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May 13, 2020

In today’s episode, Dr. John Sweetenham, Editor-in-Chief of ASCO Daily News and associate director for Clinical Affairs at the Harold C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center, discusses compelling abstracts on palliative care interventions, disparities, and an innovative home-based medical care service.




ASCO Daily News:  Welcome to the ASCO Daily News Podcast. I'm Geraldine Carroll, a reporter for the ASCO Daily News. I'm delighted to welcome Dr. John Sweetenham to the podcast today to discuss innovative approaches in palliative care, the oncology hospital-at-home concept, and disparities in cancer care that will be featured at the ASCO20 Virtual Scientific Program.


Dr. Sweetenham is editor-in-chief of the ASCO Daily News. He is also Associate Director for Clinical Affairs at the Herald C. Simmons Comprehensive Cancer Center at UT Southwestern Medical Center, and professor in the Department of Internal Medicine. Dr. Sweetenham specializes in treating lymphomas and other hematologic malignancies.


He reports no financial conflicts of interest relevant to this podcast. Dr. Sweetenham worked on Abstract 7000, discussed in this podcast, in an advisory capacity in its early stages. Full disclosures can be found on our episode pages.


Dr. Sweetenham, it's great to have you on the podcast today.


Dr. John Sweetenham: Thanks, Geraldine. I'm very happy to be here.


ASCO Daily News: There are some really interesting studies this year that address bigger picture issues regarding hematologic malignancies and beyond. What are your takeaways from some of these studies?


Dr. John Sweetenham: So I think that there are one or two very interesting takeaways. And a couple of the studies address areas which I think have not really been very extensively investigated in the past. And as one example of that, I'd draw your attention to Abstract number 12000, 12, 0, 0, 0. And this is in the palliative care and symptom management section. And it describes a multi-site randomized trial of integrating palliative and oncology care for the patients with acute myeloid leukemia.


Dr. John Sweetenham: So there's quite a body of literature which suggests that access to palliative care for patients with hematologic malignancies has been not as good as for those with solid tumor. And there have been a number of reasons why that might be. So the various people have hypothesized that this may be related to the number of treatment options of curative intent which are available to patients with hematologic malignancies. Some people have implicated a kind of cultural difference in the hematologist malignancy world to the use of palliative care.


Dr. John Sweetenham: So I think that this was a very interesting study, which took place for patients with acute myeloid leukemia who were receiving intensive induction chemotherapy. It's well known that this is a group of patients who have an extended hospital stay for their induction. They often-- well, always, really, have a pretty significant decline in their quality of life. And they often continue to receive aggressive care at the end of life, when, often, their prognosis is particularly poor.


Dr. John Sweetenham: This was a study conducted in patients with acute myeloid leukemia who were undergoing intensive induction chemotherapy. And the design of the study was such that patients were randomized to be seen by a palliative care clinician right up front, from the beginning of induction, and then at least twice a week during their hospitalization. And that was compared with standard care. And then the patients were assessed for various endpoints, including depression, quality of life, the PTSD checklist, and so on. And the primary endpoints of the study was to assess quality of life at week 2.


Dr. John Sweetenham: Overall, they were able to enroll 160 eligible patients onto the study. What they noted was that, comparing the patients who received the usual care with the intervention group, the intervention group reported a superior quality of life and lower depression, anxiety, and PTSD symptoms. And the intervention effects were sustained for up to 24 weeks for quality of life and also sustained for a similar period of time for depression and anxiety. And among the deceased participants, those who'd received an intervention were more likely to report discussing their end-of-life care preferences with their clinicians.


Dr. John Sweetenham: There was no difference in the hospice utilization or hospitalization at the end of life. But it did demonstrate that an early palliative care intervention appeared to be able to produce significant improvements in the quality of life for these patients, reduce the psychological distress. And when they required end-of-life care, it appeared that they had more easy access to that end-of-life care. So I think that's a very important observation.


Dr. John Sweetenham: A related study, again, exploring a palliative care intervention, was a study number-- excuse me, Abstract number 12001. And this looked in a different context, which was to test the palliative care intervention for patients with solid tumors who are enrolled in phase 1 therapeutic trials.


Dr. John Sweetenham: Again, in many respects, the culture of phase 1 studies is somewhat geared to offering interventions for patients who otherwise may have relatively few treatment options available to them. So the use of palliative care in that situation has not been well explored, although perhaps one might have imagined it would be, given that some of these patients have a relatively limited prognosis.


Dr. John Sweetenham: So this trial, which was a randomized trial, compared patients accrued to phase 1 clinical trials. And it was very similar in design for the previous study in that there was a palliative care intervention versus usual care. And the palliative care intervention included an assessment of quality of life and symptoms, an interdisciplinary meeting to discuss a care plan. And that included goals of care discussion.


Dr. John Sweetenham: A total of 479 subjects were followed for a total of 24 weeks. And the primary endpoints were measured at 12 weeks. And the outcomes of the study demonstrated that, compared with usual care, those patients who'd had a palliative care intervention had less psychological distress, and they had a trend towards improved quality of life, although this did not quite reach statistical significance. They did, however, observe high rates of symptom management admissions and lower rates of the advanced directive completion, and the use of supportive care services, including hospice.


