Improved Coping Explains Benefits of Integrated Palliative Care for Patients With Acute Myeloid Leukemia

Patients just diagnosed with acute myeloid leukemia (AML) face a dismal experience. On top of the shock of finding they have an abrupt-onset, aggressive cancer, they must be immediately hospitalized for four to six weeks of intensive chemotherapy that is associated with debilitating side effects.

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Massachusetts General Hospital researchers previously completed a multicenter randomized controlled trial of palliative care integrated into the standard hematology care of this population. Compared with patients receiving usual care, those receiving early integrated palliative care (IPC) reported significant improvements in quality of life (QOL) and significant reductions in symptoms of anxiety and depression two weeks into the hospitalization, when the burden of adverse effects is typically high.

Those results were published in JAMA Oncology. More recently, Ashley M. Nelson, PhD, a psychology fellow at the Mass General Cancer Center and Department of Psychiatry, Areej El-Jawahri, MD, an oncologist in the Division of Hematology and Oncology at the Mass General Cancer Center, and colleagues performed a secondary analysis of the trial data. In Cancer, they identify enhanced coping capabilities as a key mechanism of the benefits associated with IPC.

Background on the Trial

The 160 trial participants had newly diagnosed high-risk AML and were enrolled at four centers between January 2017 and July 2019. They were randomized 1:1 to receive IPC or usual care.

Specialists in palliative care who were trained to deliver IPC met with each patient in the IPC group within 72 hours of enrollment. They returned at least twice weekly during the intensive chemotherapy hospitalization and continued to follow patients throughout any subsequent hospitalizations over the 24-week study period. Patients or clinicians could also request outpatient palliative care follow-up.

Patients randomized to usual care could consult with palliative care on request or at the discretion of their clinicians. 8% of participants in the usual care group received a consultation during the intensive chemotherapy hospitalization and 32% during a subsequent hospitalization.

Data Examined in the Secondary Analysis

Among patients with solid tumors, there's compelling evidence from prior research that IPC is beneficial because it enhances the patient's ability to cope with illness. At baseline and at weeks 2, 4, 12, and 24, the researchers asked patients to complete fourteen items on the Brief Coping Orientation to Problems Experienced Inventory:

• "Approach-oriented" coping strategies that directly address or manage the impact of stress—acceptance, active coping, positive reframing and emotional support
• "Avoidant" coping strategies that involve withdrawal from stress—behavioral disengagement, denial and self-blame

At the same timepoints, patients completed the Functional Assessment of Cancer Therapy–Leukemia (a measure of QOL) and the Hospital Anxiety and Depression Scale.

Effects of IPC on Coping

At week 2, compared with the usual care group, patients who received IPC reported:

• Significantly more use of approach-oriented coping strategies (B=1.85; P=0.004)
• Significantly less use of avoidant coping strategies (B= −0.70; P=0.02)

From baseline to week 24:

• The increase in the use of approach-oriented coping strategies was significantly greater in the IPC group (B= −0.39; P=0.01)
• The change in the use of avoidant coping strategies was not significantly different between groups

Changes in Coping on QOL and Mood

The changes in approach-oriented and avoidant coping accounted for the effects of IPC on patient-reported QOL (95% CI, 2.14 to 13.63), depression (95% CI, −2.05 to −0.27), and anxiety (95% CI, −1.25 to −0.04) during the initial hospitalization. Changes in coping explained 78% of the effect of IPC on QOL, 66% of its effect on depression, and 35% of its effect on anxiety.

Recommendations

Because IPC improved patients' coping in such a short time and during intensive treatment, increasing its availability during hospitalization for AML treatment seems to be an important form of support.

Identifying other key mechanisms of the benefit of IPC will be crucial for developing focused interventions that are effective, economical, scalable and sustainable.

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