Fatigue in older adults with acute myeloid leukemia: predictors and associations with quality of life and functional status

Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG)

Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.

Fatigue in newly diagnosed acute myeloid leukaemia: general population comparison and predictive factors

OBJECTIVES

This study compared the burden of fatigue between treatment-naïve patients with newly diagnosed acute myeloid leukaemia (AML) and the general population and investigated patient factors associated with fatigue severity.

METHODS

Pretreatment patient-reported fatigue was assessed with the Functional Assessment of Chronic Illness Therapy-Fatigue questionnaire in a sample of 463 newly diagnosed patients with AML who were enrolled in a clinical trial. Multivariable linear regression models were used to estimate the adjusted mean differences in fatigue between patients with AML and adults from the general population (n=847) by AML disease risk categories. A clinically meaningful difference in fatigue was defined as ≥3 points. Univariable and multivariable linear regression models were used to identify sociodemographic, clinical and molecular correlates of worse fatigue in patients with AML.

RESULTS

Patients with AML reported adjusted mean fatigue scores that were 7.5 points worse than the general population (95% CI -8.6 to -6.4, p<0.001). Across AML disease risk categories, adjusted mean differences in fatigue compared with the general population ranged from 6.7 points worse (patients with favourable risk: 95% CI -8.6 to -4.8, p<0.001) to 8.9 points worse (patients with poor risk, 95% CI -10.5 to -7.2, p<0.001). Overall, 91% of patients with AML reported fatigue that was equal to or worse than the general population's median fatigue score. Higher pretreatment fatigue was independently associated with female sex, WHO performance status ≥1 and lower platelet levels.

CONCLUSIONS

Patients with newly diagnosed AML reported worse fatigue than the general population, and mean differences exceeded twice the threshold for clinical significance. Our findings may help to identify patients with AML most likely to benefit from supportive care interventions to reduce fatigue.

Treatment of Cancer-related-Fatigue in Acute Hematological Malignancies: Results of a Feasibility Study of using Cognitive Behavioral Therapy

BACKGROUND

Despite cancer related fatigue (CRF) being the most common, and debilitating symptom in patients with recently diagnosed acute hematological malignancies (HM), there are limited effective treatments for CRF in HM. The aim of this study was to determine the feasibility of cognitive behavioral therapy (CBT) for CRF in HM.

METHODS

In this preliminary longitudinal prospective study, HM patients diagnosed a median of one month previously with moderate to severe fatigue were enrolled. Patients received CBT in seven weekly sessions for eight weeks. Change in Functional Assessment of Cancer Illness Therapy (FACIT) - Fatigue (primary), FACT-G, Pittsburg Sleep Quality Index (PSQI), Hospital Anxiety Depression Scale (HADS), M.D. Anderson Symptom Inventory - Acute Myeloid Leukemia (MDASI-AML/MDS), and Herth Hope Index (HHI) were analyzed.

RESULTS

Twenty-seven of 36 (75 %) patients were evaluable. Adherence and satisfaction rates to the CBT intervention were 78.6% (95% CI 67.2%, 89.9%), and 92% (95% CI 76.7%, 98.3%) respectively. The median age 66, 64% female, the most common HM was AML (60%), median FACIT-F was 27. The mean (SD) improvement at end eight weeks for FACIT-F was 5.5(13.6), Cohen δ 0.4, P=0.046; and for PSQI total was 2.9 (3), Cohen δ -1, P=0.006. We also found significant improvement in HADS anxiety -2.7(4.5), P=0.049, MDASI Sleep -1.8(3.0), P=0.022, MDASI mean module symptom severity -0.7(1.6), P=0.006. However, no significant improvements were found in FACT-G, HHI, and HADS-depression scores.

CONCLUSIONS

The use of CBT was feasible with improvement of CRF, sleep quality, and anxiety scores in HM. Randomized controlled trials are justified.

Palliative care and coping in patients with acute myeloid leukemia: Mediation analysis of data from a randomized clinical trial

BACKGROUND

It has been shown previously that integrated palliative care for patients with acute myeloid leukemia (AML) during intensive chemotherapy leads to improvements in quality of life (QOL) and mood. Coping has been shown to mediate palliative care interventions in advanced cancer; the mechanisms by which improvements occur among patients with AML remain unexplained.

METHODS

The authors conducted a secondary analysis of data from a multisite randomized trial of integrated palliative and oncology care (IPC; n = 86) versus usual care (n = 74) for hospitalized patients with AML undergoing intensive chemotherapy. IPC patients met with palliative care at least twice weekly during their initial and subsequent hospitalizations. Patients completed the Functional Assessment of Cancer Therapy-Leukemia, the Hospital Anxiety and Depression Scale, and the Brief Coping Orientation to Problems Experienced Inventory to assess QOL, mood, and coping at the baseline and at weeks 2, 4, 12, and 24. Linear regression models were used to assess the effect of IPC on coping. Causal mediation regression models were used to examine whether changes in coping mediated intervention effects on patient-reported outcomes at week 2.

