1
|
Thakar MS, Sorror ML. What makes a pediatric or young adult patient an appropriate transplant candidate? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:731-736. [PMID: 38066934 PMCID: PMC10727049 DOI: 10.1182/hematology.2023000519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
A 3-year-old child with chronic granulomatous disease was brought to the transplant clinic by his parents. The patient has a history of Aspergillus fumigatus pneumonia, which required mechanical ventilation, and sepsis, resulting in several intensive care stays. He has failure to thrive and developmental delay. His parents are seeking guidance whether allogeneic hematopoietic cell transplantation (HCT) is a reasonable treatment option given concerns about his upfront major health limitations. Based on the original HCT-Comorbidity Index (CI), this child's risk for nonrelapse mortality (NRM) would be negligible with a score of 0. With use of the validated youth-nonmalignant HCT-CI, the score increases to 5, due to prior mechanical ventilation (+3), history of fungal infection (+1), and being underweight (+1), with at least 2-fold increase in risk of NRM. The role of developmental delay is unclear and not currently validated to prognosticate survival. While HCT was ultimately recommended in this case, the family was counseled to have a more realistic sense of NRM risk.
Collapse
Affiliation(s)
- Monica S Thakar
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Department of Medicine, University of Washington, Seattle, WA
| |
Collapse
|
2
|
Fraint E, Abdel-Azim H, Bhatt NS, Broglie L, Chattha A, Kohorst M, Ktena YP, Lee MA, Long S, Qayed M, Sharma A, Stefanski H, Vatsayan A, Wray L, Hamadani M, Carpenter PA. Evaluation of Children with Malignancies for Blood and Marrow Transplantation: A Report from the ASTCT Committee on Practice Guidelines. Transplant Cell Ther 2023; 29:293-301. [PMID: 36775202 DOI: 10.1016/j.jtct.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
Evaluation of a candidate for hematopoietic cell transplantation (HCT) is a complex process with substantial intercenter variability. Although literature providing guidance for evaluating the eligibility of adults is well established, similar guidance for children is lacking. To address gaps between adult recommendations and the specific needs of children, we convened a panel of pediatric HCT experts from a wide geographic range of American Society of Transplantation and Cellular Therapy (ASTCT) member institutions to offer recommendations for pediatric-focused pre-HCT evaluation. In this report from the ASTCT Committee on Practice Guidelines, we present a practical framework for evaluating children with malignancies who are candidates for HCT. We also highlight key differences from adults and emphasize areas of unmet need that require additional research to delineate best practices.
Collapse
Affiliation(s)
- Ellen Fraint
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Bronx, New York.
| | - Hisham Abdel-Azim
- Loma Linda University School of Medicine, Cancer Center, Children's Hospital and Medical Center, Loma Linda, California
| | - Neel S Bhatt
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Larisa Broglie
- Medical College of Wisconsin, Department of Pediatrics, Division of Pediatric Hematology/Oncology/Blood and Marrow Transplantation, Milwaukee, Wisconsin
| | - Asma Chattha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mira Kohorst
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Hematology/Oncology, Mayo Clinic, Rochester, Minnesota
| | - Yiouli P Ktena
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Michelle A Lee
- Division of Pediatric Hematology, Oncology, and Cellular Therapy, Children's Hospital at Montefiore, Bronx, New York
| | - Susie Long
- University of Minnesota Masonic Children's Hospital, MHealth Fairview Acute Care Pharmacy Services, Minneapolis, Minnesota
| | - Muna Qayed
- Aflac Cancer and Blood Disorders Center, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Anant Vatsayan
- Children's National Medical Center, Washington, District of Columbia
| | - Lisa Wray
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| |
Collapse
|
3
|
