Blood cancers

Outpatient management during neutropenia a viable approach for many AML patients


Neutropenia in paediatric acute myeloid leukaemia (AML) patients may be safely managed in an outpatient setting, but the decision to discharge may go beyond clinical factors, an American study suggests.

The study assessed medical and quality of life outcomes for 554 paediatric acute myeloid leukaemia patients treated for chemotherapy-related neutropenia between 2011 and 2019.

It found outpatients were managed with similar safety and efficacy to inpatients — with no significant differences in bacteremia incidence (23.8% vs 29.0%, adjusted rate ratio: 0.73, P = 0.08) or association with delays to next treatment (mean [SD]: 30.7 [12.2] days vs 32.8 [9.7] days, adjusted mean difference: −2.2, P = 0.03).

Mortality was comparable between in- and outpatients for most courses during induction, though it was higher in outpatients during intensification II (3 patients [5.4%] vs 1 patient [0.5%], P = 0.03), the authors noted in JAMA Network Open.

Patients also had similar health-related quality of life (mean [SD] Paediatric Quality of Life Inventory total score: 70.1 [18.9] vs 68.7 [19.4]).

Some caregivers did express concerns regarding hospital-associated infections and family separation during inpatient management, while others were stressed about caring for a neutropenic child at home, the authors wrote.

Optimising neutropenia management

With no single endpoint in this study highlighting an optimal management strategy, the authors said that discharge decisions may come down to a combination of medical outcomes, patient and family preferences and management feasibility.

For example, “course-specific mortality differences suggest that outpatient management in intensification II should be approached with caution”, they wrote.

Additionally, increased need for ICU-level support in some outpatients may “sway some families to prefer inpatient management”.

Regardless of treatment course, some carers felt patients would be safer in hospital, and others, at home.

“At the hospital, he got the help he needed, if things go downhill. There was a point where he was done with his chemo[therapy] and his ANC went down as expected and then started climbing up … He went to bed one night totally fine and woke up with a 104 ºF [40 ºC] fever just a few hours later,” one carer recounted during the study.

“And he was on the verge of going to the ICU. So yeah, now think of your child being at home, sitting on the couch and that happens? Do you call an ambulance? Do you get in the car and run stop signs to get to the hospital? Or would you rather already be at the hospital?”

Another parent felt they could keep their child’s bedroom “cleaner than the hospital room”, noting that he caught C. difficile each time he went to the hospital.

“…I know he probably wouldn’t have caught [C. difficile] if he was at home, because it’s a hospital-borne illness, and that was a really tough time for him too, going through that and being treated for it, bad stomach cramping. He’s like balled up in knots. He can’t eat because he’s running to jump up, and he has to have a commode by his bed,” they said.

Quality of life, stability and support access also affected patients and families’ preference for in- or outpatient management.

“To be honest, after going through it all, I actually would’ve rather stayed at the hospital, because the noise at home, after being perfectly quiet in the hospital room and the only thing happening was the beeping of the pump,” one patient said.

“That doesn’t match how many kids are in our house yelling and hitting each other daily. So I would actually kind of rather stayed—because the noise itself just caused such a lot of stress for me, because I just hated that, compared to all the nice, perfectly quiet hospital room,” they continued.

A carer said they felt more comfortable having their child at home, with their own bed, privacy, family members and a sense of normalcy.

“When I was home, I didn’t get any help and I couldn’t sleep [be]cause I was always watching her. That’s why I liked going to the hospital more. I could sleep in the hospital. And that was on a couch. I’d find that room to be like a castle.”

The authors noted that, while the “overall degree of financial distress during treatment was similar between management strategies”, financial security could influence decision making.

They advocated for “close collaboration” between medical and non-medical staff (such as social workers), patients and carers when “determining the most effective discharge strategy for an individual patient” — accounting for medical circumstances, preferences, and physical and financial security.

 

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