Outcomes for older adults with acute myeloid leukemia after an intensive care unit admission

Abstract

BACKGROUND: Older adults with acute myeloid leukemia (AML) are often assumed to have poor outcomes after admission to the intensive care unit (ICU). However, little is known about ICU utilization and post-ICU outcomes in this population. METHODS: The authors conducted a retrospective analysis for 330 patients who were 60 years old or older and were diagnosed with AML between 2005 and 2013 at 2 hospitals in Boston.They used descriptive statistics to examine the proportion of patients admitted to the ICU as well as their mortality and functional recovery. They used logistic regression to identify risk factors for in-hospital mortality. RESULTS: Ninety-six patients (29%) were admitted to the ICU, primarily because of respiratory failure (39%), septic shock (28%), and neurological compromise (9%). The proportions of patients who survived to hospital discharge, 90 days, and 1 year were 47% (45 of 96), 35% (34 of 96), and 30% (29 of 96), respectively. At 90 days, 76% of the patients had an Eastern Cooperative Oncology Group performance status (ECOG PS) of 0 or 1, and 86% were in complete remission (CR) and/or continued to receive AML-directed therapy. In a multivariate analysis, a poorer baseline ECOG PS score (odds ratio, 2.76; P = .013) and the need for 2 or more life-sustaining therapies (ie, vasopressors, invasive ventilation, and/or renal replacement therapy; odds ratio, 12.4; P < .001) were associated with increased odds of in-hospital mortality. CONCLUSIONS: Although almost one-third of older patients with AML are admitted to an ICU, nearly half survive to hospital discharge with good functional outcomes. The baseline performance status and the need for 2 or more life-sustaining therapies predict hospital mortality. These data support the judicious use of ICU resources for older patients with AML. Cancer 2019;125:3845-3852.

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“… 52 During treatment, especially within the first few months following diagnosis, older patients often experience serious toxicities requiring hospitalization. 53 Impairments in geriatric assessment domains further complicate the course of treatment. Patients with impairments are at higher risk of treatment-related toxicities that require treatment delays or discontinuation, which can compromise survival.…”

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“…In older patients, age-related frailties and social conditions pose further challenges concerning QoL and health care. Published data showed that older patients with AML spend 28% of their time in the hospital and 14% attending outpatient clinic appointments [219]; in addition, almost one-third are admitted to the intensive care unit at diagnosis or after subsequent treatments [220]. However, even if patients with aggressive hematologic malignancies have high symptom burden and impaired QoL comparable to those of solid tumor patients [221,222], the use of palliative care services is less frequent in hematologic settings [223].…”

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“…Patients receiving the best supportive care alone for AML spend 25–30% of their time in hospital and approximately 15% of their time attending clinic appointments [ 154 ]. Many of them have a high symptom burden [ 155 ], and one third of them are admitted to intensive care units during their initial symptoms [ 156 ]. Similar observations were also made in a third study; a significant proportion of elderly/unfit patients spend a significant part of their last days of life in hospital [ 157 ].…”