Broglie L, Friend BD, Chhabra S, Logan BR, Bupp C, Schiller G, Savani BN, Stadtmauer E, Abraham AA, Aljurf M, Badawy SM, Perez MAD, Guinan EC, Hashem H, Krem MM, Lazarus HM, Rotz SJ, Wirk B, Yared JA, Pasquini M, Thakar MS, Sorror ML. Expanded HCT-CI Definitions Capture Comorbidity Better for Younger Patients of Allogeneic HCT for Nonmalignant Diseases. Transplant Cell Ther 2023; 29:125.e1-125.e9. [PMID: 36442768 PMCID: PMC9911359 DOI: 10.1016/j.jtct.2022.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) can cure many nonmalignant conditions, but concern for morbidity and mortality remains. To help physicians estimate patient-specific transplant mortality risk, the HCT comorbidity index (HCT-CI) is used. However, pediatric physicians use the HCT-CI less frequently than adult counterparts. We used the Center for International Blood and Marrow Transplant Research database to expand the HCT-CI comorbidity definitions to be more inclusive of children and adolescent and young adult (AYA) patients, adding history of mechanical ventilation, history of invasive fungal infection, assessment of chronic kidney disease (CKD) by estimated glomerular filtration rate, expanding the definition of obesity, and adding an underweight category. A total of 2815 children and AYAs (<40 years old) who received first allogeneic HCT for nonmalignant diseases from 2008 to 2017 were included to create an expanded youth nonmalignant HCT-CI (expanded ynHCT-CI) and a simplified non-malignant (simplified ynHCT-CI) HCT-CI. The expanded comorbidities occurred frequently-history of mechanical ventilation (9.6%), history of invasive fungal infection (5.9%), mild CKD (12.2%), moderate/severe CKD (2.1%), obesity (10.9%), and underweight (14.5%). Thirty-nine percent of patients had an increase in their comorbidity score using the expanded ynHCT-CI, leading to a redistribution of scores: ynHCT-CI score 0 (35%), 1-2 (36.4%), and ≥3 (28.6%). Patients with an increase in their comorbidity score had an increased hazard of mortality compared to those whose score remained the same (hazard ratio = 1.41; 95% confidence interval, 1.01-1.98). Modifications to the HCT-CI can benefit children and AYA patients with nonmalignant diseases, creating a risk assessment tool that is clinically relevant and better captures comorbidity in this younger population.
Collapse
Affiliation(s)
- Larisa Broglie
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brian D Friend
- Baylor College of Medicine, Center for Cell and Gene Therapy, Houston, Texas
| | - Saurabh Chhabra
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Hematology/Oncology, Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Brent R Logan
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Caitrin Bupp
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Gary Schiller
- Hematological Malignancy/Stem Cell Transplant Program, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward Stadtmauer
- University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Allistair A Abraham
- Center for Cancer and Immunology Research, Division of Blood and Marrow Transplantation, Children's National Hospital, Washington, District of Columbia
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Miguel Angel Diaz Perez
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Eva C Guinan
- Departments of Pediatric and Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Jean A Yared
- Transplantation & Cellular Therapy Program, Division of Hematology/Oncology, Department of Medicine, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, Maryland
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Monica S Thakar
- Clinical Research Division, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington; Division of Pediatric Hematology-Oncology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
4
|
Friend BD, Broglie L, Logan BR, Chhabra S, Bupp C, Schiller G, Beitinjaneh A, Perez MAD, Guilcher GMT, Hashem H, Hildebrandt GC, Krem MM, Lazarus HM, Nishihori T, Nusrat R, Rotz SJ, Wirk B, Wieduwilt M, Pasquini M, Savani BN, Stadtmauer EA, Sorror ML, Thakar MS. Adapting the HCT-CI Definitions for Children, Adolescents, and Young Adults with Hematologic Malignancies Undergoing Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:123.e1-123.e10. [PMID: 36442769 PMCID: PMC9911376 DOI: 10.1016/j.jtct.2022.11.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic cell transplantation is a curative procedure for hematologic malignancies but is associated with a significant risk of non-relapse mortality (NRM). The Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) is a prognostic tool that discriminates this risk in all age groups. A recent survey of transplant physicians demonstrated that 79% of pediatric providers used the HCT-CI infrequently, and most reported concerns about its applicability in the younger population. We conducted a retrospective study using the Center for International Blood and Marrow Transplant Research database to examine the impact of expanded HCT-CI definitions on NRM in pediatric