RESULTS

One hundred sixty eligible patients (68.1%) were enrolled. Those randomized to IPC reported improvements in approach-oriented coping (P < .01) and reductions in avoidant coping (P < .05). These changes in coping mediated the intervention effects on QOL (95% CI, 2.14-13.63), depression (95% CI, -2.05 to -0.27), and anxiety symptoms (95% CI, -1.25 to -0.04). Changes in approach-oriented and avoidant coping accounted for 78% of the total palliative care intervention effect on QOL, for 66% of the effect on depression, and for 35% of the effect on anxiety symptoms.

CONCLUSIONS

Palliative care integrated during intensive chemotherapy for patients with AML facilitates coping strategy use. Improvement in coping skills accounts for a substantial proportion of the effect from a palliative care intervention on patient-reported outcomes.

Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021

Simple Summary

The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021.

Abstract

Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.

An update on cancer-related fatigue in older adults: A narrative review

Up to 70% of older adults report fatigue after a cancer diagnosis. For many of these patients, cancer-related fatigue (CRF) persists for years after cancer treatment and is associated with significant disability. Despite this, little has been written on the diagnosis and management of CRF in older adults. To address this gap, we performed a narrative review of the literature on CRF in older adults and used literature from the general population when evidence was lacking to provide guidance to clinical providers on how to tailor care to this population. We recommend evidence-based options for evaluating CRF and address their limitations in the assessment of older adults. We also provide guidance and a treatment algorithm on evaluating CRF using the Comprehensive Geriatrics Assessment. Lastly, we present evidence for the use of non-pharmacologic and pharmacologic therapies in the management of CRF in older adults.

Clinically significant symptoms prevalence in breast and colon cancers and leukemia patients: a comparison analysis of patient-reported outcomes

PURPOSE

To assess the prevalence and severity of clinically significant symptoms (CSSs) for breast cancer, colon cancer, and leukemia patients undergoing chemotherapy.

METHODS

A retrospective review of the Edmonton Symptom Assessment System scores reported by patients from the database of our previous large-scale study, which was collected between May 2018 and January 2019. We described the prevalence of CSSs in proportion and severity in mean ± SD.

RESULTS

Of 546 cancer patients, 209 were breast cancer, 159 were colon cancer, and 178 were leukemia. The majority of participants were females 345 (63.2%), and the mean age of the entire study sample was 49.4 ± 13.93. Diminished feeling of well-being was the most prevalent CSS across the three cancers, with a statistically significant difference (p < 0.001). Fatigue (6.59 ± 2.07), pain (6.55 ± 2.01), and loss of appetite were the most distressing CSSs (6.49 ± 1.99) across the whole sample. Loss of appetite (6.34 ± 2.05) was the most distressing CSS in breast cancer, fatigue (6.97 ± 2.07) in leukemia, and pain (7.00 ± 2.11) in colon cancer. Statistically significant differences were found in the severity between the three cancer in pain (p < 0.001), fatigue (p = 0.010), nausea (p = 0.001), and diminished feeling of well-being (p = 0.033). Cancer type, sleeping hours, dependence on caregiver, female gender, level of education, and employment were significantly associated with higher odds of CSS severity.

CONCLUSION

Breast and colon cancer and leukemia patients undergoing chemotherapy experience multiple distressing CSSs. Our study validates CSSs as a discrete set of distressing symptoms that may serve and guide quality of care assessment and cancer clinical research, particularly among patients undergoing chemotherapy.

Developing and adapting a mobile health exercise intervention for older patients with myeloid neoplasms: A qualitative study

INTRODUCTION

Older patients with myeloid neoplasms (MN) receiving outpatient chemotherapy are at risk of experiencing treatment-related toxicities such as functional decline. A mobile health (mHealth) exercise intervention may ameliorate these toxicities. This qualitative study aimed to inform the design of a mHealth exercise intervention for this population.

METHODS

This was a qualitative study of thirteen patients aged ≥60 years receiving hypomethylating agents for MN. EXCAP©® is a home-based walking and progressive resistance exercise program. We combined EXCAP©® with a mobile app; the combination (GO-EXCAP Mobile App) has not been previously tested. A brief verbal description about the intervention was provided to the participants but they did not perform it. Participants were interviewed and inductive thematic analysis was used to analyze the data.

RESULTS

Mean age was 71.6 (SD 8.5). Three themes were identified: 1) Perceptions of the intervention feasibility, 2) Ways to leverage the app to deliver the exercise intervention, and 3) Personalized exercise goals. Walking and resistance exercises were perceived to be feasible. Patients were comfortable initiating the intervention in cycle 2 of chemotherapy, with exercise increments occurring from week 2-4 of the cycle. Ways to leverage the app to deliver EXCAP©® include 1) Video feature for exercise demonstration and interactions, and 2) Exercise data and symptom surveys to be communicated to the exercise physiologist and primary oncology team. Preservation of existing function and activity was an important goal to participants.

CONCLUSIONS

Our findings provide insights about the preferences of older adults with MN for a mHealth exercise intervention.

