In recent years, considerable progress has been made in frontline therapy for elderly/physically unfit patients with CLL. The combination of obinutuzumab and chlorambucil (O-Clb) has been shown to prolong progression free survival (PFS, median PFS-31.5 months) and overall survival (OS) compared to chlorambucil alone. More recently, obinutuzumab given in combination with either ibrutinib or venetoclax improved PFS but not OS when compared to O-Clb. In this retrospective multinational, multicenter co-operative study, we evaluated the efficacy and safety of frontline treatment with O ± Clb in unfit patients with CLL, in a "real-world" setting. Patients with documented del (17p13.1)/TP53 mutation were excluded. A total of 437 patients (median age, 75.9 years; median CIRS score, 8; median creatinine clearance, 61.1 mL/min) were included. The clinical overall response rate was 80.3% (clinical complete and partial responses in 38.7% and 41.6% of patients, respectively). Median observation time was 14.1 months and estimated median PFS was 27.6 months (95% CI, 24.2-31.0). In a multivariate analysis, high-risk disease [del (11q22.3) and/or IGHV-unmutated], lymph nodes of diameter > 5 cm, obinutuzumab monotherapy and reduced cumulative dose of obinutuzumab, were all independently associated with shorter PFS. The median OS has not yet been reached and estimated 2-year OS is 88%. In conclusion, in a "real-world" setting, frontline treatment with O-Clb achieves PFS comparable to that reported in clinical trials. Inferior outcomes were noted in patients with del (11q22.3) and/or unmutated IGHV and those treated with obinutuzumab-monotherapy. Thus, O-Clb can be still considered as legitimate frontline therapy for unfit CLL patients with low-risk disease.
Background: One of the main obstacles of providing home-based palliative care to transfusion-dependent hematology patients is the lack of home transfusions services. While healthcare professionals are concerned with safety and cost of home transfusions, the attitude of the patients toward home transfusions are mostly unknown. Aim: To obtain quantitative data regarding the willingness and concerns of transfusion-dependent patients with hematological diseases toward the option of home transfusions. Design: A cross sectional survey including a self-administered questionnaire in one of the three main spoken languages in Israel was administered to patients in 17 hospital hematology outpatient clinics between May 2019 and March 2020. Results: About 52% of 385 patients that participated in the survey preferred home transfusions to hospital transfusions. Gender, age, education, or type of disease were not associated with preference for home transfusions, nor were hospital location or its size. The likelihood to prefer home transfusions was significantly higher among the Hebrew-speakers and those who had not experienced adverse effects previously. The most significant factor associated with preference of home transfusions was a perceived negative effect of hospital-based transfusion on quality of life. The main reason to reject home transfusions was fear of possible adverse effects and concerns over losing contact with the medical staff at the treating hospital. Conclusion: These data suggest that a significant portion of transfusion-dependent patients in Israel view home transfusions as a preferred treatment option and that its successful implementation requires maintaining ongoing contact with the treating hospital.
Abstract Background : Most cancer patients want to die at home; however, many die in hospital. The aim of the current study is to elucidate the correlation between dying at home and various personal factors in the Israeli population of cancer patients. Methods : Data on cancer incidence (2008-2015) and death (2008-2017) was provided by the Israeli Central Bureau of Statistics and the Israel National Cancer Registry. Binary logistic regression analyses were performed to assess odds ratios for death at home following cancer diagnosis while controlling for age, sex, ethnicity, years of education, residential socioeconomic score, and time from diagnosis. We also assessed the relation between place of death and specific cancer sites, as well as the time trend from 2008-2017. Results : About one quarter (26.7%) of the study population died at home. Death at home was most frequent among patients diagnosed with brain tumors (37.0%), while it was the lowest among patients with hematologic malignancies (lymphoma and leukemia, 20.3% and 20.0%, respectively). Rates of dying at home among patients with residential socioeconomic scores of 1, 2-9, and 10 were about 15%, 30%, and 42.9%, respectively. In patients from the 4 th to the 7 th decades of life, rates of death at home increased at a linear rate that increased exponentially from the 8 th decade onwards. After controlling for potential confounders, predictive variables for death at home included age (HR=1.020 per year), male sex (HR=1.18), years of education (HR=1.029 per year), and time from diagnosis (HR=1.003 per month, all p<0.001). No trend was seen from 2008-2013, while from 2014-2017 a slight increase in the rate of death at home was seen each year. Conclusions : These results indicate that inequality exists among cancer patients in Israel regarding the opportunity to die at home. The present findings stress the importance of delivering efficient palliative care at home, mainly for patients with hematologic malignancies, younger patients, and patients of very low socioeconomic statuses. Understanding the complex mechanisms whereby patient preferences and the above variables may determine the preferred place of death remains an important research priority.
Abstract Objectives To compare end‐of‐life (EOL) care for solid tumor and hematologic malignancy (HM) patients. Methods We collected data on the last 100 consecutive deceased HM and 100 consecutive deceased solid tumor patients who died prior to June 1st 2020, treated at a single center. We compared demographic parameters, cause of death as ascertained by review of medical records by two independent investigators, and EOL quality indicators including: place of death, use of chemotherapy or targeted/biologic treatment, emergency department visits as well as hospital, inpatient hospice and Intensive Care Unit admissions and the time spent as inpatient over the last 30 days of life; mechanical ventilation and use of blood products during the last 14 days of life. Results In comparison with solid tumor patients, HM patients more commonly died from treatment complications (13% vs. 1%) and unrelated causes (16% vs. 2%, p < .001 for all comparisons). HM patients died more frequently than solid tumor patients in the intensive care unit (14% vs. 7%) and the emergency department (9% vs. 0%) and less frequently in hospice (9% vs. 15%, p = .005 for all comparisons). In the 2 weeks prior to death HM patients were more likely than solid tumor patients to undergo mechanical ventilation (14% vs. 4%, p = .013), receive blood (47% vs. 27%, p = .003) and platelet transfusions (32% vs. 7%, p < .001); however, no statistical difference was found in use of either of chemotherapy (18% vs. 13%, p = .28) or targeted treatment (10% vs. 5%, p = .16). Conclusions HM patients were more likely than solid tumor patients to undergo aggressive measures at EOL. Rarity of HM deaths, frequently caused by complications of treatment and unrelated causes, may affect treatment choices at EOL.
The experience of a patient's death on medical students is powerful and may entail distress and anxiety. We review the experience of death and dying as perceived by medical students. Students are exposed to death and dying while dissecting cadavers in pre-clinical years, following patient death in clinical years, and commonly as a result of personal exposure. Students report sadness and anger in response to patient death, particularly following their first experience. The patient's identity and the student's past exposure to death were found to influence the way students experience death and dying. Coping methods may include conversation, reflection, and religion as well as detachment and avoidance. Although time and resources are invested in preparing students for a patient's death, many of them feel inadequately prepared. Greater understanding of and investment in processing medical students' experience of patient death may be helpful in their personal and professional development.