and young adult patients with hematologic malignancies. We included 5790 patients <40 years old receiving allogeneic transplants between 2008 and 2017 to examine broader definitions of comorbidities in the HCT-CI, including history of mechanical ventilation and fungal infection, estimated glomerular filtration rate, and body mass index (BMI) percentiles. Multivariable Fine-Gray models were created to determine the effect of each HCT-CI defining comorbidity and its modification on NRM and were used to develop 2 novel risk scores. We next developed the expanded HCT-CI for children and young adults (youth with malignancies; expanded ymHCT-CI), where 23% patients had an increased comorbidity score, compared to the HCT-CI. Comorbidities with hazard ratio < 1.2 were then removed to create the simplified HCT-CI for children and young adults (youth with malignancies; simplified ymHCT-CI), which demonstrated higher scores corresponded to a greater risk of NRM (P < .001). These novel comorbidity indexes with broader definitions are more relevant to pediatric and young adult patients, and prospective studies are needed to validate these in the younger patient population. It remains to be seen whether the development of these pediatric-specific and practical risk indexes increases their use by the pediatric transplant community.
Collapse
Affiliation(s)
- Brian D Friend
- Baylor College of Medicine Center for Cell and Gene Therapy, Houston, Texas
| | - Larisa Broglie
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brent R Logan
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, Wisconsin; CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saurabh Chhabra
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Hematology/Oncology, Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Caitrin Bupp
- CIBMTR (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Gary Schiller
- Hematological Malignancy/Stem Cell Transplant Program, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami Hospital and Clinics, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Miguel Angel Diaz Perez
- Department of Hematology/Oncology, Hospital Infantil Universitario Niño Jesus, Madrid, Spain
| | - Gregory M T Guilcher
- Section of Pediatric Oncology/Cellular Therapy, Alberta Children's Hospital, Departments of Oncology and Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | | | | | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Taiga Nishihori
- Department of Blood & Marrow Transplant and Cellular Immunotherapy (BMT CI), Moffitt Cancer Center, Tampa, Florida
| | | | - Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Baldeep Wirk
- Bone Marrow Transplant Program, Penn State Cancer Institute, Hershey, Pennsylvania
| | - Matthew Wieduwilt
- Department of Medicine, University of Oklahoma, Stephenson Cancer Center, Oklahoma City, Oklahoma
| | - Marcelo Pasquini
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Bipin N Savani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Edward A Stadtmauer
- University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
| | - Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington; Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Monica S Thakar
- Clinical Research Division, Fred Hutchinson Cancer Center, University of Washington, Seattle, Washington; Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
5
|
Broglie L, Friend BD, Chhabra S, Bupp C, Schiller GJ, Logan B, Pasquini MC, Savani B, Stadtmauer EA, Thakar MS, Sorror M. Differential use of the hematopoietic cell transplantation-comorbidity index among adult and pediatric transplant physicians. Leuk Lymphoma 2022; 63:2507-2510. [PMID: 35583292 PMCID: PMC9875328 DOI: 10.1080/10428194.2022.2076848] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/14/2022] [Accepted: 05/04/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Larisa Broglie
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brian D Friend
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Saurabh Chhabra
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Caitrin Bupp
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gary J Schiller
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Brent Logan
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marcelo C Pasquini
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Bipin Savani
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Edward A Stadtmauer
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Monica S Thakar
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mohamed Sorror
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
6
|
