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Improving End-of-Life Care for Patients With Acute Myeloid Leukemia Receiving Non-Curative Therapy: Richa Thakur, MD

In this interview from the American Society of Hematology (ASH) Annual Meeting, Dr. Richa Thakur, OncData Fellows Forum member and Hematology/Oncology Fellow at Northwell Health, discusses her poster presentation on end-of-life outcomes in patients with acute myeloid leukemia (AML) receiving non-curative chemotherapy. Dr. Thakur shares her passion for improving palliative and end-of-life care for this patient population, as well as the highlights of her experience of attending ASH as a Fellow.  

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're here at the ASH Annual Meeting, and I'm joined by one of our Fellows Forum members, Dr. Richa Thakur.

Richa Thakur, MD: It's so good to be here. Thank you for having me.

Oncology Data Advisor: Of course. It's wonderful to have finally met you in person yesterday and to be able to chat and everything here.

Dr. Thakur: I know, it's so great that we're finally able to start doing things in person now.

Oncology Data Advisor: Yes, definitely. So, I know you're presenting a poster tonight on end-of-life outcomes in patients with acute myeloid leukemia receiving non-curative chemotherapy. To give a little bit of background, why did you decide to investigate this?

Dr. Thakur: When I started doing palliative care, one of the most eye-opening experiences was doing my hospice rotation. I would drive house-to-house and see patients getting hospice at home. It was just such a unique way to look at hospice and all of the things that we can do to support patients in their home.

Then when I switched to hematology/oncology and I started seeing leukemia patients, it was really heartbreaking for me. We couldn't do a lot of these things that we do in outpatient hospice for our leukemic patients, just because of the concept of hospice doesn't really fit well with AML. That's part of where the idea for my research project was born—to get an idea of what we really need to help improve outcomes in the end-of-life portion for patients with AML so that we could design a better program for them.

Oncology Data Advisor: It's definitely a huge gap and an important avenue to investigate. How did you go about designing this study?

Dr. Thakur: With end-of-life outcomes, the patient population usually selects itself. I looked at a year of charts for patients at Northwell who were diagnosed with AML and had passed away. Within that population, I picked a very small selection of patients receiving non-curative therapy for AML.

One of the other problems you have with AML is that most of the time, the goal for treatment is cure. It's very, very hard to stop a treatment that's going to cure your patient, even if they are dying. It's really at the very end where you have to stop treatment. But when you have a non-curative population, that's your opportunity to stop. Of all the patients who had died, I excluded anyone who was transplant-eligible, and then I looked at what treatments they got as later-line treatment, such a hypomethylating agent with venetoclax.

Oncology Data Advisor: What results did you find in the study?

Dr. Thakur: It was really sad. We had about 84 patients who were included in the study, but half of hem died while taking some sort of hypomethylating agent with venetoclax. I had a different analysis for those patients, but the 42 that continued on to next-line treatment were divided into three groups. About 15 of these patients ended up getting best supportive care, which means no chemotherapy, but blood transfusions. Then within that 42-patient population, there was a subgroup that went on to next-line chemotherapy, and then another smaller group just went to hospice.

From these groups, what we found was that the median overall survival for patients who went on to next-line treatment was around 56 days. Patients who went onto best supportive care didn't have that significantly lower of an overall survival. The median overall survival for our hospice patients was seven days, which makes sense because if you have a patient who transfusion-dependent, they don't really have much time when you can't transfuse them.

The thing is, the study is retrospective. It's a very small patient population, so obviously there's much more that we need to do to really extrapolate. But what this is telling me is that maybe we shouldn't be doing chemotherapy after decitabine or another hypomethylating agent when venetoclax stops working on our patients. Maybe it might just be better to monitor these patients and treat supportively. But which subset this would be better for, I think we need to do much more research on.

Oncology Data Advisor: Going along with this, what are some other opportunities you've identified either through this research or similar research for improving end-of-life care for this population?