Impact of age, functional status, and comorbidities on quality of life and outcomes in elderly patients with AML: review

The incidence of acute myeloid leukemia increases with age, and more than half of AML patients are over 60 years old. Treating elderly AML patients presents several challenges and uncertainties, linked partly to disease characteristics and partly to the difficulty of establishing which patients could benefit from the best treatment. Although some elderly fit patients can receive intensive therapy, many of them are not treated and not enrolled in clinical trials. Yet supportive care is associated with significantly lower survival rates compared to intensive therapy or lower intensive therapy. A poorer prognosis in elderly patients is related to age, functional status, and comorbidities, combined with leukemia characteristics. Chronological age is not the best surrogate factor for selecting patients eligible for intensive chemotherapy. Scoring systems-including patient characteristics (ECOG, comorbidities) and disease characteristics (cytogenetics and molecular parameters)-designed to evaluate probabilities of response to treatment, morbidity, and survival may be used to balance the risk-benefit ratio for intensive therapy. A geriatric assessment (GA) to evaluate physical function, comorbidities, nutritional status, cognitive function, and social support could help identify the most vulnerable patients so that they can receive intensive therapy. A GA would also help take the necessary steps to improve tolerance to treatment. Evaluating markers of fitness and quality of life as part of clinical trials should be favored.

Clinically Significant Fatigue in Adult Leukemia Patients: Prevalence, Predictors, and Impact on Quality of Life

Background

Cancer-related fatigue (CRF) is a common distressing symptom in leukemia patients. CRF becomes clinically significant fatigue (CSF) when adversely affects health-related quality of life (HRQoL) and warrants further workup, referrals, and treatment. Objective: To assess the prevalence and predictors of CSF and assesses its impact on HRQoL in adult leukemia patients.

Method

Analysis was performed on 168 leukemia patients. The primary study outcomes were CSF (score ≥4) as measured by the fatigue numerical rating scale and HRQoL using a validated Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) scale.

Result

The prevalence of CSF was 89 (53%), with a mean score of 6.66±2.02. About 106 (63.1%) of leukemia patients had poor Health-related quality of life (HRQoL) (102.61±23.50). Overall, FACT-Leu mean score indicated that study participants had poor HRQoL (114.70±29.67). There was a statistically significant difference in HRQoL between the patients with CSF 104.89±28.82 and Non-CSF 125.76±26.71, p<0.001. Poor appetite (odd ratio: 3.02 [95% CI: 1.33-6.85]) was statistically significant predictors (p<0.010) of CSF. Dependence on caregiver (odd ratio: 3.31 [95% CI: 0.41-0.75]) and having non-CSF (odd ratio: 5.22 [95% CI: 2.44-11.19]) were found statistically significant predictors of good HRQoL.

Conclusion

CSF is prevalent among leukemia patients, and adversely affects their HRQoL. Holistic assessment and supportive care are needed to reduce the burden of CSF and improve leukemia patients HRQoL.

Health-Related Quality of Life and Treatment of Older Adults with Acute Myeloid Leukemia: a Young International Society of Geriatric Oncology Review Paper

PURPOSE OF REVIEW

The treatment landscape for older patients with acute myeloid leukemia (AML) is evolving. Many treatments have comparable efficacy making their impact on quality of life (QoL) an important differentiating factor. In this review, we discuss QoL in older adults with AML, focusing on therapeutic and observational trials that have incorporated QoL assessments.

RECENT FINDINGS

Health-related quality of life (HRQoL) is a multi-dimensional concept incorporating physical, mental, emotional, and social functioning domains. HRQoL components overlap with components of geriatric assessment, a multidisciplinary diagnostic process that identifies underlying vulnerabilities of older adults and guides subsequent management strategies. HRQoL questionnaires may be general, cancer-specific, leukemia-specific, or symptom-focused. Therapeutic and observational cohort studies suggest HRQoL improves, or at least remains stable, during intensive and lower-intensity therapies. Nonetheless, HRQoL is not routinely incorporated in AML therapeutic trials. HRQoL assessments can inform both decision-making and management for older adults with AML.

Validated Instruments of Quality of Life (QOL) in Patients With Acute Myeloid Leukemia (AML) and Other Cancers

Introduction

Acute myeloid leukemia (AML) can negatively impact quality of life (QOL). Few QOL instruments are specific to and have been validated in AML. This review aims to identify QOL instruments that have been validated in patients with AML and other cancers and summarize their psychometric properties reported in published literature. A literature review search was performed using PubMed and OVID (Biosis, Embase, MEDLINE) databases through June 25, 2020. Search terms included: QOL, health-related QOL, patient-reported outcomes and validity, reliability, validated, tools, instruments, test-retest, and leukemia myeloid acute, leukemia, myeloid, acute, acute myeloid leukemia. Articles were included if they focused on cancer and reported psychometric properties that could be extracted. Abstracts and their references were reviewed for inclusion.

Results

Twelve evaluating ten instruments were included. Functional Assessment of Cancer Therapy Leukemia (FACT-Leu) showed internal consistency (IC) of α = 0.86 to >0.9, correlation with EQ-5D-3L of r > 0.50, correlation with European Organisation for Research and Treatment of Cancer (EORTC) QLQ-Leu of ρ = 0.29–0.63, test-retest reliability of κ = 0.861. FACT-F showed correlations with EORTC QLQ-C30 of r = 0.40–0.83. Hematological Malignancy Patient-Reported Outcome (HM-PRO) showed intraclass correlation coefficient (ICC) of 0.94–0.98. EORTC-8D and EQ-5D-3L showed ICC = 0.595, correlations with each other of ρ = 0.137–0.634 and with EORTC QLQ-C30 of r = 0.651–0.917. EORTC QLQ-C30 showed person separation reliability of 0.47 to 0.90 and patient-observer agreement of 0.85. Life Ingredient Profile (LIP) showed IC of α = 0.29–0.77 and test-retest reliability of κ = 0.42–1.0. QOL-E showed correlation with FACT-general of R = 0.71, internal validity of α = 0.7, and test-retest reliability of standardized Cronbach’s α = 0.7–0.92. EORTC QLQ-Leu showed IC of α = 0.6–0.79. The Acute Myeloid Leukemia–Quality of Life (AML-QOL) instrument showed IC of α = 0.72, correlations with EORTC QLQ-30 of magnitudes ρ = 0.59–0.72, and test-retest reliability of ICC = 0.52–0.91.