Dr. John Sweetenham: So overall, the patients' satisfaction with oncology care, which was already high at baseline, didn't significantly improve. But there were signals that the use of a palliative care intervention was beneficial in terms of improving quality of life for this group of patients. So I think sometimes overlooked in terms of their kind of supportive needs while they're on phase 1 studies.


Dr. John Sweetenham: Another issue which is addressed in just one of the abstracts which caught my eye is on Abstract number 7555. This is a study which is looking at potential disparities in care. In this case, the patients with myelodysplastic syndrome-- so returning to the hematologic malignancies theme for a moment. Of course, there are many, many examples of disparities in cancer care, which are highlighted throughout the virtual meeting this year, and indeed, have been highlighted at many previous meetings. This one caught my eye in that it explores the potential disparity in the workup of patients with myelodysplasia.


Dr. John Sweetenham: So a complete diagnostic evaluation for MDS includes a bone marrow biopsy. It includes cytogenetic testing, a FISH panel, plus or minus flow cytometry. And these investigations are really generally regarded as being a standard approach to the evaluation of patients with MDS.


Dr. John Sweetenham: The study was based on Medicare data. And the investigators were able to identify a total of 45,000 patients, just over, with MDS, of whom around 70% actually received a complete diagnostic evaluation, including bone marrow biopsy and the relevant to chromosomal studies.


Dr. John Sweetenham: What they found was that the number of patients who actually underwent a complete diagnostic evaluation, which was significantly lower among those that were aged of 85 years or older, which perhaps is not surprising, given that the physicians, the providers would have had an eye to making sure that these patients had a good quality of life. And so to some extent, I think the disparity based on age may have been reasonable.


Dr. John Sweetenham: But disturbingly, they also noticed that the likelihood of having a complete diagnostic evaluation was lower in women. And it was lower in African-American patients.


So in multivariate analysis on this study, advanced age, female sex, black race, and a higher comorbidity burden were all associated with a lower likelihood of receiving a complete diagnostic evaluation.


Some of those are, I think, explicable because of the clinical context of, for example, older patients with poor performance status who may not be felt to be able to withstand some of the more aggressive and intensive therapies for MDS. But the racial disparity disclosed there is concerning, and it's clearly something which needs further investigation.


ASCO Daily News: Dr. Sweetenham, some of the abstracts this year feature new models of care, such as the oncology hospital at home concept. Can you tell us about this abstract?


Dr. John Sweetenham: The other abstract which caught my eye, and for which I must disclose some conflict, is abstract number 7000. I think this is a very interesting abstract because it highlights the importance of a new model of care, which is the concept of an oncology hospital at home.


Dr. John Sweetenham: The disclosure I should make is that this study comes from the Huntsman Cancer Institute at the University of Utah. And I had some involvement in the early stages of this program, so I am familiar with it and think it is a very interesting program.


I think that the relevance is especially high at the moment, when many cancer patients are trying to avoid emergency departments. And indeed, we're doing our best to limit hospital admission and emergency department visits as a result of the COVID-19 pandemic.


Dr. John Sweetenham: This abstract describes a program which began at the University of Utah in 2018. And it's a home-based, acute-level medical care service, which is run predominantly by advanced practice providers and nurses under the directorship of a medical director. And it takes patients with acute issues, either emergent, unstable symptoms, or those with disease progression that would otherwise require an emergency department evaluation, and manages those patients at their own homes.


Dr. John Sweetenham: The study population was compared with a similar group of patients who were matched for condition and were matched for as many factors as possible but lived outside the service zip codes of the patients that were included in the hospital at home program. And the investigators have explored the number of hospitalizations, length of hospital stay, ED visits, and cumulative charges over 30 and over 90 days for the patients who are admitted to the program or not.


Dr. John Sweetenham: The authors report 367 patients, of whom 169 were in the Huntsman at Home group. And 198 were the control group, who received usual care. The patients had an average age of 62 years. 70-plus percent of them had stage IV cancer. And the commonest cancers were colon, gynecologic, prostate, and lung cancers.


Dr. John Sweetenham: Compared to usual care, they noted that there were more female patients in the Huntsman at Home group. Important findings from the study were that the Huntsman at Home patient group was associated with a lower length of stay, 50% lower odds of an unplanned hospitalization, 45% lower odds of an emergency department visit, and 50% lower cumulative charges.


Dr. John Sweetenham: So this is one of the first reports from an adult oncology hospital at home program. And it demonstrates very strong evidence for reduced hospitalizations, fewer ED visits, and lower costs. So I think that this is a very promising model for the future. And it will be very interesting to see if other similar programs develop in the coming years.


ASCO Daily News: Well, thanks very much, Dr. Sweetenham, for sharing some really interesting highlights with us today.


Dr. John Sweetenham: Thank you very much for the opportunity, Geraldine.


ASCO Daily News: And thank you to our listeners for joining us. If you're enjoying the content on the podcast, please rate and review us on Apple Podcasts.


Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.


COI Disclosure: 

Dr. John Sweetenham

Honoraria: Seattle Genetics