Abstract
Background: Randomized trials demonstrate that patients with AML hospitalized for intensive chemotherapy benefit significantly from early integrated palliative care (PC), yielding improvements in quality of life (QOL) and end of life (EOL) care (El-Jawahri, JAMA Onc 2021). A second trial examining PC involvement in patients with AML/MDS on non-intensive chemotherapy demonstrated similar outcomes, notably yielding reduced EOL hospitalization and improved QOL (El-Jawahri, Blood 2024). However, PC utilization rates are largely unknown in the context of real-world use of low-intensity regimens. We examined PC utilization in AML patients receiveing venetoclax-based treatment at our center.
Methods: We identified patients diagnosed with AML between 2018-2023 treated with venetoclax-based therapy in the first line setting. Chart abstractions were completed for 160 patients, and data cut off was May 1st, 2025. We investigated the impact of PC on EOL care and PC utilization. Aggressive EOL care was defined as cancer-directed therapy within the last 14 days of life; >1 ED visit or >1 hospital admission within the last 30 days of life; hospice entry within the last 3 days of lifeor no hospice use at all; or in-hospital death. Chi-squared test or unpaired-samples t-test with descriptive statistics mean and standard deviation were used to describe differences, with a statistical significance threshold of p<0.05.
Results:
Impact of PC on EOL care
PC involvement was associated with higher rates of hospice enrollment (66% vs 44% did not receive hospice, p<0.01) and of out of hospital or inpatient hospice death (57% vs 41% passed away in-hospital, p=0.19). Patients with PC received similar amounts of aggressive EOL care (77%) compared to patients without PC (79%) (p=0.73). Time spent on hospice was similar between patients who received PC (M=11 days, SD=20.7) and those not receiving PC (M=10.2 days, SD=10.8) (p=0.84). The time from diagnosis to death was similar between patients who received PC (8 months) and those not receiving PC (9.1 months).
PC utilization
Patients diagnosed after 2021 received less PC (31%) compared to those diagnosed before 2021 (58%) (p<0.001). Male patients received less PC (35%) than female patients (48%) (p=0.10). Those identifying as African American had less PC involvement (33%) compared to patients identifying as White (40%) (p=0.52). Patients with Medicaid or Commercial based insurance at diagnosis received less PC (35-41%) compared to those with Medicare or Military based coverage (50%) (p=0.79). Patients with worse performance status at diagnosis (ECOG 2+) received less PC (40%) than patients with ECOG 1 (47%), but more than patients with ECOG 0 (29%) (p=0.57).
Patients with AML-MRC received less PC (32%) than patients with de novo AML (46%) or t-AML (48%) (p=0.17). Those with poor or no response to treatment received less PC (47%) than patients who achieved morphological leukemia free state (66%) or partial response (50%). Patients with CR (defined as CR, CRi, or CRh) received the least amount of PC (34%).
Conclusions:
These findings suggest disparate trends in receipt of PC services by gender, race, and insurance status, as well as according to disease-related characteristics (ECOG score and AML type). Surprisingly, patients with poor or no response to induction therapy did not have an increase in PC utilization, and PC utilization decreased after 2021, when the pivotal trial of PC as part of standard AML intensive induction care was completed at our site. For patients who received PC, there was an increase in hospice enrollment and out of hospital/inpatient hospice death, in alignment with improved EOL care. However, the similar rates of aggressive EOL care regardless of PC involvement highlights areas of persistent unmet need to improve EOL care quality. Some results may be confounded by clinical presentation of disease and patient performance status.
Ongoing attention is needed to continue addressing disparities in PC access to improve EOL care quality, in alignment with patient and family preferences. The significant increase in use of venetoclax-based regimens in AML care calls for further examination of the role and impact of PC involvement in improving care and outcomes.
