Updates from the annual ASH meeting, December 2018.
Surabhi Dangi-Garimella, PhD
“Placing patients in the contextÂ of his or her familyâ€ť and â€ścaring for the livingâ€ť were how palliative care was defined by one of the speakers participating in the Special Symposium on Quality at the 60th American Society of Hematology Annual Meeting & Exposition, held December 1-4, 2018, in San Diego, California. The speakers were tasked with reviewing the difference in the quality of symptom management, palliative care, and end-of-life (EOL) care delivered to patients with blood cancer and patients with other life-threatening illnesses.
Integrated palliative care, which combines care coordination for comorbidities, behavioral health issues, and EOL care, was proved to lend both symptom control and psychosocial support.1 However, these services are not always readily accessible to patients, especially in rural areas and among populations with sparse access to medical care. Organizations like Project ECHO (Extension for Community Health Outcomes) are working to fill this gap.2
Additionally, controversy persists on whether patients with liquid cancers receive appropriate symptom management or whether they receive higher-intensity care, such as chemotherapy in the few weeks prior to death or a low hospice referral. Questions have also been raised over measuring the quality of symptom management and palliative care.
Palliative care is traditionally defined as â€śinterdisciplinary care focused on improving the quality of life for persons of any age who are living with any serious illness, and for their families,â€ť said Anthony Oâ€™Brien, MB, FRCPI, medical director of Marymount Hospice and consultant physician in palliative medicine at Cork University Hospital, Ireland, who was the first presenter.
Quality-of-life (QOL) is multifaceted and dynamic and changes over time. The traditional definition embraces patients of all ages and places the patient in the context of his or her family, Oâ€™Brien said.
Oâ€™Brien shared the clinical practice guidelines for quality palliative care, which he said are focused on life rather than death. The guidelines are:
â€śThis is not a sequential approach, rather an integrated/concurrent model of care, alongside potentially curative treatmentâ€ť that the patient is receiving, he added, defining palliative care as caring for the living rather than caring for a bodily organ, age, or lack of response to treatment.
â€śBeyond evidence-based medicine, palliative care is a model of interpersonal medicine that is effective and has narrative competence, where we try to understand the patientâ€™s narrative,â€ť Oâ€™Brien said. Pointing out that several organizations, including the American Society of Clinical Oncology, are committed to integrating palliative care in the main frame of healthcare systems, he added that such integration is extremely beneficial to patients within the context of their QOL, mood, satisfaction with care, symptom burden, and â€śsometimes survival.â€ť
Oâ€™Brien concluded his talk by highlighting the discomfort of treating physicians in broaching this discussion, as was documented by a study that interviewed hematologists on the topic.3 The authors found that despite the positive attitude toward palliative care, barriers included difficulty with defining the role of specialist palliative care services, which resulted in referral timing being determined by their personal confidence in providing EOL care. Additionally, the participating physicians indicated the lack of an inpatient palliative care unit as a barrier to offering palliative care to their patients. Oâ€™Brien firmly believes that families must plan for dying the same way they plan for the birth of a child, and he is a strong proponent of a frank dialogue between physicians and patients.
When it comes to measuring the quality of palliative services, however, Kelly Marie Trevino, PhD, assistant attending psychol- ogist at Memorial Sloan Kettering Cancer Center, wondered whether existing measures are meaningful and sufficient to fulfill patient needs. Trevino believes that quality measures can be used to evaluate the processes being implemented throughout the administration of care, not just toward EOL.
Although the National Quality Forumâ€™s focus for quality of palliative care includes safety, benefit, equity, timeliness, patient-cen- teredness, and efficiency of care, Trevino listed the measures that care providers currently use:
Providing an update on where the field currently stands, Trevino said that some of the existing quality measures are acceptable, but gaps persist. She particularly pointed out gaps in EOL care measures and the importance of patient-reported outcomes in this process, which she said are often underutilized in healthcare.
â€śThere is inadequate attention to the disease trajectory as well. So, integration of palliative care from the beginning of treatment to EOL is important.â€ť
Treating R/R CLL With Ibrutinib Alongside CAR T-Cell Therapy Reduces Toxicity, Findings Show
Patients with relapsed orÂ refractory (R/R) chronic lymphocytic leukemia (CLL) may have a new treatment option with chimeric antigen receptor (CAR) T-cell therapy, and for patients who have already been treated with ibrutinib, continuing the targeted therapy may decrease cytokine release syndrome (CRS), based on results presented at the 60th American Society of Hematology Annual Meeting & Exposition, December 1-4, 2018, in San Diego, California.
Researchers led by Jordan Gauthier, MD, treated a total of 43 patients, starting with 24 patients with CLL were treated with ibrutinib until their condition worsened and the targeted therapy was stopped. These patients were then treated with JCAR014, a CAR T-cell therapy being developed by Juno Therapeutics.
Then, the research team treated a second cohort of 19 patients with ibrutinib; this group was similar in age and level of disease as the first group. The second cohort started ibrutinib and stayed on it during CAR T-cell therapy and for 3 months afterward.
Gauthier and his colleagues reported the following results:
The authors said results must be confirmed in a larger study, but they expressed optimism with the findings. â€śTo our knowledge, these are the most encouraging results that have been seen to date in humans with a combination of CAR T cells and a targeted agent,â€ť Gauthier said in a press briefing.2 â€śWhile the CAR T cells expanded robustly in both groups and led to high rates of response, we did not observe a single case of severe CRS in patients receiving ibrutinib during CAR T therapy.â€ť
Teens, Young Adults With Public Insurance Linked to Worse Outcomes in Leukemia, Lymphoma
Adolescents and young adultsÂ (AYAs), defined as those 15 to 39 years of age, have not seen the same improvement in cancer survival as other age groups in recent decades. In addition, being uninsured or on public insurance, such as Medicaid, has been associated with worse overall survival than having commercial insurance.
Authors from the University of California, Davis, presented a study at the 60th American Society of Hematology Meeting & Exposition, held in San Diego, California, linking Medicaid to the California Cancer Registry to take a fresh look at these interrelated issues The research team identified AYAs diagnosed with non-Hodgkin lymphoma (NHL), Hodgkin lymphoma, (HL) acute lymphocytic lymphoma (ALL), and acute myeloid lymphoma (AML) between 2005 and 2014. These patients were classified by what type of insurance they had, including whether they had Medicaid at diagnosis or whether they were not in Medicaid and had to enroll after their received their diagnosis.
Of the 11,667 patients in the study, 4435 had NHL, 4161 had HL, 1549 had ALL, and 1522 had AML. Private insurance was most common among those with HL (66%) and NHL (60%), followed by AML (50%) and ALL (37%). Of the participants, 4059 had Medicaid, including 41% of this group who had been enrolled continuously, 43% who were enrolled upon diagnosis, and 15% who were not enrolled continuously throughout treatment. According to the authors, only 2% to 4% of patients, depending on diagnosis, remained uninsured.