In Canada, investigators have been evaluating a shared-care model for acute myeloid leukemia (AML) post-consolidation supportive therapy. The collaborative program permits patients to visit local centers, thus avoiding prolonged hospitalization or long commutes for care. Samantha Hershenfeld from the Princess Margaret Cancer Centre in Ontario who presented this research at the 2015 ASH Meeting on Hematologic Malignancies, told ASH Clinical News that the center “is very gung ho about this model.”
“AML usually requires intensive induction and consolidation chemotherapy. What our group and others have shown in the past is that you can actually deliver that consolidation care on an outpatient basis at quaternary centers,” Ms. Hershenfeld said. “On the flipside, that also requires patients to travel often very long distances back and forth for frequent treatments at the hospital.”
To help solve this problem and reduce travel burden for patients with AML, clinicians at Princess Margaret Cancer Centre developed a shared-care model in which patients receive their consolidation chemotherapy for AML at the specialized quaternary care center, but receive post-consolidation supportive care (including blood checks, transfusions, and treatment for febrile neutropenia) at their local hospitals.
Between 2009 and 2013, 73 patients with AML (n=61,) or acute promyelocytic leukemia (APL) (n=12) who had received induction and consolidation therapy at a quaternary care center (Princess Margaret) were treated under the shared-care model, receiving post-consolidation care after first complete remission at one of 14 local centers.
These 14 centers were regional cancer centers staffed by oncologists and/or hematologists experienced in the management of cytopenias and febrile neutropenia, but which did not provide induction or consolidation chemotherapy for AML.
Patients were seen at least weekly as outpatients at these hospitals while recovering from their consolidation chemotherapy. Centers were located a median of 70 km (range = 36-190 km) from the quaternary center. Each local center treated a median of two patients (range = 1-19 patients) during the time frame evaluated.
“In terms of demographics, the [shared-care] group was actually no different in age, gender, and cytogenetic prognosis than those who received all their care at our center,” Ms. Hershenfeld noted. Patients receiving shared-care had a median age of 57 years (range: 21.7-78.6) and 40 (54.8%) were male. Seven (9.6%) had favorable, 42 (57.5%) had intermediate, six (8.2%) had poor, and 18 (24.7%) had indeterminate cytogenetic profiles.
Patients in the shared-care model travelled a mean distance of 99.5 ± 57.8 km (median = 87.8; range = 28.4-266 km) each way to the quaternary care center, compared with 26.3 ± 33.6 km (median = 14.5; range = 0.55-211 km) each way to their local treatment center (p <0.001 for difference).
The estimated mean travel time was also reduced (p<0.001 for difference):
- Travel time from home to the quaternary center was 71.6 ± 38 minutes (median = 62; range = 29-170)
- Travel time from home to their local center was 23.3 ± 21.9 minutes (median = 18; range = 2-137)
By receiving post-consolidation care locally, then, patients were able to save 146.5 ± 99.6 km in round-trip distance and 96.7 ± 63.4 minutes of round-trip travel time, per visit, compared with travelling to the quaternary care center.
Patients in the shared-care model had similar rates of overall survival to those who received all of their care at Princess Margaret (p>0.05). Thirty-, 60-, and 90-day survival from the start of consolidation chemotherapy was: 98.6, 97.2, and 95.9 percent (shared-care model) and 98.8, 97.1, and 95.3 percent (quaternary center).
“Multivariate Cox proportional hazards models revealed no significant increase in hazard of death for the shared-care patients compared to control when controlling for age, gender, AML versus APL, and cytogenetic prognosis (p>0.05),” Dr. Hershenfeld and her co-authors wrote.
Though the shared-care model “is still in its infancy, it does work,” Ms. Hershenfeld said. “The results are encouraging to be able to expand this model at more centers across the country.”
Hershenfeld SA, Maki K, Rothfels L, et al. Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising safety and efficacy. Abstract #27. Presented at the 2015 ASH Annual Meeting on Hematologic Malignancies; September 19, 2015; Chicago, IL.