Abstract presented at the 50th Annual Meeting of the American Society of Hematology ASH (San Francisco, 2008).

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Home Management of Unfit Patients with Articles by Alfieri, P.
Multiple Myeloma: An Italian Single-Center Articles by Torelli, G.
PubMed
Experience Articles by Alfieri, P.
Articles by Torelli, G.
Pierluigi Alfieri1,*, Enzo Favale1,*, Giovanna Leonardi2,*, Social Bookmarking
Leonardo Ferrara3,*, Amedea Donelli2,*, Alessia Bari3,*,
Franco Narni2,*, Roberto Marasca2 and Giuseppe Torelli2,* What's this?
1Hematology Home Care Service, A.I.L. (Italian Association against Leukemia-Lymphoma-Myeloma), Modena, Italy, 2 Division
of Hematology, Modena University Hospital, Modena, Italy, 3 Division of Oncology, Modena University Hospital, Modena, Italy
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.