Rialland F, Grain A, Labopin M, Michel G, Gandemer V, Paillard C, Pochon C, Clement L, Brissot E, Jubert C, Sirvent A, Rohrlich PS, Plantaz D, Dalle JH, Mohty M. Reduced-toxicity myeloablative conditioning regimen using fludarabine and full doses of intravenous busulfan in pediatric patients not eligible for standard myeloablative conditioning regimens: Results of a multicenter prospective phase 2 trial. Bone Marrow Transplant 2022; 57:1698-1703. [PMID: 36028757 DOI: 10.1038/s41409-022-01769-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 07/18/2022] [Accepted: 07/21/2022] [Indexed: 11/09/2022]
Abstract
Data regarding the safety and efficacy of reduced-toxicity conditioning regimen (RTC) prior to allogeneic stem cell transplantation (allo-SCT) to treat hematological malignancies in pediatric patients are limited. This prospective multicenter, phase 2 trial investigated a RTC regimen based on the combination of intravenous busulfan (3.2 mg/kg/d x 4 days), fludarabine (30 mg/m2/d x 5 days) and antithymocyte globulin (Thymoglobulin®, Genzyme; 5 mg/kg total dose) with the aim of delivering high dose myeloablation that would allow optimal disease control while minimizing toxicity, in a subgroup of children at very high risk of non-relapse mortality (NRM). The primary endpoint was NRM at 1 year after allo-SCT. A total of 48 high risk patients were included (median age, 13 years; range, 3-24). At 1 year, the cumulative incidence of recurrence/disease progression and NRM were 33% and 8%, respectively. With a median follow-up of 23 months, the Kaplan-Meier estimates of overall survival (OS) and disease-free survival (DFS) at 1 year were 69% and 58%, respectively. We conclude that the RTC regimen used in this prospective trial is safe, with a < 10% NRM rate noted among high-risk children and adolescents, paving the way for larger phase 3 trials incorporating novel agents pre- and post-allo-SCT.(ClinicalTrials.gov Identifier: NCT01572181).
Collapse
Affiliation(s)
| | | | - Myriam Labopin
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | - Gerard Michel
- Department of Pediatric Immunology, Hematology and Oncology, Timone Enfants Hospital and Aix-Marseille University, Marseille, France
| | - Virginie Gandemer
- University hospital of Rennes, University of Rennes1, Rennes, France
| | - Catherine Paillard
- Department of Paediatric Haematology and Oncology, Strasbourg University Hospital, Strasbourg, France
| | | | | | - Eolia Brissot
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | | | | | | | | | - Jean-Hugues Dalle
- Hôpital Robert Debré, GH APHP Nord - Université de Paris, Paris, France
| | - Mohamad Mohty
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| |
Collapse
|
7
|
Phelan R, Chen M, Bupp C, Bolon YT, Broglie L, Brunner-Grady J, Burns LJ, Chhabra S, Christianson D, Cusatis R, Devine SM, D’Souza A, Eapen M, Hamadani M, Hengen M, Lee SJ, Moskop A, Page KM, Pasquini M, Pérez WS, Riches M, Rizzo D, Saber W, Spellman SR, Stefanski HE, Steinert P, Weisdorf D, Horowitz M, Auletta JJ, Shaw BE, Arora M. Updated Trends in Hematopoietic Cell Transplantation in the United States with an Additional Focus on Adolescent and Young Adult Transplantation Activity and Outcomes. Transplant Cell Ther 2022; 28:409.e1-409.e10. [PMID: 35447374 PMCID: PMC9840526 DOI: 10.1016/j.jtct.2022.04.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 01/17/2023]
Abstract
Hematopoietic cell transplantation (HCT) has been successfully used to treat many malignant and nonmalignant conditions. As supportive care, donor selection, and treatment modalities evolve, documenting HCT trends and outcomes is critical. This report from the Center for International Blood and Marrow Transplant Research (CIBMTR) provides an update on current transplantation activity and survival rates in the United States. Additional data on the use and outcomes of HCT in the adolescent and young adult (AYA) population are included. AYA patients more frequently receive peripheral blood stem cell grafts than pediatric patients, which may reflect differences in practice in pediatric versus adult treatment centers. The proportions of donor types also differ those in adult and pediatric populations. Outcomes for patients in the AYA age range are similar to those of pediatric patients for acute myelogenous leukemia but worse for acute lymphoblastic leukemia. Outcomes for both leukemias are better in AYA patients compared with older adults. Comparing the time periods 2000 to 2009 and 2010 to 2019 revealed significant improvement in overall survival across the age spectrum, but the greatest improvement in the AYA age group.