Conclusion

Although several QOL instruments have been validated, more research is needed to determine the most clinically useful instruments in patients with AML.

A real-world, cross-sectional, community survey of symptoms and health-related quality of life of adults with acute myeloid leukemia

Aim: We used Adelphi Real World Disease-Specific Programme data to characterize adults with newly diagnosed or relapsed/refractory de novo acute myeloid leukemia (AML). Materials & methods: Community-practice hematologists/oncologists completed patient record forms for their regular AML patients. Patients were invited to complete patient self-completion forms including 3-Level EuroQol 5-Dimensions (EQ-5D-3L) and Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) questionnaires. Results: Physicians provided patient record forms for 389 patients (339 newly diagnosed, 50 relapsed/refractory); 68 patients completed patient self-completion forms. Mean EQ-5D visual-analog scale and index and FACT-General scores were significantly lower than US population norms (p < 0.0001); health-related quality of life (HRQoL) scores were generally lower than 11 other cancers. Conclusion: HRQoL impairment is grave in AML. Efforts are needed to improve HRQoL in affected patients.

Systematic reviews of economic burden and health-related quality of life in patients with acute myeloid leukemia

BACKGROUND

Acute myeloid leukemia (AML) is a rare hematologic malignancy largely affecting older adults. Comorbidities may compromise fitness and eligibility for high-intensity chemotherapy (HIC). This study presents the results of two systematic reviews (SRs) assessing (1) the impact of AML and current treatments on health-related quality of life (HRQoL), and (2) the economic burden and cost drivers of AML in patients who are ineligible for HIC.

METHODS

Electronic searches (MEDLINE, EMBASE, EconLit, Cochrane library) were supplemented with manual searching of conference, utility, and HTA databases. All studies reporting HRQoL or economic data for patients with AML who were ineligible for HIC were included.

RESULTS

The HRQoL SR included ten studies. Patients with AML have lower baseline HRQoL than other cancer patients or the general population, and those receiving lower intensity treatment have lower HRQoL than those eligible for HIC. Low baseline HRQoL predicts poor outcomes, and treatment had variable effects on HRQoL. The economic burden SR included nine studies. Medical costs varied widely, reflecting the heterogeneity of AML. Hospitalization is a key cost driver in AML treatment but was largely not considered in cost studies. Medical resource utilization comprised drug acquisition, drug administration, disease monitoring tests, transfusions, adverse event management, supportive care/monitoring costs and terminal care.

CONCLUSION

As new drugs emerge that extend survival, assessment of HRQoL will be important to evaluate the quality of that survival. Cost data, driven by transfusions and hospitalization, will be important to evaluate the economic value of new treatments.

Long-term recovery of quality of life and physical function over three years in adult survivors of acute myeloid leukemia after intensive chemotherapy

We previously described impairments in quality of life (QOL) and physical function among acute myeloid leukemia (AML) survivors between diagnosis and 1 year. The aim of the current study is to describe and compare to normative data QOL and physical function recovery over 3 years from diagnosis and treatment with intensive chemotherapy (IC). At assessments done at baseline (pre-IC) and at 11 time points over 3 years, QOL, fatigue, and 3 physical performance measures (PPMs; grip strength, 6-min walk test (6MWT), and timed chair stands) were collected. Long-term recovery was defined by reaching scores within the minimum clinically important difference of normative data. Global QOL recovery was seen in 79% at 1 year, 75% at 2 years, and 86% at 3 years. At 3 years, the QLQ-C30 subscales with the greatest recovery were physical and emotional functioning. For FACT-fatigue, recovery was seen in 68% at 1 year and 77% at 3 years. Recovery on PPMs was poorer on average, with only 17% on the 6MWT and 42% in grip strength returning to normal at 3 years. The vast majority of AML survivors after IC achieve recovery in QOL and fatigue by three years. However, recovery in physical performance remained blunted.

A Systematic Review of Psychometric Properties of Health-Related Quality-of-Life and Symptom Instruments in Adult Acute Leukemia Survivors

BACKGROUND

Acute leukemia represents 4% of cancer cases in the United States annually. There are more than 302 000 people living with acute and chronic leukemia in the United States. Treatment has been shown to have both positive and negative effects on health-related quality of life (HRQOL).

OBJECTIVE

The aims of this study were to examine psychometric properties of symptom and HRQOL instruments and to provide implications for the assessment in adults with acute leukemia relevant to clinical practice and future research.

METHODS

Systematic literature search was conducted from 1990 to 2014 using electronic databases and manual searches. Psychometric studies were considered eligible for inclusion if (1) the psychometric paper was published using at least 1 HRQOL or symptom instrument, and (2) adults with acute leukemia were included in the sample. Studies were excluded if the age groups were not adults, or if the instrument was in a language other than English.

