1. Fuerst, Mark L.

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SAN DIEGO-Older patients with acute myeloid leukemia (AML) appear to substantially misperceive the risks of their treatment and tend to overestimate the likelihood of cure as compared to their oncologists' estimates, according to a new study.


"Patients with AML face very challenging treatment decisions that are often placed upon them within days after being diagnosed," noted senior author Areej El-Jawahri, MD, Assistant Professor of Medicine at Massachusetts General Hospital in Boston. "Because they face a grave decision, they need to understand what the risks of treatment are versus the possibility of a cure."


El-Jawahri presented the findings at the 2017 Palliative and Supportive Care in Oncology Symposium (Abstract 43).


Older patients age 60 years and up with AML face difficult treatment decisions as they can be treated either with risky multi-drug intensive chemotherapy for a small chance of a cure, or non-intensive and non-curative palliative chemotherapy.


AML Research

El-Jawahri and colleagues conducted a longitudinal study of 100 older patients newly diagnosed with AML at two tertiary care hospitals. At enrollment, they assessed patients' and oncologists' perception of treatment-related mortality. Within 3 days after starting treatment, both the patients and their physicians were given a questionnaire to assess how they perceived the likelihood of dying from the treatment. At 1 month, they assessed patients' and oncologists' perception of prognosis using the Prognosis and Treatment Perception Questionnaire. Within that time frame, most patients received laboratory results that more definitively established the type and stage of cancer.


The researchers enrolled consecutive patients within 72 hours of initiating therapy. Fifty patients received intensive care for AML, which usually meant hospitalization for 4-6 weeks, and 50 patients received non-intensive care, often given as outpatient treatment. The patients, median age of 71 years, were almost exclusively white (92%), more than half had a college education, and most of them were from higher income brackets.


Regardless of whether they received intensive or non-intensive care, about two-thirds (63%) of patients thought it was somewhat likely they would die due to treatment, and about one-quarter (28%) thought it was extremely likely they would die. In contrast, 80 percent of the treating oncologists thought it was very unlikely that their patients would die due to treatment.


One month later, nearly all (90%) of patients thought it was somewhat or very likely they would be cured of their AML. In contrast, three-quarters of their oncologists thought it was unlikely or very unlikely that their patients would be cured. The gap between patient and doctor perceptions was most striking for patients receiving non-intensive therapy, with 44 percent of patients believing they would very likely be cured, while none of their oncologists thought this was very likely.


Patients receiving both intensive and non-intensive chemotherapy had significant misperceptions about their prognosis, he said.


Cultivating Conversations

"Prognostic misperceptions are especially striking in patients receiving non-intensive chemotherapy," El-Jawahri said. "Interventions to facilitate communication are needed to ensure patients with AML have an accurate understanding of their treatment risks and prognosis and are therefore enabled to make informed decisions about treatment.


"There were several very important factors we were not able to capture in our study, including what was actually discussed between patients and their oncologists, and whether patients simply misunderstood or misheard the information conveyed to them. Perhaps most importantly, we did not audio-record the discussions between the patients and their physicians, which could provide additional details regarding barriers to accurate prognostic understanding in these conversations."


Previously, the researchers had examined similar perceptions among patients with lung, colorectal, and other cancers, as well as those with blood cancers receiving hematopoietic stem cell transplantation. The gaps in perception of treatment risk and cure for patients were larger in AML patients as compared to patients with other cancers, which the researchers attribute to higher levels of distress seen among AML patients due to the urgency of their treatment decisions.


Early consideration of palliative care in a treatment plan for patients with solid tumors improves patients' understanding of the prognosis, he said. The researchers hope to implement a similar study in leukemia patients.


"Clearly there are important communication gaps between oncologists and their patients," said El-Jawahri. "We need to find ways to help physicians do a better job of communicating with their patients, especially in diseases like AML where stress levels are remarkably high."


ASCO Expert Andrew S. Epstein, MD, Medical Oncologist at Memorial Sloan Kettering Cancer Center in New York, commented: "Regardless of when cancer is detected, the experience of being diagnosed can cause patients a tremendous amount of stress and anxiety. Effective physician-patient communication is critical so that patients can have an accurate understanding of treatment risks and likely outcomes and make better-informed decisions with their doctor."


Mark L. Fuerst is a contributing writer.


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