Innovation in oncology care management: exploring a novel treatment model for outpatient leukemia induction chemotherapy

The initiation of intense induction chemotherapy for patients with Acute Myeloid Leukemia (AML) has traditionally required long inpatient admissions. These hospitalizations – lasting four to five weeks on average – have been accepted as the standard of care given the need for management of treatment-related cytopenia and the associated infectious and bleeding risks. However, prolonged hospital stays are resource- and cost-intensive, accounting for over 75% of health care costs incurred by the average AML patient annually1. Additionally, prolonged hospitalizations may lead to impaired quality of life for affected patients given the fatigue and deconditioning that can be associated with inpatient admissions2.

Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Standard care A treatment or other intervention currently being used and considered to be of proven effectiveness based on past studies.
Anna B. Halpern, MD
Anna B. Halpern, MD

The industry leading oncology experts at the Seattle Cancer Care Alliance (SCCA) have developed a new outpatient induction and consolidation care pathway in AML. This High Intensity Treatment Team (HITT) model has leveraged improvements in healthcare delivery – including more effective oral antimicrobials, longer infusion center hours, accessibility to home infusion support, and approval of new AML drugs – towards an induction therapy program that is based primarily in the outpatient setting. Notably, this model involved a careful restructuring of SCCA care teams to provide patients with the right amount of support during different phases of treatment.

This transition away from predominantly inpatient care models was informed by innovative research studies performed by investigators at the Seattle Cancer Care Alliance on early hospital discharge following intensive induction chemotherapy. One such study – Led by Anna Halpern, MD, Assistant Professor of Hematology at the University of Washington School of Medicine – contrasted outcomes following early hospital discharge (less than 72 hours after completion of the first cycle of chemotherapy) with outcomes after longer hospitalizations in a population patients with newly diagnosed non-acute promyelocytic leukemia AML (non-APL AML) or other high-grade myeloid neoplasms3. 375 patients were included in the analysis including 236 early hospital discharge patients (EHD) and 139 patients who were admitted for greater than 72 hours after completing the first cycle of chemotherapy (controls).

The study manuscript published in the journal Leukemia highlights no difference in early death rate or number of days spent in the ICU for clinically matched populations of EHD and control patients. Although most EHD patients required at least 1 readmission during the study dates, the median time to first readmission was 8 days and EHD patients spent an average of 71% of their study time outside the hospital.

SCCA has a long history of innovation in outpatient coordination of oncology care, as clinicians at the center were pioneers in providing patients with outpatient care following moderately intensive treatments such as autologous stem cell transplant or reduced-intensity allogeneic stem cell transplant. Translating these innovations to the care of patients with AML and other high grade myeloid neoplasms has thus been a natural progression.

In the new SCCA HITT model for AML and MDS, three high intensity teams were created to care for patients during their most acute phase of care. Each high intensity team manages 25-30 patients at a time including performing at least 3 provider visits per patient every week. A standard support team takes over management of patients after they have completed their intense induction or consolidation regimens, when patients need fewer transfusions and less frequent follow up for symptom management.

This HITT model is poised to confer many long-term benefits for patients and the health system including:

  • Provision of higher quality care with standardization of treatment
  • Easier transition to allogeneic hematopoietic cell transplantation through collaborative and coordinated care
  • Sustained continuity of care through the multidisciplinary team
  • Less inpatient care leading to improved quality of life for the patients

Citations

  1. Meyers J, Yu Y, Kaye JA, Davis KL. Medicare fee-for-service enrollees with primary acute myeloid leukemia: an analysis of treatment patterns, survival, and healthcare resource utilization and costs. Appl Health Econ Health Policy. 2013 Jun;11(3):275-86. Doi: 10.1007/s40258-013-0032-2. PMID: 23677706.
  2. Halpern AB, Walter RB, Estey EH. Outpatient induction and consolidation care strategies in acute myeloid leukemia. Curr Opin Hematol. 2019 Mar;26(2):65-70. Doi: 10.1097/MOH.0000000000000481. PMID: 30585894.
  3. Halpern AB, Howard NP, Othus M, Hendrie PC, Baclig NV, Buckley SA, Percival MM, Becker PS, Scott BL, Oehler VG, Gernsheimer TB, Keel SB, Orozco JJ, Cassaday RD, Shustov AR, Hartley GA, Welch VL, Estey EH, Walter RB. Early hospital discharge after intensive induction chemotherapy for adults with acute myeloid leukemia or other high-grade myeloid neoplasm. Leukemia. 2020 Feb;34(2):635-639. doi: 10.1038/s41375-019-0586-6. Epub 2019 Oct 4. PMID: 31586148.
Allogeneic stem cell transplant Uses bone marrow or stem cells from a related or unrelated donor whose tissue type closely matches the patient’s. Replaces blood-forming cells that have been destroyed by disease or cancer treatment. Uses bone marrow or stem cells from a donor whose tissue type closely matches the patient’s to replace blood-forming cells that have been destroyed by disease or cancer treatment. This can be from a related or unrelated donor. Bone marrow transplant The process of treating disease with high doses of chemotherapy, radiation therapy or both. Bone marrow or peripheral blood stem cells are given after treatment to help the body make more blood cells. The process of treating disease with high doses of chemotherapy, radiation therapy or both. Because this treatment destroys the bone marrow’s ability to produce blood cells, bone marrow or peripheral blood stem cells are given after treatment to help the body make more blood cells. Chemotherapy Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. It may be given alone or with other treatments. Treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Chemotherapy may be given by mouth, injection, infusion or on the skin, depending on the type and stage of the cancer being treated. It may be given alone or with other treatments, such as surgery, radiation therapy or biologic therapy. Grade In cancer, a grade is a description of a tumor based on how abnormal the cancer cells and tissue look under a microscope and how quickly the cancer cells are likely to grow and spread. In cancer, a grade is a description of a tumor based on how abnormal the cancer cells and tissue look under a microscope and how quickly the cancer cells are likely to grow and spread. Low-grade cancer cells look more like normal cells and tend to grow and spread more slowly than high-grade cancer cells. Grading systems are different for each type of cancer. They are used to help plan treatment and determine prognosis. Also called histologic grade and tumor grade. Infusion An injection of medications or fluids into a vein over a period of time. Nurse practitioner A registered nurse who has additional education and training in how to diagnose and treat disease. In cancer care, a nurse practitioner may manage the primary care of patients and their families. A registered nurse who has additional education and training in how to diagnose and treat disease. Nurse practitioners are licensed at the state level and certified by national nursing organizations. In cancer care, a nurse practitioner may manage the primary care of patients and their families, based on a practice agreement with a physician. Progression In medicine, the course of a disease, such as cancer, as it becomes worse or spreads in the body. Stem cell A cell from which other types of cells develop. For example, blood cells develop from blood-forming stem cells. Symptom A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. Some examples of symptoms are headache, fatigue, nausea and pain.