RESULTS

Review identified a total of 7 instruments (1 cancer generic HRQOL, 2 symptom related, 3 HRQOL combined with symptom questions, and 1 disease specific). The most commonly used instrument was the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, followed by the Functional Assessment of Cancer Therapy-Fatigue.

CONCLUSIONS

An acute leukemia diagnosis can have a significant impact on HRQOL. Our recommendations include using both an HRQOL and symptom instrument to capture patient experiences during and after treatment.

IMPLICATIONS FOR PRACTICE

The availability of comprehensive, valid, and reliable HRQOL and symptom instruments to capture the experiences of adults with acute leukemia during and after treatment is limited.

Surgical Oncology: Evolution of Postoperative Fatigue and Factors Related to Its Severity

BACKGROUND

Fatigue has been reported by many patients undergoing surgery and is associated with a negative prognosis. The factors associated with postoperative fatigue and its evolution during the postoperative period are unclear. Adequate fatigue measurement instruments are necessary to obtain reliable evaluations and to direct effective care to control fatigue in this patient population.

OBJECTIVES

This article describes the evolution of postoperative fatigue in patients with cancer as well as related factors.

METHODS

A review of the literature using the CINAHL® and PubMed databases was undertaken.

FINDINGS

The prevalence of moderate and severe fatigue varies during the postoperative period, with a reduction in the 12 months after surgery. Various factors (e.g., stress, anxiety, depression, pain, changes in sleep patterns) seem to influence the severity of fatigue. More evidence is needed to explore the relationship between immediate postoperative fatigue and the evolution of fatigue during the period following surgical treatment for cancer.

Health-Related Quality of Life of Patients with Acute Myeloid Leukemia: A Systematic Literature Review

INTRODUCTION

Patients with acute myeloid leukemia (AML), especially those with relapsed or refractory AML, have poor clinical prognosis and outcomes. Health-related quality of life (HRQoL) assessments have become increasingly important in oncology, aiding in identifying and informing supportive therapy needs during treatment and beyond; however, HRQoL in hematology, and AML in particular, has received relatively minor attention. The aim was to identify and summarize estimates of HRQoL in patients with AML, including patients with relapsed or refractory AML.

METHODS

A systematic literature review was performed. MEDLINE and EMBASE databases were searched for peer-reviewed literature published between 2004 and 2014 in the US and Europe. Abstracts from four relevant conference proceedings between 2012 and 2014 were reviewed. Data from eligible studies were extracted describing the HRQoL instruments used, domains assessed, and HRQoL scores reported.

RESULTS

Fourteen peer-reviewed studies met the eligibility criteria and were included in the review. Cancer- or leukemia-specific HRQoL measures were used in 78.6% of the studies. Overall, HRQoL was superior among AML survivors compared to individuals on active treatment. Fatigue was identified as the most problematic symptom domain in patients, irrespective of their treatment status. Reported HRQoL declined shortly after diagnosis or treatment initiation and recovered over time.

CONCLUSION

The included studies identified a decrease in HRQoL after treatment initiation and highlighted the role of fatigue in HRQoL in this patient population. Limited HRQoL data were identified among relapsed or refractory AML patients although they have worse prognostic outcomes. New treatment options that have less negative impact on HRQoL or health initiatives specifically targeting HRQoL of patients with AML are warranted. In addition, further studies exploring HRQoL in the relapsed or refractory patient population are needed to inform disease management and treatment decisions.

The Patient Perspective on Living with Acute Myeloid Leukemia

INTRODUCTION

Acute myeloid leukemia (AML) imposes significant burden on patients, their families, and the healthcare system. Published literature has reported many AML signs and symptoms, as well as their impact on patients. However, there are no publications on the experience of living with AML from the patient's perspective. In this study, we performed qualitative interviews with patients with AML to understand their experience.

METHODS

Participants were recruited from the US and Japan. All patients were screened to assess eligibility, and were divided into four subgroups (i.e., newly-diagnosed, high-intensity chemotherapy; newly-diagnosed, low-intensity chemotherapy; relapse/refractory; and post-transplant). Patients were interviewed over the phone by a trained researcher and asked about their day-to-day experience with AML. Signs/symptoms and impacts were coded, analyzed using Atlas.ti software, and reported as frequencies, with the medians of patient-reported disturbance levels (0-10) computed for each symptom and impact.

RESULTS

The most commonly reported sign/symptom in the US was fatigue (95.7%), followed by bruising and weakness (both 78.3%), and in Japan, nausea (94.4%), followed by fatigue and headache (both 88.9%). The most commonly reported impact in the US was a decreased ability to maintain social/familial roles (91.3%), followed by anxiety and a decreased ability to function (both 87.0%), and most commonly reported in Japan was anxiety, a decreased ability to function, and remission uncertainty (94.4%).

CONCLUSION

Although the frequency of signs/symptoms and their level of disturbance varied between the US and Japan, there was remarkable consistency in the types of signs/symptoms and impacts reported across all patients. The consistency in the experience of the disease across patients suggests that measurement of AML experience can be achieved by using the same tool for most, if not all, of these patients.

FUNDING

Astellas Pharma Inc., Northbrook, IL, USA.

