Novel Home-Based Transfusion Model of Palliative Care in Malignant Hematology

Background: Patients with hematologic malignancies often receive aggressive care at the end of life (EOL) and utilize hospice services less frequently than patients with solid tumors¹. Hospice utilization rates are low, and patients enroll late in the disease, spending an average of 3 days on hospice², thereby limiting the potential benefit of hospice care^1,3. Access to transfusions has been identified as a major barrier to hospice enrollment in hematologic malignancies despite representing an important strategy that can help improve quality of life (QOL) and symptoms for these individuals^4,5. Therefore, we hypothesized that the creation of a home-based transfusion system that allows patients to receive blood and platelet transfusions while enrolled in hospice would improve their QOL and symptom burden. Furthermore, we created a program with symptom-based triggers for transfusion, rather than the standard transfusion practices with complete blood count (CBC) triggers. In this interim analysis of our novel home-based transfusion pilot study, we sought to investigate feasibility, transfusion reaction incidence, QOL and symptom improvement, and hospice outcomes.

Methods: Patients enrolled in hospice and participated in the home-based transfusion system from 8/17/2020 to 2/16/2022 (n=12 out of a planned 20). Eligibility criteria included: age ≥18 years, primary hematologic malignancy, transfusion dependence and an absence of previous blood transfusion reactions or difficulty with blood typing. Evaluable patients received one unit of packed red blood cells (RBCs) and/or platelet transfusions weekly based on trigger symptoms (Common Terminology Criteria for Adverse Events [CTCAE] defined grade 2+ symptoms secondary to anemia and/or thrombocytopenia) continued until unacceptable toxicities or death. Patients were assessed by study personnel via a phone call at the start of every week. All patients who received transfusions, received follow-up phone calls 48-72 hours after transfusion to assess for post-transfusion reactions, symptoms, and QOL via the EORTC QLQ C30 questionnaire.

The primary end point was feasibility of home based transfusion system with secondary endpoints assessing QOL and symptoms, transfusion rate and reaction incidence, length of time on hospice, incidence of revocation of hospice, hospitalization while on hospice and site of death. Weekly CBC data was collected throughout the course of this study and CBC data was blinded to the study personnel until study completion.

Results: 12 patients were enrolled. Median patient age was 66 (range 31-83) years. Patients’ diseases included Acute Myeloid Leukemia (9 [75%]), Non-Hodgkin Lymphoma (2 [16.7%]), and Myelodysplastic Syndrome (1 [8.3%]). The average number of transfusions per patient was 2.91 (n=11) with no reported transfusion reactions. The average number of reported grade 2+ symptoms decreased from 2.93 to 1.97, pre- and post-infusion respectively. Patients reported that pre-transfusion dyspnea and fatigue were the most common symptoms, both of which improved after transfusions by 55% (patients reported dyspnea 66.67% of the time pre-transfusion vs 30% post transfusion) and 22% (patients reported fatigue 90% of the time pre-transfusion and 70% post transfusion), respectively. Median time on hospice was 11.5 days. The mean number of transfusions per patient while on hospice was 2.67 (n=11) packed RBCs and 1.50 (n=10) platelets. The mean EORTC QOL score pre-transfusion was 50.49 and post transfusion 51.95 with a mean difference of 1.46. There was one hospitalization (for fever and severe thrombocytopenia), no ICU admissions and no hospice revocations. All 12 patients died at home.

Conclusion: In this interim analysis, we described the potential feasibility of a novel home-based transfusion system, with high enrollment rates and no transfusion reactions. Notably, the number of transfusions required was quite small, and we found that patients’ most common symptoms improved following transfusion. In our small pilot study, the time on hospice increased from a standard 3 days to 11.5 days. No transfusion reactions were noted, and transfusions improved QOL. Future work is needed in a larger demonstration project to evaluate if home-based transfusion system could improve hospice utilization and quality of hospice care in patients with hematologic malignancies.

Asch:Gilead Sciences: Research Funding. Ibrahimi:KARYOPHARM THERAPUTICS: Divested equity in a private or publicly-traded company in the past 24 months.