© 2006 European Society for Medical Oncology
editorial |
Home treatment for intensive hematological therapies: who will benefit?
University Hospital Maastricht, PO Box 5800, 6202 AZ Maastricht, Netherlands
(E-mail: h.schouten{at}intmed.unimass.nl)
The treatment of patients with acute leukemia underwent a significant change in the second half of the 20th century. It was increasingly recognized that standard dose chemotherapy only had a palliative effect and did not change the natural course of the disease. To achieve long-lasting survival it appeared to be necessary to obtain a complete remission [1
]. Also, in elderly patients, it was recognized that only intensive treatment was able to change the natural course of the disease [2]. So, based on these results, intensive chemotherapy aimed at the induction of a remission and the subsequent prevention of relapse has become standard care [3].
This intensive chemotherapy can only be given to (younger and older) patients if adequate supportive care can be provided. Not only was the supplementation of red blood cells and platelets important but, above all, it appeared to be very relevant to prevent infections. In those early years of intensive therapies a special focus was laid on the prevention of infections using reversed isolation, gowns etc. These methods were introduced without the proven value derived from randomized studies. Even maximum effort was not always good enough. The value of a protective environment was one of the measures questioned subsequently because it became clear that the patient himself was the source of infections in the majority of cases, or that the patient already carried the fungus with him at admission in the hospital (as may be the case in aspergillosis) [4].
In addition, prophylactic antibiotics were introduced generally based on common sense and data from early transplant studies [5]. However, this introduction of prophylactic antibiotics was questioned [6]. Many arguments in favor but also against the prophylactic use of antibiotics can be summarized, such as the emergence of resistance in case of increased use, expenses related to prophylactic and therapeutic use, etc. Only recently randomized studies have provided evidence on the value of prophylactic antibiotics in intensive therapies for hematological malignancies and solid tumors [7–9]. However, despite these debates the further development of supportive care has enabled the improvement of the results of intensive therapies in hematology.
Because of increasing health care costs and relatively insufficient budgets in several countries there is an emerging interest to move the treatment of patients from the hospital to the outpatient setting. Not evidence but practical (less costs, less burden to health care systems, etc.) and logical arguments (less resistance to antibiotics at home, patients prefer to be at home and not in hospital, etc) were the basis for this change. Several relatively small phase II studies have tackled this issue (summarized in [4]) showing feasibility but not ultimate proof of safety.
In this issue of the Annals of Oncology Savoie et al. report on their experience of treating patients with acute myeloid leukemia in the outpatient setting [10]. They conclude that this approach is feasible and safe. However, the numbers of patients treated in this study again are limited and a control group was absent. This may limit the potential to generalize the conclusions of this study.
To come to firmer conclusions randomized trials should be done. Recently, the first interim data of a randomized study comparing hospital care with home care in 160 patients in an autologous transplant setting were reported at the 32nd annual meeting of the European Group for Blood and Marrow Transplantation (EBMT) [11]. The authors came to the conclusions that this approach of homecare is feasible; however, anxiety, satisfaction evaluation and quality of life favored in-hospital treatment!
The treatment of patients with intensive therapies has come a long way. There is no doubt that this is, to a large extent, the result of developments in supportive care. History shows that progress can be made, also in the absence of randomized studies. However, if the first results of Faucher [11], at the final analysis, appear to be correct we are facing the problem that we may change the treatment location from in-hospital to outpatient for budgetary reasons and also assuming that patients will favor outpatient therapy but that the patients, at the end of the day, don't like it at all. Whom are we benefiting?
References
1. Ellison RR, Holland JF, Weil M et al. Arabinosyl cytosine: a useful agent in the treatment of acute leukemia in adults. Blood 1968; 32: 507–523.
2. Lowenberg B, Zittoun R, Kerkhofs H et al. On the value of intensive remission-induction chemotherapy in elderly patients of 65+ years with acute myeloid leukemia: a randomized phase III study of the European Organization for Research and Treatment of Cancer Leukemia Group. J Clin Oncol 1989; 7: 1268.[Abstract]
3. Tallman MS, Gilliland DG, Rowe JM. Drug therapy for acute myeloid leukemia. Blood 2005; 106: 1154–1163.
4. van Tiel FH, Harbers MM, Kessels AG, Schouten HC. Home care versus hospital care of patients with hematological malignancies and chemotherapy-induced cytopenia. Ann Oncol 2005; 16: 195–205.
5. Vossen J, van der Waay D. Reverse isolation in bone marrow transplantation: ultra-clean room compared with laminar flow technique. I. Isolation systems. Rev Eur d'Etudes Clin Biol 1972; 17: 457–461.
6. Donnelly JP. Selective decontamination of the digestive tract and its role in antimicrobial prophylaxis. J Antimicrob Chemother 1993; 31: 813–829.
7. Tjan-Heijnen VC, Postmus PE, Ardizzoni A et al. Reduction of chemotherapy-induced febrile leucopenia by prophylactic use of ciprofloxacin and roxithromycin in small-cell lung cancer patients: an EORTC double-blind placebo-controlled phase III study. Ann Oncol 2001; 12: 1359–1368.
8. Bucaneve G, Micozzi A, Menichetti F et al. Levofloxacin to prevent bacterial infection in patients with cancer and neutropenia. N Engl J Med 2005; 353: 977–987.
9. Cullen M, Steven N, Billingham L et al. Antibacterial Prophylaxis after Chemotherapy for Solid Tumors and Lymphomas. N Engl J Med 2005; 353: 988–998.
10. Savoie M, Nevil T, Song K et al. Shifting to outpatient management of acute myeloid leukemia: a prospective experience. Ann Oncol 2006; 17: 763–768.
11. Faucher C, Le Corroller A, Vey N et al. Ambulatory autologous transplant: is it feasible and is it desirable? Results of a prospective large randomised study. In European Group for Blood and Marrow Transplantation, Edition Hamburg: Bone Marrow Transplantation 2006; S59.
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