Palliative Care Shortcomings for Patients With Hematologic Malignancies Addressed in New Review

Patients with hematologic malignancies (HMs) encounter barriers to early palliative care (EPC) despite this care type being known to significantly improve quality of life (QOL) for those with advanced cancer. A review published in The British Journal of Haematology provides insight into recent research on EPC in HMs and potential models to facilitate integration of EPC for patients with HMs.

Patients with solid tumors often have EPC integrated into their disease management, but patients with HMs are often referred later in the course of their disease. This is despite patients with HMs having similar symptom burdens and psychosocial distress to patients with solid tumors, the review authors note.

“Patients with HMs could benefit greatly from the interdisciplinary approach offered by PC, which is focused on improving symptoms, communication, shared decision making, psychosocial support, community care resources, advance care planning, and caregiver support,” the authors wrote. “Moreover, there is emerging evidence that supports early specialized PC in HM.”

The authors highlight a conceptual model that stratifies PC into 3 categories: primary, secondary, and tertiary. Primary PC, which entails practices to relieve pain, nausea, and mood disorders, is handled by primary care clinicians who are well versed in PC. Hospitals and specialists provide secondary PC, which oncologists should all be knowledgeable about. PC consultants provide tertiary PC, which is more specialized and helps manage refractory symptoms, severe psychosocial issues, and family conflicts, for example.

HMs can have less predictable disease tracks than solid tumors, but the review separates them into 3 main risk groups based on disease trajectory, care settings, and PC delivery challenges: aggressive HMs, indolent HMs, and HMs with bone marrow failure that rely on blood transfusions.

Aggressive HMs, such as acute leukemias, aggressive lymphomas, or graft-versus-host disease after stem cell transplantation, are difficult to prognosticate and carry a possibility of curative treatment until just days before death. The courses of such diseases can have a roller-coaster effect and lead to patient and provider uncertainty.

Indolent HMs, like chronic lymphocytic leukemia (CLL), indolent lymphomas, and multiple myeloma in many cases, are incurable but may face prolonged prognosis and multiple relapses. With novel drug options evolving, patients with advanced disease may achieve remissions, but prognostication is difficult.

The third group includes myelodysplastic syndromes, myelofibrosis, aplastic anemia, and end-stage HMs with bone marrow disease infiltration or aplasia after treatment. Patients with severe anemia rely on blood transfusions to relieve a host of symptoms, including fatigue, shortness of breath, and chest pain. With chronic bone marrow failure can come severe neutropenia and subsequent bacterial and fungal infections.

Despite the extensive and often overwhelming symptoms of HMs, these patients are not sufficiently referred to PC. In addition, although psychological distress is a significant symptom considering the potentially roller-coaster–like disease courses, few are referred to psychologists. All solid tumor oncologists reported referring patients to PC in one study, while only 30% of hemato-oncologists had referred patients to PC. For patients with HMs, PC is often only discussed when death is imminent, and they are less likely to have been prescribed opioids for pain management at hospice care initiation. This suggests symptom management may be inadequate compared with patients with solid tumors.

The barriers to integration of PC in patients with HM include prognostication difficulties, differing attitudes toward PC in hemato-oncology vs other specialties, and hospice criteria that can limit access to therapies that may benefit QOL for patients with HMs.

Randomized controlled trials have demonstrated benefits of EPC in solid tumors, but data on EPC from randomized trials in HMs is only just emerging. Solid tumor studies have also been conducted in inpatient and outpatient settings, while studies in HMs have been conducted nearly exclusively in the inpatient setting. In the inpatient setting, EPC effectively reduced anxiety and improved QOL for patients with HM in one study, which also showed benefits for caregivers. More trials are underway to confirm the benefits of EPC for patients with HMs. Trials of PC in the outpatient setting for multiple myeloma and trials of blood transfusions in hospice settings may provide better options for patients with indolent HMs and HMs with bone marrow failure.

Further research is also needed on models of referral to tertiary PC, which can be based on physician judgment or automated. Clinician referral is currently most common, but as discussed, referral is not typically adequate for patients with HMs compared with patients with solid tumors. Better training for oncologists who provide secondary PC services could also improve patient experiences.

“As the understanding of the biology of HMs and targeted treatments continue to progress, HM patients will continue to face challenges in maintaining QOL and in making treatment decisions in the context of prognostic uncertainty,” the authors concluded. “With its interdisciplinary and holistic approach, PC has much to offer these patients. Increased understanding of PC by haemato-oncologists as well as improved models for integration of tertiary PC will open the door to improved quality of care for this underserved population.”

Reference

Shaulov A, Aviv A, Alcalde J, Zimmermann C. Early integration of palliative care for patients with haematological malignancies. Br J Haematol. Published online June 7, 2022. doi:10.1111/bjh.18286