Collapse
Affiliation(s)
- Rachel Phelan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Min Chen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Caitrin Bupp
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Yung-Tsi Bolon
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Janet Brunner-Grady
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Linda J. Burns
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI
| | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Debra Christianson
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Rachel Cusatis
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Steven M. Devine
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Anita D’Souza
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Eapen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mehdi Hamadani
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,BMT & Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mary Hengen
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Stephanie J. Lee
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, WI,Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Amy Moskop
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Kristin M. Page
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI,Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Marcelo Pasquini
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Waleska S. Pérez
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Marcie Riches
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Doug Rizzo
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Stephen R. Spellman
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Heather E. Stefanski
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Patricia Steinert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Daniel Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Mary Horowitz
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jeffery J. Auletta
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN
| | - Bronwen E. Shaw
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Mukta Arora
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program®/Be The Match®, Minneapolis, MN,Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| |
Collapse
|
8
|
Kindler JM, Guo M, Baker J, McCormack S, Armenian SH, Zemel BS, Leonard MB, Mostoufi-Moab S. Persistent Musculoskeletal Deficits in Pediatric, Adolescent and Young Adult Survivors of Allogeneic Hematopoietic Stem-Cell Transplantation. J Bone Miner Res 2022; 37:794-803. [PMID: 35080067 DOI: 10.1002/jbmr.4513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 11/08/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is a common therapy for pediatric hematologic malignancies. With improved supportive care, addressing treatment-related late effects is at the forefront of survivor long-term health and quality of life. We previously demonstrated that alloHSCT survivors had increased adiposity, decreased lean mass, and lower bone density and strength, 7 years (median) from alloHSCT compared to their healthy peers. Yet it is unknown whether these deficits persist. Our longitudinal study characterized changes in muscle and bone over a period of 3.4 (range, 2.0 to 4.9) years in 47 childhood alloHSCT survivors, age 5-26 years at baseline (34% female). Tibia cortical bone geometry and volumetric density and lower leg muscle cross-sectional area (MCSA) were assessed via peripheral quantitative computed tomography (pQCT). Anthropometric and pQCT measurements were converted to age, sex, and ancestry-specific standard deviation scores, adjusted for leg length. Muscle-specific force was assessed as strength relative to MCSA adjusted for leg length (strength Z-score). Measurements were compared to a healthy reference cohort (n = 921), age 5-30 years (52% female). At baseline and follow-up, alloHSCT survivors demonstrated lower height Z-scores, weight Z-scores, and leg length Z-scores compared to the healthy reference cohort. Deficits in MCSA, trabecular volumetric bone density, and cortical bone size and estimated strength (section modulus) were evident in survivors (all p < 0.05). Between the two study time points, anthropometric, muscle, and bone Z-scores did not change significantly in alloHSCT survivors. Approximately 15% and 17% of alloHSCT survivors had MCSA and section modulus Z-score < -2.0, at baseline and follow-up, respectively. Furthermore, those with a history of total body irradiation compared to those without demonstrated lower MCSA at follow-up. The persistent muscle and bone deficits in pediatric alloHSCT survivors support the need for strategies to improve bone and muscle health in this at-risk population. © 2022 American Society for Bone and Mineral Research (ASBMR).
