Page 118 - 2018_12-Haematologica-web

P. Bories et al.
Table 1. Clinical Vignettes of older AML patients derived from real life activity. General instructions
• Six clinical cases of AML patients derived from real life activity are presented.
• You are not alone to decide but we are asking you to state which treatment option would you recommend for each of these
patients among:
1. Intensive chemotherapy
2. Low-intensity therapy (hypomethylating agent or low-dose cytarabine) 3. Best supportive care
• These patients have announced they would accept medical treatment decision • You do not have any clinical trial to offer them.
• You have unlimited possibilities of hospitalization as inpatient or outpatient
Vignette#1: A 72-year old female, with no comorbidity. Normal cardiac function. Untreated low-risk myelodysplastic syndrome for 3 years (refractory anemia, IPSS 0.5). CBC: WBC 1x109/L incl. neutrophil count 0.3x109/L and PB count 5%, Hb 11g/dL, platelets 120x109/L. BMA: FAB1 AML with 40% marrow blast infiltrate, and adverse karyotype (monosomy 7).
Vignette#2: A 75-year old male, coronary artery disease with anterior interventricular artery stenting in 2010, controlled ischemic cardiopathy with medication (LVEF 52%), ECOG 2, recent weight loss 4 kg. CBC: WBC count 75x109/L, PB blast count 40%, Hb 10 g/dL, platelets 50x109/L. BMA: FAB2 AML (marrow blast infiltrate 60%) with normal karyotype.
Vignette#3: A 77-year old female, with an 8-year history of hypertension controlled with angiotensin-converting-enzyme inhibitor, a recent echocardio- gram
showed LVEF of 55%. She is natural carer of her husband affected by Alzheimer’s disease. CBC: WBC 18x109/L incl. 25% peripheral blast, Hb 10g/dL,
platelets 80x109/L, BMA: FAB4 AML with favorable karyotype (inv16).
Vignette#4: A 63-year old male, with a 5-year history of asymptomatic Parkinson disease and recently diagnosed with an asymptomatic carotid artery stenosis (90%). CBC: WBC 2x109/L incl. 5% PB blast count, Hb 8g/dL, platelets 35x109/L. BMA: FAB2 AML (marrow blast infiltrate 30%, tri-lineage dysplasia) with complex Karyotype incl. inv3, -5q, -7.
Vignette#5: Patient from the Vignette#4 but 73-year old.
Vignette#6: Patient from the Vignette#4 but with WBC count 40x109/L incl. PB blast count 25%.
IPSS: International Prognosis Scoring System; CBC: complete blood count; WBC: white blood cell count; Hb: hemoglobin; FAB: French-American-British classification system; BMA: bone marrow aspirate; PB peripheral blast; LVEF: left ventricular ejection fraction; ECOG: Eastern Cooperative Oncology Group Performance Status.
Society of Hematology mailing list received a unique link to enter the survey or opt out. After duplicate names were removed, the panel of potentially eligible subjects contained 1337 physicians, including 220 residents with an email address. On November 30th 2015 we emailed the survey link; non-responders received three subsequent reminders every eight weeks. Before entering the sur- vey, physicians were informed they would not be compensated for their participation. Consent was implied based on reading the sur- vey goals and participating. Assessable respondents included those who answered the 6 vignettes. Data were collected from November 30th 2015 to June 6th 2016, and analyzed at the Toulouse University Cancer Institute and Toulouse Faculty of Medicine.
Statistical analysis
We described physicians’ characteristics using counts and fre- quency for qualitative data, and mean and standard deviation for quantitative data.
To assess the clinician pattern of decision-making for the 6 clin- ical vignettes, we used K-means clustering to define clinician groups with homogeneous patterns of responses to the clinical cases.28 The aim of this method was to define clusters of subjects by maximizing the between-cluster differences in the subjects’ medical choices and by minimizing the within-cluster differences in subjects’ medical choices. This allowed us to define two clus- ters: clinicians more likely to choose intensive chemotherapy (IC), i.e. the “intensive treatment group” (IC group), and those who were more likely to choose less intensive therapy, i.e. the “non- intensive treatment group” (Non-IC group). Only the K-means analyses are presented in this paper. A 6-18 point MDM-score was also calculated for each physician, assigning 1 point for IC, 2 points for LIT, and 3 points for BSC from the responses in the 6
vignettes. The results of this score and its association with the K- means clustering are given in Online Supplementary Table S1. We first tested the physicians’ demographic, occupational and behav- ioral characteristics associated with belonging to the IC group in bivariate analyses at the threshold of 0.2. These variables were then included in a multivariate model systematically adjusted for age and gender. From this step, the variables to keep in the final parsimonious model were determined using a stepwise backward selection based on log-likelihood tests between nested models. All analyses were made using STATA release 14 (Stata Corp LP, College Station, TX, USA).
Results
Of the 1337 invitations sent out to complete the ques- tionnaire, 1295 were eligible and 230 completed question- naires were received (response rate: 17.20%). According to the American Association of Public Opinion Reporting standard definitions, and by taking the characteristics of the mailing list and the interrogated population into account, the adjusted response rate was 45.4% (see Online Supplementary Table S2). No differences were found according to gender or by geographical area between respondents and non-respondents (see Online Supplementary Table S3).
Respondents’ demographic and occupational characteristics
The median age of the respondent cohort was 42 years [standard deviation (SD)±11.2], 123 were male (54%), 160
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