Patient-reported symptoms and quality of life in adults with acute leukemia: a systematic review

PURPOSE/OBJECTIVES

Systematically summarize findings from research conducted on adult acute leukemia survivors as they relate to symptoms and quality of life (QOL). 


DATA SOURCES

Systematic review of the literature from 1990–2013 found in the PubMed, PsycINFO®, EMBASE, and CINAHL® databases, as well as manual searches. 


DATA SYNTHESIS

The review identified 16 quantitative studies and 1 qualitative study published from 1990–2013 that used a self-reported QOL or symptom questionnaire. Fatigue was the most commonly assessed and reported symptom, followed by depression. 


CONCLUSIONS

Acute leukemia and its treatment have a significant impact in all QOL domains. Future studies should include longitudinal research, more than one recruitment site, increased minority representation, and home-based exercise interventions as ways to improve all domains of QOL. 


IMPLICATIONS FOR NURSING

This review increases awareness of commonly reported symptoms faced by adults with acute leukemia. Oncology nurses are central in monitoring and reporting symptoms to the interdisciplinary team that may contribute to changes in function, with the overall goal of optimizing QOL over time. 


A phase II exercise randomized controlled trial for patients with acute myeloid leukemia undergoing induction chemotherapy

Curative treatment for acute myeloid leukemia (AML) involves induction chemotherapy (IC) which is associated with bed rest and toxicities, leading to worsening quality of life (QOL), fatigue, and fitness. Exercise during IC may ameliorate declines but has not been rigorously tested. We examined the efficacy of supervised exercise during IC on QOL, fatigue, and fitness. Eighty-three inpatients age 18-80 scheduled to receive IC for newly diagnosed or relapsed AML were randomized 2:1 (exercise intervention:control group). Study measures were completed at baseline, post-IC, and following the first cycle of consolidation. The intervention consisted of a supervised mixed-modality, moderate-intensity exercise program (4-5 days per week, 30-60min per session) throughout admission. Recruitment was good (56%), retention excellent (96%), and adherence was 54%. Global QOL improved similarly in both groups from baseline to post-IC (between-group difference 3.0 points, p=0.62). Fatigue improved in the exercise group from baseline to post-IC (potentially clinically important between-group difference of 3.6 points, p=0.23). Aerobic fitness, lower body strength, and grip strength improved in the exercise group (between-group differences p=0.005, p<0.001, p=0.03, respectively). Supervised exercise for patients with AML undergoing IC is feasible, safe, and appears effective at improving fitness and possibly fatigue. A larger trial is warranted.

Health-related quality of life and symptom assessment in randomized controlled trials of patients with leukemia and myelodysplastic syndromes: What have we learned?

Health-related quality of life (HRQOL) and other patient-reported outcomes (PROs) are crucial for a comprehensive evaluation of treatment effectiveness. A systematic review of randomized controlled trials (RCTs) with a PRO endpoint conducted in patients with leukemia and myelodysplastic syndromes (MDS) was performed. Eligible studies were evaluated independently, according to a pre-defined coding scheme, by two reviewers. Thirteen RCTs, enrolling overall 3380 patients were identified. There were four RCTs involving acute myeloid leukemia patients (AML), one with acute lymphoid leukemia (ALL), five with chronic lymphocytic leukemia (CLL) and three with MDS. Six RCTs accurately documented PRO methodology assessment and were thus considered likely to robustly inform clinical decision-making. Of these, three RCTs dealt with AML, two with CLL, one with MDS. A growing number of RCTs in leukemia and MDS have included a PRO component in recent years. Inclusion of PROs in RCTs is feasible and can provide unique information to facilitate clinical decision-making.

A systematic review on the use of exercise interventions for individuals with myeloid leukemia

PURPOSE

The aim of this study is to explore the current literature examining the feasibility, safety, and efficacy of exercise interventions for individuals with myeloid leukemia.

METHODS

A literature search was conducted in Ovid MEDLINE, AMED, Embase, PsycINFO, CINAHL, CENTRAL, and Web of Science using the terms "exercise" OR "physical activity" AND "myeloid leukemia." Two reviewers performed duplicate title/abstract and full text screening of clinical trials comparing outcomes for people with myeloid leukemia participating in an exercise program. Initial searches yielded 149 articles. Two reviewers independently extracted data using piloted forms and assessed risk of bias using Cochrane's tool. Data was extracted in relation to the study population, study intervention, comparator intervention, and outcomes assessed.

RESULTS

Five trials were included in this review after 20 full-text articles were screened. Risk of bias was determined to be high in all five studies. Adherence rates were found to be low (<30 %) in all studies measuring this outcome. Positive improvements were found for fatigue, physical functioning, quality of life, and psychological distress for patients with AML; however, not all findings were significant. Leukocyte and BCR-ABL1 levels increased significantly post-exercise for participants with CML. Only one adverse event was reported.

CONCLUSIONS

Exercise interventions appear safe and feasible for individuals with AML. Not enough evidence was presented to comment on the feasibility of exercise programs for individuals with CML. Inconclusive evidence was found on the effectiveness of exercise to minimize side effects for participants with AML.

Adult Acute Myeloid Leukemia Long-term Survivors

The number of leukemia patients and survivors is growing. This review summarizes what is known regarding the health related quality of life (HRQOL) and medical complications associated with acute myeloid leukemia (AML) disease and treatment and highlights understudied aspects of adult AML survivorship care, and potential novel areas for intervention.

