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Who Benefits From Maintenance Therapy in Acute Promyelocytic Leukemia?

Edmond Marzbani and Elihu Estey

Acute promyelocytic leukemia (APL) is remarkable for its upfront mortality rate from disseminated intravascular coagulation and its high cure rate with therapy. Although induction and consolidation regimens continue to evolve, newer approaches combine an anthracycline with or without cytarabine and the highly effective differentiating drugs all-trans retinoic acid and arsenic trioxide. Early trials showed a benefit of maintenance therapy on overall survival, although this benefit has been less clear in subsequent trials. This review assesses the differences in these trials and outlines a rational approach to maintenance therapy in APL, generally advising against maintenance in patients who underwent adequate consolidation therapy, particularly if they presented with low-risk disease (WBC < 10,000) and experienced molecular complete remission after completion of consolidation.

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Financial Implications of Early Hospital Discharge After AML-Like Induction Chemotherapy: A 4-Year Retrospective Analysis

Nathan J. Moore, Megan Othus, Anna B. Halpern, Nicholas P. Howard, Linyi Tang, Kyle E. Bastys, Mary-Elizabeth M. Percival, Paul C. Hendrie, Garrett A. Hartley, Verna L. Welch, Elihu H. Estey, and Roland B. Walter

Background: Early hospital discharge (EHD) after intensive acute myeloid leukemia (AML) induction chemotherapy has become routine at the University of Washington/Seattle Cancer Care Alliance over the past several years. We assessed the financial implications of EHD over the first 4 years after its broad adoption for patients with AML and other high-grade myeloid neoplasms undergoing AML-like induction chemotherapy. Patients and Methods: We retrospectively compared charges between 189 patients with EHD who received all postinduction inpatient/outpatient care within our care system between August 2014 and July 2018 and 139 medically matched control patients who remained hospitalized for logistical reasons. Charges from the day of initial discharge (patients with EHD) or end of chemotherapy (control patients) until blood count recovery, additional chemotherapy or care transition, hospital discharge (for control patients only), an elapse of 42 days, or death were extracted from financial databases and separated into categories: facility/provider, emergency department, transfusions, laboratory, imaging, pharmacy, and miscellaneous. Results: Combined charges averaged $4,157/day (range, $905–$13,119/day) for patients with EHD versus $9,248/day (range, $4,363–$48,522/day) for control patients (P<.001). The EHD cohort had lower mean facility/provider, transfusion, laboratory, and pharmacy charges but not imaging or miscellaneous charges. During readmissions, there was no statistically significant difference in daily inpatient charges between the EHD and control cohorts. After multivariable adjustment, average charges were $3,837/day lower for patients with EHD (P<.001). Conclusions: Together with previous data from our center showing that EHD is safe and associated with reduced healthcare resource utilization, this study further supports this care approach for AML and other high-grade myeloid neoplasms if infrastructure is available to enable close outpatient follow-up.