"Use of palliative prognostic score (PaP-score) in terminally ill elderly patients with acute myeloid leukaemia referred to a domiciliary program of supportive and palliative care". Poster presented at the 10th Congress of the Italian Society of Experimental Hematology SIES (Bari, 2008).

1. USE OF PALLIATIVE PROGNOSTIC SCORE (PaP-SCORE)
(PaP-
IN TERMINALLY ILL ELDERLY PATIENTS WITH ACUTE MYELOID LEUKAEMIA
REFERRED TO A DOMICILIARY PROGRAM OF SUPPORTIVE AND PALLIATIVE CARE CARE
Alfieri P*, Favale E*, Luppi M° and Torelli G°
°Division of Haematology, Modena University Hospital – *AIL Modena Home Care Service
Introduction
Home care (HC) has achieved a relevant role in the global management of patients with blood
malignancies improving quality of life and reducing health care costs, especially in groups of unfit
and elderly patients such as those affected by acute myeloid leukaemia (AML). In this clinical
setting there is lack of consensus in predicting life expectancy and establishing the true terminal
phase of disease. Unlike in haematologic neoplasms a palliative prognostic score (PaP-score) has
been validated for terminally ill patients with solid tumours (see Figure 1), based on predictive role
of six factors (dyspnoea, anorexia, Karnofsky index, clinical prediction of survival, white blood
count, lymphocyte percentage). Here we report our attempt to apply the same prognostic score on
a population of 36 terminally ill patients with AML, aged more than 65 years and undergone
domiciliary assistance.
Methods
In our division a haematologic home care service is active according to a protocol agreed in 1998 by
university hospital, community health services and the fundraising organisation AIL (Italian
Association against Leukaemia-Lymphoma-Myeloma). Eligibility criteria are: diagnosis of blood
malignancy, age > 18, low performance status, distance from hospital < 15 km, availability of a
care-giver, proper home logistics.
Results
In our study population, consisting of 36 patients (M=15, F=21) with a median age of 79 years
(range 66-92), PaP-score was retrospectively calculated based on clinical information at the onset
of terminal phase, that generally corresponded to the starting-day of home care. As shown in Table
1, patients have been divided in three risk-groups comparing the 30-day survival probability with
actual duration of home assistance (91 days on average). Clinical estimation of survival was the
most impacting feature on prognosis. Median PaP-score in patients deceased within the first month,
was 11.1, matching the high-risk group, while in long-surviving patients PaP-score revealed a better
survival probability.
Fig. 1 Tab. 1
Target population HC median duration Patients surviving > 30 days
Group A (n=5, score=3.1) 153 days 4 (80%)
Group B (n=15, score=9.4) 125 days 12 (80%)
Group C (n=17, score=13.1) 44 days 9 (53%)
Overall (n=36, score=10.3) 91 days 25 (69%)
Target population Median PaP-score HC median duration
Patients died < 30 days (n=11) 11.1 20 days
Patients died from day + 31 to + 90 (n=13) 10.1 55 days
Patients died > 90 days (n=12) 8.4 138 days
Conclusions
In the ongoing effort to improve the quality of remaining life in terminal elderly patients with AML a
prognostic tool like PaP-score can represent a valid resource to predict life expectancy and to
address decision-making processes toward a home care setting. The investigation of other
prognostic factors, less subjective and more related to AML, such as peripheral blast percentage,
bleeding, fever and transfusion requirement, might concur to define outcome and management in
end-of-life care.
References
Maltoni M et al. Successful Validation of the Palliative Prognostic Score in Terminally Ill Cancer
Patients. Journal of Pain and Symptom Management. April, 1999; 17(4): 240-247.
Author’s details
Dr. Pierluigi Alfieri
Servizio di Assistenza Domiciliare Ematologica AIL – Divisione di Ematologia – Policlinico di Modena
E-mail: pierluigi.alfieri@unimore.it – Mobile: +39.338.4153347 – Website: www.ailmodena.it