A pilot phase II RCT of a home-based exercise intervention for survivors of AML

BACKGROUND

Fatigue is the most common and disabling symptom affecting quality of life (QOL) and daily function in patients who have completed treatment for acute myeloid leukemia (AML). Although trials in patients with various solid tumors have reported improved fatigue and QOL following exercise interventions, there have been no studies in AML patients post treatment.

METHODS

Forty patients aged ≥ 40 years who had completed treatment for AML were enrolled in a 12-week randomized phase II exercise intervention to determine feasibility (recruitment, retention, and adherence), efficacy, and safety of the intervention. Patients assigned to the exercise group received an individualized, moderate-intensity, 12-week home-based exercise program with weekly telephone support from a certified exercise physiologist. QOL, fatigue, and fitness outcomes were measured at baseline, 6 weeks, and 12 weeks. Between-group differences in 12-week change scores were calculated using linear regression adjusting for age and baseline function.

RESULTS

Recruitment and retention rates were 38% and 91%, respectively. Adherence was low at 28%. Analyses did not suggest statistically significant or clinically important benefits in QOL, fatigue, or physical fitness with the intervention. The level of adherence did not appear to impact outcomes. There were no adverse events.

CONCLUSION

A home-based exercise program for post-treatment AML patients age 40 years or older can be safely delivered with reasonable recruitment and high retention. However, feasibility was hampered by low adherence. Further research and program modification are needed to better understand and overcome barriers to exercise delivery and adherence in AML survivors.

Review of health-related quality of life data in multiple myeloma patients treated with novel agents

In multiple myeloma (MM), health-related quality of life (HRQoL) data is becoming increasingly important, owing to improved survival outcomes and the impact of treatment-related toxicity on HRQoL. Researchers are more frequently including HRQoL assessments in clinical trials, but analysis and reporting of this data has not been consistent. A systematic literature review assessed the effect of novel agents (thalidomide, bortezomib and lenalidomide) on HRQoL in MM patients, and evaluated the subsequent reporting of these HRQoL results. A relatively small body of literature addresses HRQoL data in MM patients treated with novel MM therapeutic agents: 9 manuscripts and 15 conference proceedings. The literature demonstrates the complementary value of HRQoL when assessing clinical response, progression, overall survival and toxicity. However, weaknesses and inconsistencies in analysis and presentation of HRQoL data were observed, often complicating interpretation of the impact of treatment on HRQoL in MM. Further evaluation of HRQoL in MM patients treated with novel agents is required in larger cohorts, and ideally in head-to-head comparative studies. Additionally, the development of standardised MM-specific best practice guidelines in HRQoL data collection and analysis is recommended. These would ensure that future data are more useful in guiding predictive models and clinical decisions.

Performance status in elderly patients with acute myeloid leukemia: exploring gene expression signatures of cytokines and chemokines

Acute myeloid leukemia (AML) is an aggressive disease that predominantly affects elderly patients. Cytokines and chemokines are major players in the pathogenesis of AML. They regulate the disease course and play a deleterious role in the progression of AML. The geriatric population is particularly vulnerable to these mediators as these cytokines and chemokines are also implicated in the development of frailty, fatigue, and declining cognitive function. It is the combination of these adverse effects of cytokines and chemokines that affect performance status and, in turn, the poor prognosis in this age group. Cytokines and chemokines are emerging as therapeutic targets in AML. Future endeavors to treat AML will likely involve cytokines and chemokines as attempts are made to disrupt the bone marrow environment. By modulating the bone marrow stroma, the goal is to create an environment less favorable to AML cells and more favorable to the effects of chemotherapy against AML.

Caregivers of patients with cancer fatigue: a high level of symptom burden

Fatigue is the problematic symptom identified by patients with cancer. However, fatigue has not been widely examined in caregivers of patients with cancer. In this study, 131 caregivers of patients diagnosed with advanced stage cancer and actively receiving radiotherapy reported experiencing the most difficulties with fatigue (mean 46.9; on a 0-100 scale, with a 10-point difference having clinical meaning) at baseline and at a 6-month follow-up (mean 48.3). This is in sharp contrast to other domains of quality of life and functioning being rated in the 60s, 70s and 80s by the caregivers of patients with cancer. Given the level of fatigue reported by the caregivers of patients with cancer, if confirmed by other investigators in larger and more diverse samples, interventions targeting caregiver fatigue should be explored.

Chronic fatigue is the most important factor limiting health-related quality of life of chronic myeloid leukemia patients treated with imatinib

Health-related quality of life (HRQOL) is an important goal of therapy for chronic myeloid leukemia (CML) patients treated with current molecular-targeted therapies. The main objective of this study was to investigate factors associated with long-term HRQOL outcomes of CML patients receiving imatinib. Analysis was performed on 422 CML patients recruited in an observational multicenter study. HRQOL was assessed with the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Key socio-demographic and clinical data were investigated for their association with HRQOL outcomes. Chronic fatigue and social support were also investigated. Univariate and multivariate linear regression analyses were used to identify independent factors associated with HRQOL outcomes. Fatigue was the only variable showing an independent and consistent association across all physical and mental HRQOL outcomes (P<0.01). Differences between patients reporting low versus high fatigue levels were more than eight and seven times the magnitude of a clinically meaningful difference, respectively, for the role physical (Δ=70 points) and emotional scale (Δ=63 points) of the SF-36. Fatigue did not occur as an isolated symptom and was most highly correlated with musculoskeletal pain (r=0.511; P≤0.001) and muscular cramps (r=0.448; P≤0.001). Chronic fatigue is the major factor limiting HRQOL of CML patients receiving imatinib.

