What Is the Clinical Course of Hematologic Malignancies?

Introduction and Scope of the Problem

The hematologic malignancies consist of a broad group of disorders comprising approximately 10% of new cancer diagnoses each year in the United States. Patients with hematological malignancies experience widely varying clinical trajectories, prognoses, and treatment intensities. Some patients, with chronic or more indolent diseases characteristics may have no symptoms from their disease and can be managed with observation alone. Others, such as those with acute leukemias or aggressive lymphomas, may experience a rapid decline of health at the time of diagnosis and require prolonged hospitalization and intensive therapy to achieve disease control. Moreover, patients with hematological malignancies often suffer from substantial morbidity including bone marrow failure, infections, and transfusion requirements. Despite the recent introduction of novel therapies such as targeted agents and immunotherapy in the treatment of patients with hematological malignancies, mortality remains high, with approximately 56,000 individuals dying each year in the United States from these diseases. There remains a critical need for innovations that optimize the quality of life and care delivery for patients with hematological malignancies.

In recent years, there has been an increasing interest in describing palliative care needs of and overcoming barriers to palliative care integration for patients with hematological malignancies. These barriers include patients, families, and clinicians equating palliative care with end-of-life care, prognostic uncertainty and misconceptions about prognosis, and system-level factors such as lack of palliative care availability and inability to receive transfusions in hospice (see Chapter 37 for an in-depth discussion of these barriers). This chapter outlines the unique trajectory and features of hematological malignancies that lead to the specific palliative care needs of those affected by them. Specific topics include an overview of hematological malignancies, symptom burden, prognostic awareness of patients and families, and patterns of resource utilization, particularly near the end of life.

Overview of Hematological Malignancies

Hematological malignancies are a remarkably heterogeneous group of diseases, and are rarer in general than most solid tumors. While a thorough review of hematological malignancies is beyond the scope of this chapter, it is important to understand the fundamental differences between types of hematological malignancies, and to recognize how these diseases contrast with more common solid tumors. Unique features of hematological malignancies include at least one of the following: (1) an unpredictable illness course, or wide variability in the range of possible outcomes including the possibility of cure; (2) the need for intensive treatments to achieve a good outcome, which is associated with risk of toxicity and early death; (3) a nontraditional staging system; and (4) in some diseases, a more chronic course punctuated by the intermittent need for active therapy, or a requirement for continuous therapy indefinitely. Following is a brief review of the three major categories of hematological malignancies and their salient features.