Dr. Thakur: I think one of the things that really shocked me from what I found in our study was the ability of our patients to receive goal-concordant care. It's really tough to measure this retrospectively, so what I used as a surrogate marker was the proportion of patients that had a Medical Orders for Life-Sustaining Treatment (MOLST) form—a code status that was discussed and filled out—or also a healthcare proxy. About 80% of our patients did have these filled out regardless of the treatment outcomes. But of the patients who chose "do not resuscitate" and "do not intubate," more than half made these decisions within the last 24 hours of life. If you can imagine what that looks like for a patient, that's just absolutely terrible.

The thing is, it's when you start these patients on treatment, they're already slightly older. They're very frail. You know you're not going to cure them, so there's really no reason to wait so long to at least discuss these wishes for the patients. I think that would be a great opportunity where we can intervene on interventions earlier on. But when to consider transitioning them from next-line treatment to best supportive care versus hospice, I think that needs so much more research. Especially with all of the trials that are coming out with different lines like selinexor in this population, who knows what will come out next and what will actually be better for our patients?

Oncology Data Advisor: Definitely, those are such important questions to investigate. Do you have any next steps planned for this study?

Dr. Thakur: So, I picked a very, very small population that had passed away. What I do want to do moving forward is to expand this population to include patients who were getting curative-intent therapy. What I'm hoping to do is get an idea of their palliative care needs throughout the spectrum of their illness. I expect that around the time of each relapse, there's probably going to be a higher symptom burden or a need to address things like goal-concordant care. Then towards the end of life is where you would also need much more aggressive palliative interventions. At least having an idea of where things are and when they're needed would help design a prospective trial so that I could intervene to get better palliative care for AML patients.

Oncology Data Advisor: Definitely. Thank you so much for explaining this research to us, and also thank you for embarking in this research and helping to improve outcomes for these patients.

Dr. Thakur: Thank you for giving me the opportunity to share about it. I really appreciate it.

Oncology Data Advisor: To wrap up, I also want to ask, how has your experience been of attending ASH as a Fellow? What kind of opportunities have you seen here?

Dr. Thakur: Oh, it's been absolutely amazing. Every trainee should sign up for ASH if you can. ASH-a-Palooza was one of my favorites. It was just really nice to meet other co-Fellows. One of the things I love about ASH is that there's just so much help that you get, whether it's from education with these great lectures, meeting other co-Fellows to share and bond over your training experience, and also networking. You really, really grow a lot. Meeting other people here who are also just as passionate about Hematology helps so much. Whether it's job hunting, interdisciplinary research, or project collaborations, it's a really great way to just get to know more about the field.

Oncology Data Advisor: Absolutely. Is there anything in particular you've seen here that you're planning on bringing back to your other Fellows at your institution, or maybe anything you'll share with patients when you get back?

Dr. Thakur: Oh boy, that's a good question. I think one of the things I really, really appreciated was that they had a lot of networking opportunities for women in medicine, especially in Hematology. One of the talks that they had, as well as at ASH-a-Palooza, was about imposter syndrome. We often use the phrase "imposter syndrome" when something doesn't really fit for a population, meaning the world isn't always built for women or minorities. You look at surgical instruments—things are designed for a man's hands, and women have smaller hands. The talk was trying to reinforce that it's not imposter syndrome; you do belong in medicine. This was a really great confidence boost, and to help build other women up is something I'm definitely going to take back.

Oncology Data Advisor: Awesome, that sounds really amazing. This has been so great talking with you today. Thank you so much for stopping by, and we're looking forward to having many more interviews with the Fellows Forum.

Dr. Thakur: Thank you for having me. It's so nice to meet you guys, too. I hope you have fun here.

About Dr. Thakur

Richa Thakur, MD, is both a Palliative Care Physician and Hematology/Oncology Fellow at Zucker School of Medicine at Hofstra/Northwell Health. She graduated from Washington University in St. Louis with a bachelor's in chemistry, medical school at Texas A&M, residency in Internal Medicine, and a fellowship Palliative Care at Zucker School of Medicine. Her research interests include improving quality of life in patients diagnosed with hematologic malignancies.

For More Information

Thakur R, Boisclair S, Naing PT, et al (2023). End-of-life outcomes in patients with acute myeloid leukemia receiving non-curative chemotherapy. Presented at: 2023 American Society of Hematology Annual Meeting. Abstract 3807. Available at: https://ash.confex.com/ash/2023/webprogram/Paper190266.html

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor. 


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