Correlation between cytokine levels and changes in fatigue and quality of life in patients with acute myeloid leukemia

Cancer-related fatigue (CRF) is a major problem in patients with acute myeloid leukemia (AML) and may be mediated by circulating cytokines. We examined this relationship in 74 adult AML patients before and after the first cycle of induction chemotherapy. Plasma levels of 13 cytokines were measured via electrochemiluminescence. At baseline, potentially clinically important (r>0.30) correlations were seen between tumor necrosis factor (TNF)-α and fatigue (r=-0.336, p=0.017). Over time, correlations with fatigue were noted with TNF-α (r=-0.341, p=0.006) and interferon-inducible protein (IP)-10 (r=0.353, p=0.005). The link between IP-10 and fatigue is novel, implicating CXC chemokine pathways for CRF in hematologic malignancies.

A clinical trial of supervised exercise for adult inpatients with acute myeloid leukemia (AML) undergoing induction chemotherapy

Patients with acute myeloid leukemia (AML) receiving induction chemotherapy (IC) were enrolled in a supervised exercise intervention to determine safety, feasibility, and efficacy. Physical fitness measures, quality of life (QOL) and fatigue were assessed using standardized measures at baseline, post-induction, and post first consolidation. Retention was excellent, the intervention was safe, and efficacy estimates suggested benefits in physical fitness and QOL outcomes. Exercise is a safe, promising intervention for improving fitness and QOL in this patient population. These results provide a foundation for a randomized trial to better understand the impact of exercise during IC on clinically important outcomes.

Quality of life issues in elderly acute myeloid leukemia patients

The median age of acute myeloid leukemia (AML) is 70 years. Treatment approaches include standard chemotherapy, palliative chemotherapy and investigational agents, depending upon disease biology and patient factors. In this article, we highlight the issues involved in the treatment of AML in older patients, focusing on the quality of life changes associated with each treatment modality at different stages of their disease course. We further discuss recent insights into the biological basis of quality of life changes, and examine potential ways to improve these through pharmacological and nonpharmacological means. Finally, we explore avenues for future research into the quality of life of the older AML patient.

Registro do diagnóstico de enfermagem fadiga em prontuários de pacientes oncológicos

OBJETIVO: Identificar o registro de diagnóstico de enfermagem (DE) fadiga, as características definidoras e as intervenções de enfermagem em prontuários de pacientes oncológicos internados em hospital. MÉTODOS: Trata-se de um estudo transversal retrospectivo. A coleta de dados foi realizada em 107 prontuários de pacientes com diagnóstico médico de câncer, nos meses de agosto a dezembro de 2007. RESULTADOS: Foi encontrado um DE fadiga representando 0,9%, entretanto, foram encontradas, nas evoluções diárias registradas pelo enfermeiro, as características definidoras do DE fadiga em 15,9% dos prontuários. CONCLUSÃO: Apesar de identificar as características definidoras (sinais e sintomas), os enfermeiros não estabelecem o DE fadiga. Por esta razão, surgem dúvidas quanto à adequação das características definidoras deste diagnóstico Outros estudos sobre esta temática devem ser feitos para aprimorar a assistência de enfermagem ao paciente oncológico.

Quality of life beyond 6 months after diagnosis in older adults with acute myeloid leukemia

Although intensive chemotherapy may improve survival in older people with acute myeloid leukemia (AML) without adverse cytogenetics, its impact on quality of life (QOL) is mixed and most patients complain of fatigue up to 6 months after diagnosis. Little information is available on longer-term QOL outcomes. We prospectively followed 20 patients age 60 or older with AML who provided QOL data more than 6 months after diagnosis. Over the first 6 months, there were clinically important improvements in global health, role function, social function, and emotional function. Physical function and cognitive function were stable over time. Over the next 6 months, social function and fatigue improved, and other domains remained stable. Achievement of complete remission appeared to be associated with improvements in global health, physical function, and role function without negatively affecting other health domains. This information may aid discussions with patients about treatment.

The impact of acute myeloid leukemia and its treatment on quality of life and functional status in older adults

Although intensive chemotherapy (IC) may modestly improve survival compared to supportive care in older people with acute myeloid leukemia (AML), treatment may worsen quality of life (QOL) and functional status. We assessed QOL and functional status at baseline, 1 month, 4 months, and 6 months in 65 consecutive, English-speaking, patients age 60 or older with newly diagnosed AML. At baseline, functional status was high but QOL was negatively affected in global health and most QOL domains. Over time, QOL remained stable or improved in most patients and was generally similar between IC and non-IC groups. Basic activities of daily living (ADL) scores did not change over time, whereas instrumental ADL scores declined slightly regardless of treatment. Receiving IC does not appear to lead to worse QOL or functional status than more palliative approaches. This information may aid treatment discussions in older patients with AML.