’ induction regimens: a report from SWOG and MD Anderson. Leukemia. 2014;28:289–92.

    Article  CAS  Google Scholar 

  4. Percival ME, Tao L, Medeiros BC, Clarke CA. Improvements in the early death rate among 9380 patients with acute myeloid leukemia after initial therapy: a SEER database analysis. Cancer. 2015;121:2004–12.

    Article  Google Scholar 

  5. Halpern AB, Culakova E, Walter RB, Lyman GH. Association of risk factors, mortality, and care costs of adults with acute myeloid leukemia with admission to the intensive care unit. JAMA Oncol. 2017;3:374–81.

    Article  Google Scholar 

  6. Ruiz-Argüelles GJ, Apreza-Molina MG, Alemán-Hoey DD, Gómez-Almaguer D, Marín-López A, Mercado-Díaz L. Outpatient supportive therapy after induction to remission therapy in adult acute myelogenous leukaemia (AML) is feasible: a multicentre study. Eur J Haematol. 1995;54:18–20.

    PubMed  Google Scholar 

  7. Gillis S, Dann EJ, Rund D. Selective discharge of patients with acute myeloid leukemia during chemotherapy-induced neutropenia. Am J Hematol. 1996;51:26–31.

    Article  CAS  Google Scholar 

  8. Allan DS, Buckstein R, Imrie KR. Outpatient supportive care following chemotherapy for acute myeloblastic leukemia. Leuk Lymphoma. 2001;42:339–46.

    Article  CAS  Google Scholar 

  9. Savoie ML, Nevil TJ, Song KW, Forrest DL, Hogge DE, Nantel SH, et al. Shifting to outpatient management of acute myeloid leukemia: a prospective experience. Ann Oncol. 2006;17:763–8.

    Article  CAS  Google Scholar 

  10. Halim TY, Song KW, Barnett MJ, Forrest DL, Hogge DE, Nantel SH, et al. Positive impact of selective outpatient management of high-risk acute myelogenous leukemia on the incidence of septicemia. Ann Oncol. 2007;18:1246–52.

    Article  CAS  Google Scholar 

  11. Møller T, Nielsen OJ, Welinder P, Dünweber A, Hjerming M, Moser C, et al. Safe and feasible outpatient treatment following induction and consolidation chemotherapy for patients with acute leukaemia. Eur J Haematol. 2010;84:316–22.

    Article  Google Scholar 

  12. Walter RB, Lee SJ, Gardner KM, Chai X, Shannon-Dorcy K, Appelbaum FR, et al. Outpatient management following intensive induction chemotherapy for myelodysplastic syndromes and acute myeloid leukemia: a pilot study. Haematologica. 2011;96:914–7.

    Article  CAS  Google Scholar 

  13. Vaughn JE, Othus M, Powell MA, Gardner KM, Rizzuto DL, Hendrie PC, et al. Resource utilization and safety of outpatient management following intensive induction or salvage chemotherapy for acute myeloid leukemia or myelodysplastic syndrome: a nonrandomized clinical comparative analysis. JAMA Oncol. 2015;1:1120–7.

    Article  Google Scholar 

  14. Walter RB, Othus M, Borthakur G, Ravandi F, Cortes JE, Pierce SA, et al. Prediction of early death after induction therapy for newly diagnosed acute myeloid leukemia with pretreatment risk scores: a novel paradigm for treatment assignment. J Clin Oncol. 2011;29:4417–23.

    Article  Google Scholar 

  15. Döhner H, Estey EH, Amadori S, Appelbaum FR, Büchner T, Burnett AK, et al. Diagnosis and managementof acute myeloid leukemia in adults: recommendations from an international expert panel, on behalf of teh European Leukemia. Net. Blood. 2010;115:453–74.

    Article  Google Scholar 

Download references

Acknowledgements

Research reported in this publication was supported by a Sponsored Research Agreement with Pfizer, Inc. and a Department of Medicine/University of Washington Quality and Safety Accelerator Grant (both to RBW). The study sponsors played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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Authors and Affiliations

  1. Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA

    Anna B. Halpern, Paul C. Hendrie, Mary-Elizabeth M. Percival, Pamela S. Becker, Vivian G. Oehler, Terry B. Gernsheimer, Siobán B. Keel, Ryan D. Cassaday, Andrei R. Shustov, Elihu H. Estey & Roland B. Walter

  2. Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Anna B. Halpern, Nicholas P. Howard, Sarah A. Buckley, Mary-Elizabeth M. Percival, Pamela S. Becker, Bart L. Scott, Vivian G. Oehler, Terry B. Gernsheimer, Johnnie J. Orozco, Ryan D. Cassaday, Andrei R. Shustov, Elihu H. Estey & Roland B. Walter

  3. Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

    Megan Othus

  4. Department of Medicine, Residency Program, University of Washington, Seattle, WA, USA

    Nikita V. Baclig

  5. Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA

    Bart L. Scott & Johnnie J. Orozco

  6. Pfizer Inc., New York, NY, USA

    Garrett A. Hartley & Verna L. Welch

  7. Department of Pathology, University of Washington, Seattle, WA, USA

    Roland B. Walter

  8. Department of Epidemiology, University of Washington, Seattle, WA, USA

    Roland B. Walter

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  1. Anna B. Halpern
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  2. Nicholas P. Howard
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Correspondence to Roland B. Walter.

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Halpern, A.B., Howard, N.P., Othus, M. et al. Early hospital discharge after intensive induction chemotherapy for adults with acute myeloid leukemia or other high-grade myeloid neoplasm. Leukemia 34, 635–639 (2020). https://doi.org/10.1038/s41375-019-0586-6

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