Pamela S. Becker, MD, PhD
University of Washington School of Medicine
Although many patients with cancer now receive chemotherapy as outpatients, most cancer treatment centers do not extend this practice to patients with acute myeloid leukemia (AML) or advanced myelodysplastic syndromes (MDS) who are receiving initial intensive induction therapy. This reluctance primarily reflects the propensity of such therapy to damage the gastrointestinal tract and aggravate patients’ preexisting low neutrophil counts, thus producing potentially life-threatening infections. AML and its treatment also cause a significant reduction in platelet counts and thus a significant risk of bleeding.
The high-risk nature of AML and its initial treatment has traditionally led physicians to keep patients in the hospital until patients’ neutrophil and platelet counts recover, which doesn’t happen for 4 to 5 weeks after the start of chemotherapy. Based on growing experience with oral prophylactic antibiotics and transfusion support, physicians at Seattle Cancer Care Alliance (SCCA) have begun routinely discharging patients from its inpatient facility at University of Washington Medical Center (UWMC) immediately following the completion of intensive induction chemotherapy for AML and MDS. This allows patients to spend only 5 to 7 days, rather than 4 to 5 weeks, in the hospital. In June 2013, SCCA researchers initiated a pilot clinical trial involving complete outpatient administration of chemotherapy for AML and advanced MDS. The trial’s principal goals are to assess the safety of this practice and its effects on quality of life and cost.
Building Confidence in Early Discharge
Clinicians at SCCA were pioneers in providing patients with outpatient care following moderately intensive treatments such as high-dose chemotherapy and autologous stem cell transplant or reduced-intensity allogeneic stem cell transplant. The physicians at Fred Hutchinson Cancer Research Center started doing outpatient transplants decades ago, so the idea to be able to give the more standard chemotherapy induction regimens in the outpatient setting seemed feasible.
Before joining the University of Washington and SCCA in 2008, Elihu Estey, MD, professor in the Division of Hematology, had gained experience with early discharge of newly diagnosed patients with AML at The University of Texas MD Anderson Cancer Center in Houston. These patients were typically young and were discharged on an ad hoc basis.
But changing the way things have always been done requires more formal evidence. Doctors, nurses, and patients had come to equate heavyduty chemotherapy with hospitalization.
To build confidence in the potential switch, Roland B. Walter, MD, PhD, assistant professor in the Division of Hematology at the UW School of Medicine, built on Estey’s experience and led an SCCA pilot study exploring the medical and financial effects of early hospital discharge in patients who met medical criteria (ie, good liver, kidney, and heart function; no bleeding; no need for intravenous antibiotics), lived within 30 minutes of SCCA, and had a routinely available caregiver.
The study showed that even though many of the patients who were discharged early required readmission before recovery of their blood counts, no deaths or intensive care admissions resulted.1
Patients spent less time in the hospital and required less IV antibiotic treatment and fewer red blood cell transfusions than they would have without early discharge. The average daily cost of caring for the patient was also reduced (Table 1
Overall, the small SCCA study documented the feasibility and safety of outpatient management of selected patients with AML or MDS and signaled a turning point in routine care for leukemia treatment in Seattle.
“We now have regimens that are given partly or almost entirely outpatient,” said Paul Hendrie, MD, PhD, associate professor in the UW Division of Hematology and clinical medical director for the Inpatient Oncology Service. “What we tell new patients has definitely changed. In the past we would tell them to expect to stay in the hospital until their blood counts recovered from chemotherapy. Now it’s changed to, ‘You will come in, receive chemotherapy, and then, if everything is going right, we should be able to discharge you to our outpatient clinics.’”