Collapse
Affiliation(s)
- Joseph M Kindler
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Guo
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Joshua Baker
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.,Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shana McCormack
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Saro H Armenian
- Department of Pediatrics, City of Hope, Duarte, CA, USA.,Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
9
|
Pennarola BW, Fry A, Prichett L, Beri AE, Shah NN, Wiener L. Mapping the Landscape of Advance Care Planning in Adolescents and Young Adults Receiving Allogeneic Hematopoietic Stem Cell Transplantation: A 5-Year Retrospective Review. Transplant Cell Ther 2022; 28:164.e1-164.e8. [PMID: 34936929 PMCID: PMC8923987 DOI: 10.1016/j.jtct.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 12/03/2021] [Accepted: 12/05/2021] [Indexed: 12/17/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) carries significant risks of morbidity and mortality. Participation in advance care planning (ACP) is crucial to promote patient-centered care and has been shown to have positive impacts on patients, caregivers, and providers. Historically, both HSCT recipients and adolescents and young adults (AYAs) are significantly less likely to engage in ACP. We sought to characterize ACP utilization in AYAs undergoing HSCT by evaluating the frequency of different types of ACP documentation over time and identifying demographic and clinical factors associated with documentation of each type of ACP. We conducted a single-center retrospective review of the electronic health record (EHR) of AYAs (age 15 to 39 years) who underwent allogeneic HSCT between 2015 and 2020. EHR documents were screened for 3 predefined categories of ACP: (1) advance directives (ADs) or medical orders (MOs), which included proof of signed paper directives, expressions of preferred code status, and identification of a healthcare proxy; (2) goals of care (GOC) conversations, which included discussions of medical care in a specific situation informed by patients' priorities; and (3) other ACP conversations, which included more general discussions of patients' values regarding their care or legacy wishes. Documents were coded by 2 researchers, and discrepant categorizations were reviewed by a third researcher. Patients age <18 years on the day of transplantation were excluded in the analyses of AD/MO documentation. Univariate and multivariate logistic regression were used to test for associations between patient factors and documentation of each type of ACP. For deceased patients, Kaplan-Meier curves were created to illustrate the time-to-event relationship between days before death and documentation of each type of ACP. Sixty-eight thousand documents associated with 219 patients were reviewed, and 666 ACP documents associated with 190 patients were identified. Few of the 219 patients had documented GOC (n = 29; 13%) or other ACP conversations (n = 81; 37%). A subset of patients (n = 28; 13%) had no documented ACP. Most of the 201 patients age ≥18 years had a documented AD/MO (n = 172; 86%). No tested factors were significantly associated with documentation of ADs/MOs. GOC and other ACP conversations were more likely to occur in patients with a palliative care consult, and patients with a malignant diagnosis were also more likely to engage in GOC conversations. More than 50% of the documentation occurred in the subset of 39 deceased patients, with one-half of AD/MO documentation in the last 67 days of life, one-half of other ACP documentation in the last 20 days of life, and one-half of GOC documentation in the final 2 days of life. Although the majority of AYA patients receiving HSCT did have documentation of ADs/MOs, few patients had documented GOC or other ACP conversations. The bulk of all ACP conversations occurred in patients that ultimately died and who were very close to the end of life. Our results support ongoing efforts to improve the implementation of ACP in this vulnerable population, particularly for those undergoing HSCT for nonmalignant conditions.
Collapse
Affiliation(s)
- Brian W. Pennarola
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD,Department of Pediatric Oncology, Johns Hopkins Hospital, Baltimore, MD
| | - Abigail Fry
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Laura Prichett
- Johns Hopkins School of Medicine, Department of Pediatrics, Biostatistics, Epidemiology, and Data Management (BEAD) Core, Baltimore, MD
| | - Andrea E. Beri
- NIH Biomedical Translational Research Information System (BTRIS), Bethesda, MD
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| | - Lori Wiener
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), National Institutes of Health (NIH), Bethesda, MD
| |
Collapse
|
10
|
