Home Management of Unfit Patients with Multiple Myeloma: An Italian Single-Center Experience

Abstract

The majority of patients with multiple myeloma are not eligible for curative treatments because of advanced age at diagnosis or contraindications to high-dose chemotherapy. Several anti-myeloma agents and other supportive medications, generally provided on outpatient basis, have shown to improve overall survival and quality of life even in the setting of unfit and fragile patients. Frequent accesses to day-hospital or outpatient clinic may however cause discomfort and unease in myeloma patients presenting vertebral lesions, bone pain, severe immunodeficiency and comorbidities. In our department a hospital-based home care service supported by the fundraising organisation A.I.L. (Italian Association against Leukemia-Lymphoma-Myeloma) is active in order to assist hematology patients who have poor performance status and fulfil other inclusion criteria (appropriate home logistics, caregiver availability and trainability, distance from hospital within 20 km, cooperation with general practitioners, community nurses and on-call doctors). Through a 9-yrs period (July 1999 – June 2008) 53 patients (male=26, female=27) affected by multiple myeloma have been enrolled in a domiciliary program of supportive and palliative care agreed by the hospital Division of Hematology, the Community Health Trust and the local section of the Italian Association against Leukemia-Lymphoma-Myeloma (A.I.L.).All patients were stage II or III according to Salmon-Durie classification. ECOG performance status was 2.8 on average. Median age was 76 years (under 60 years=4 patients, between 60 and 70 yrs=11 pts, between 70 and 80 yrs=17 pts, over 80 yrs=21 pts). At the time they were referred to the service, 14 patients were in terminal phase of disease with a life expectancy of about 3 months; 35 patients presented progressive disease after at least one previous therapy; there were also 4 patients undergoing transplant-based therapeutic programs and discharged early from the ward.Patients were generally followed-up on weekly-basis for collection of blood samples, clinical assessment and intravenous therapies (bisphosphonates, blood and platelet transfusions, anti-myeloma agents, antimicrobials, immunoglobulins). Median duration of a home care cycle was 323 days, with significant differences among the three groups of patients (in terminal phase=84 days, in progressive disease=466 days, in causal treatment=55 days). Excluding 4 ongoing patients, the end of home care resulted in 15 patients deceased at home (37%) and 26 died as inpatients (63%) while 8 patients were referred back to day hospital or ward. Urgent hospital admissions were 66, corresponding to an average of 1.25 admissions per home care cycle: main reasons were infection and fever, cardiopulmonary complications, renal failure, major bleeding and caregiver burnout. Once-monthly bisphosphonate treatment regarded 31 patients for a total of 332 infusions (pamidronate=191, zoledronic acid=141). Blood transfusions were provided to 22 patients for a total of 202 erythrocyte units while 8 patients required platelet transfusions (82 bags). Although most patients were off-therapy or in treatment with oral drugs, several novel and conventional anti-myeloma agents were administered intravenously at home in monotherapy or in combination, such as bortezomib, dexamethazone, vincristine, cyclophosphamide, carmustine, doxorubicine. No serious adverse event was reported as direct consequence of home intravenous therapies.Home care has achieved a relevant role in the global management of patients with blood malignancies improving quality of life and reducing health care costs. Thanks to our operating model, characterized by the presence of a full-time specialist team and by a careful selection of patients, home care of unfit patients with multiple myeloma represents a valid integration to the standard in-hospital hematology services. Many issues remain open, such as cost analysis, quality-of-life assessment, legislation on domiciliary medications, role of fundraising organisations and recognition in public health system.