Forlanini F, Zinter MS, Dvorak CC, Bailey-Olson M, Winestone LE, Shimano KA, Higham CS, Melton A, Chu J, Kharbanda S. Hematopoietic Cell Transplantation-Comorbidity Index Score Is Correlated with Treatment-Related Mortality and Overall Survival following Second Allogeneic Hematopoietic Cell Transplantation in Children. Transplant Cell Ther 2021; 28:155.e1-155.e8. [PMID: 34848362 DOI: 10.1016/j.jtct.2021.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) can lead to considerable complications and treatment-related mortality (TRM); therefore, a detailed assessment of risks is essential. The Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI) can predict both TRM and overall survival (OS). Although the HCT-CI has been validated as a useful tool for first HCT, its potential utility for second HCT has not yet been investigated. Here we aimed to evaluate the utility of the HCT-CI score in assessing the risk of TRM and OS in the setting of a second allogeneic HCT. This was a retrospective analysis of all pediatric patients (age <21 years) who underwent a second allogeneic HCT at UCSF Benioff Children's Hospital San Francisco between 2008 and 2019. According to their HCT-CI, patients were classified as "low risk" with an HCT-CI of 0 or "intermediate-high risk" with an HCT-CI ≥1. A total of 59 patients were included in the study. Our primary endpoint was TRM, observed at 100 days, 180 days, 1 year, and last follow-up following HCT, and our secondary endpoint was OS at 1 year and at 5 years or last follow-up. We also evaluated outcomes of patients admitted to the pediatric intensive care unit based on the HCT-CI score. Seventy-six percent of patients had an HCT-CI of 0. The most frequent comorbidities were pulmonary, seen in 7 patients (12%; 95% CI, 5% to 23%), including 5 (71%) with moderate and 2 (29%) with severe comorbidities. The OS and the cumulative incidence of TRM at 1 year for the entire cohort were 81% (95% CI, 69% to 90%) and 12% (95% CI, 5% to 22%), respectively. The cumulative incidence of TRM and OS at 1 year showed a significant correlation with HCT-CI score; TRM was 4% (95% CI, 1% to 13%) for an HCT-CI of 0 versus 36% (95% CI, 13% to 60%) for an HCT-CI ≥1 (P < .001), and OS was 89% (95% CI, 75% to 99%) for an HCT-CI of 0 versus 57% (95% CI, 28% to 78%) for an HCT-CI ≥1 (P = .003). After adjusting for covariates, HCT-CI continued to be associated with both TRM (P = .004) and OS (P = .003). In addition, comparing patients with malignancies and nonmalignant disorders, disease-free-survival at last follow-up was higher in the nonmalignant disorder group and also was influenced by the HCT-CI score in each group (P = .0035). There also was a significant difference in outcomes of patients admitted to the pediatric intensive care unit; 15 patients (68%) with an HCT-CI of 0 were alive at last follow-up, compared with only two (22%) with an HCT-CI ≥1 (P = .016). HCT-CI has an impact on TRM and OS and may serve as a predictor of outcomes of second allogeneic transplantation. Although this study was conducted in a relatively small sample, it is the first to investigate the utility of the HCT-CI score in predicting outcomes after a second allogeneic HCT in pediatric recipients. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
Collapse
Affiliation(s)
- Federica Forlanini
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California; Department of Pediatrics, V. Buzzi Hospital, Università degli Studi di Milano, Milan, Italy
| | - Matt S Zinter
- Division of Pediatric Critical Care Medicine, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Mara Bailey-Olson
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Lena E Winestone
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Kristin A Shimano
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Christine S Higham
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Julia Chu
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Sandhya Kharbanda
- Division of Pediatric Allergy, Immunology & Bone Marrow Transplantation, UCSF Benioff Children's Hospital, University of California, San Francisco, California.
| |
Collapse
|
11
|
Friend BD, Schiller GJ. Beyond steroids: A systematic review and proposed solutions to managing acute graft-versus-host disease in adolescents and young adults. Blood Rev 2021; 52:100886. [PMID: 34509319 DOI: 10.1016/j.blre.2021.100886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/11/2022]
Abstract
The outcomes of allogeneic hematopoietic cell transplantation (HCT) in adolescents and young adults (AYAs) with hematologic malignancies have been shown to be poorer when compared to results in children, due to a combination of higher relapse rates and greater treatment-related mortality (TRM). Although differences in relapse risk have been studied extensively, toxicity has been examined and reported less often. In this systematic review, we summarize recently published studies that have examined the differences in rates of TRM and acute graft-versus-host disease (GVHD) in AYAs and children with hematologic malignancies, and attempt to explain why these disparities exist and how they impact outcomes. In addition, we present best practices for management of steroid-refractory GVHD that are likely to improve survival in this patient population. Further, we propose the development of personalized, risk-based approaches for the prevention and treatment of GVHD that incorporate novel platforms and interventions. We believe this individualized approach is likely to reduce toxicity and greatly improve outcomes for this vulnerable population.
Collapse
Affiliation(s)
- Brian D Friend
- Department of Pediatrics, Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital, 1102 Bates Ave, Suite 1630, Houston, TX 77030, USA.
| | - Gary J Schiller
- Department of Medicine, Division of Hematology-Oncology, University of California Los Angeles, 10833 Le Conte Ave, 42-121 CHS, Los Angeles, CA 90095, USA.
| |
Collapse
|
12
|
Clinical management of adolescents and young adults suffering from sarcoma in the French Rhône-Alpes region: A prospective exhaustive cohort with 10 years follow up. Eur J Surg Oncol 2020; 46:1301-1309. [PMID: 32334938 DOI: 10.1016/j.ejso.2020.03.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 03/09/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Survival of adolescents and young adults (AYA) with sarcoma is lower than in younger patients. The objective of this study was to describe the regional healthcare circuits, the differences in the management between adult, paediatric and mixed units and to assess the prognostic impact of compliance with clinical practice guidelines (CPGs) on overall survival (OS) and on relapse free survival (RFS). MATERIALS AND METHODS Retrospective analysis of the management and long term follow-up of all 13-25 year old patients with a sarcoma diagnosed in the Rhône-Alpes area between 2000 and 2005. RESULTS 140 patients satisfied inclusion criteria and were selected. The majority of 13-25 year old patients were treated in paediatric units. Joint management resulted in a higher rate of discussion in multidisciplinary tumour board, inclusion in clinical trials, and fertility preservation. Non-compliance with guidelines was observed in 65% of cases. Overall compliance was not reported to correlate to survival. Compliance of radiotherapy with CPG's seemed associated with a better prognosis for OS (HR = 0.20, 95% CI = [0.10-0.40]; p < 0.0001) and RFS (HR = 0.18, 95% CI = [0.09-0.37; p < 0.0001) as well as compliance of surgery for OS (HR = 0.43, 95% CI = [0.23-0.81]; p = 0.01). Multivariate Cox regression analysis revealed other independent predictors of OS like age at diagnosis, stage and histological subtype. CONCLUSIONS Management of AYA in joint units seems to improve the quality of care. Compliance of surgery and radiotherapy with CGP's seems to improve survival.
Collapse
|
13
|
Abstract
Multiple sclerosis is the leading non-traumatic cause of disability in young adults, affecting up to 100,000 Canadians. This chronic inflammatory and neurodegenerative disease of the central nervous system leads to irreversible neurologic disability if inadequately controlled. Though many current medications are available that reduce inflammatory damage, most patients continue to show some evidence of disease activity and accrue disability. In this review, we discuss the role of immune ablation followed by autologous hematopoietic stem cell transplantation (AHSCT), a therapeutic option for select patients with a more aggressive disease course. By "resetting" the immune system with a variety of ablative conditioning regimens, followed by immune reconstitution, this therapy has shown a durable response in halting evidence of inflammatory activity in most patients, without the need for continued disease-modifying therapies (DMT). Since the introduction of this therapy, there have been advances in patient selection and supportive care, such that morbidity has significantly declined and treatment-related mortality is minimized. Recent phase-II trials have shown excellent results in efficacy and safety of AHSCT; however, challenges exist which require ongoing study. The future challenges include comparing the variety of AHSCT conditioning regimens with each other as well as with existing highly effective DMT; identifying patients with an aggressive disease course through novel biomarkers who may benefit the most from AHSCT; and surveillance of long-term outcomes of different treatment protocols. In select patients, replacing the immune system with AHSCT holds promise of fundamentally altering the trajectory of their aggressive disease course.
Collapse
|