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Ye P, Wu M, Cao J, Pei R, Yuan J, Zhuang H, Fang Y, Lu Y. Reduced-toxicity conditioning regimen with low dose post-transplantation cyclophosphamide and low-dose anti-thymocyte globulin as graft-versus-host disease prophylaxis for haploidentical stem cell transplantation in older patients. Ann Hematol 2024:10.1007/s00277-024-05818-5. [PMID: 38809457 DOI: 10.1007/s00277-024-05818-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 05/26/2024] [Indexed: 05/30/2024]
Abstract
Reduced-toxicity conditioning (RIC) regimens are used for allogeneic hematopoietic stem cell transplantation in older patients. However, successful outcomes are hindered by graft-versus-host disease (GVHD), treatment-related mortality, and relapse, particularly after haploidentical donor hematopoietic stem cell transplantation (HID-HSCT). The aim of this study was to evaluate the effectiveness of an RIC conditioning regimen that included a combination of cyclosporin A, methotrexate (on day + 1), mycophenolate, lower doses of post-transplantation PTCy (40 mg/kg on day + 3), and ATG (7.5 mg/kg) as GVHD prophylaxis prior to haplo-stem cell transplantation (haplo-SCT) in older patients. METHODS We retrospectively analyzed outcomes in 55 patients ≥ 55 years of age with hematologic malignancies treated with fludarabine, cytarabine, busulfan, and low-dose cyclophosphamide as the conditioning regimen between January 1, 2019, and November 30, 2023. RESULTS Neutrophil engraftment was successful in all patients within 28 days, with 54 patients (98.2%) achieving complete donor chimerism. The cumulative incidence of non-relapse mortality was 0% at 30 days, 7.5% at 100 days, and 19% at 1 year. The cumulative incidence of grade II-IV acute graft-versus-host disease (aGVHD) was 25% (95%CI, 15-38%), whereas that of grade III-IV aGVHD was 9.1% (95% CI, 3.3-19%). The cumulative incidence of extensive chronic graft-versus-host disease at 1 year was 3.6% (95%CI, 0.66-11%). The cumulative incidences of relapse, overall survival, and GVHD-free/relapse-free survival at 1 year were 9.0%, 71.6%, and 67.1%, respectively. CONCLUSIONS An RIC conditioning regimen, including a combination of lower PTCy/ATG as GVHD prophylaxis, followed by haplo-SCT, might be a promising option for appropriately selected older patients.
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Affiliation(s)
- Peipei Ye
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Mengjie Wu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Junjie Cao
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Renzhi Pei
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Jiaojiao Yuan
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Haihui Zhuang
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Ying Fang
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China
| | - Ying Lu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang, China.
- Institute of Hematology, Ningbo University, Ningbo, Zhejiang, China.
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2
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Avenoso D, Mehra V, Slonim LB, de Farias M, Alshehri H, Bouziana S, Krishnamurthy P, Kulasekararaj A, Dazzi F, Wood H, Kenyon M, Leung YT, Anteh S, Shah MN, Hannah G, Serpenti F, Gameil A, Bourlon C, Dragoi OD, Pagliuca A, Potter V. Myeloablative Dose of Busulfan and Fludarabine Combined with In Vivo T Cell Depletion Is Safe and Effective Conditioning for Acute Myeloid Leukemia and Myelodysplastic Syndrome Patients. Transplant Cell Ther 2023; 29:698.e1-698.e6. [PMID: 37579918 DOI: 10.1016/j.jtct.2023.08.012] [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: 04/10/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative strategy for acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). The prediction of transplantation-related mortality (TRM) using the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) score and an arbitrary upper age limit of 55 years for administering myeloablative conditioning (MAC) are common strategies to ensure a safe procedure. The use of reduced-toxicity conditioning regimens is an additional approach to providing safe and effective myeloablation. Herein we report the outcome of AML and MDS patients conditioned with fludarabine and a myeloablative dose of busulfan (FB4) stratified by age and HCT-CI score. The primary objective was overall survival (OS) for patients age ≥55 years. Secondary objectives were total OS, TRM, graft-versus-host disease (GVHD), and GVHD, relapse-free survival (GRFS). The 2 year OS was 72% in patients age <55 and 51% in patients age ≥55. In patients age ≥55 with an HCT-CI <2, the estimated 2 year OS was 64%, with median OS not reached. In those with HCT-CI ≥2, the 2-year OS was 43%, with a median OS of 14 months. The total cumulative incidence of relapse was 30% regardless of age or HCT-CI score. FB4 conditioning regimen offers a high rate of prolonged remission with a relapse rate similar to that reported in previous studies. These positive outcomes suggest that this conditioning platform can be offered to patients age ≥55 years in the absence of comorbidities, and that age should not be the sole determinant of conditioning intensity.
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Affiliation(s)
- Daniele Avenoso
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom.
| | - Varun Mehra
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Liron Barnea Slonim
- King's College Hospital NHS Foundation Trust, Department of Histopathology, Denmark Hill, London, United Kingdom
| | - Madson de Farias
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Hassan Alshehri
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Styliani Bouziana
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Pramila Krishnamurthy
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Austin Kulasekararaj
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Francesco Dazzi
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Henry Wood
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Michelle Kenyon
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Ye Ting Leung
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Sandra Anteh
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Mili Naresh Shah
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Guy Hannah
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Fabio Serpenti
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Amna Gameil
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Christianne Bourlon
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Oana Diana Dragoi
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Antonio Pagliuca
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
| | - Victoria Potter
- King's College Hospital NHS Foundation Trust, Department of Haematological Medicine, Denmark Hill, London, United Kingdom
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3
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Duda K, Wieczorkiewicz-Kabut A, Koclęga A, Zielińska P, Woźniczka K, Krzemień H, Armatys A, Helbig G. Allogeneic hematopoietic stem cell transplantation remains a feasible approach for elderly with acute myeloid leukemia: a 10-year experience. Ann Hematol 2023:10.1007/s00277-023-05226-1. [PMID: 37074379 DOI: 10.1007/s00277-023-05226-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/10/2023] [Indexed: 04/20/2023]
Abstract
The incidence of AML increases with age. The implementation of reduced intensity conditioning and progress in supportive care enabled to perform allo-HSCT in elderly patients. The main objective of the study was to assess the safety and efficacy of allotransplantation in elderly AML.Forty nine patients (33 males) at median age of 68 years were identified. Data on patients' and transplant's related variables were retrieved from our local transplant registry. Most patients (65%) were transplanted from 10/10-HLA or 9/10-HLA matched unrelated donor, seven patients (14%) received stem cells from matched related donor and ten patients (20%) from haploidentical donor. All patients received reduced-intensity conditioning (RIC). Peripheral blood was a source of stem cells in all patients except one (98%). Acute GVHD developed in 22 patients (44%) with 5 individuals presenting grade III-IV. CMV reactivation was demonstrated in 19 patients (39%) till day + 100. In total, 22 patients (45%) have died. The main causes of death included infectious complications (n = 9), relapse with subsequent chemotherapy resistance (n = 7), steroid-resistant GvHD (n = 4) and other causes (n = 2). Twenty-seven patients (55%) were alive at the last contact, presented full donor chimerism and remained in the complete remission. The probability of OS and relapse-free survival (RFS) were 57% and 81% at 2 years, respectively. Older donor age showed negative impact on relapse. CMV reactivation, the severity of acute graft versus host disease and older donor age negatively influenced survival. Allo-HSCT remains a safe, feasible and effective procedure for elderly AML patients.
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Affiliation(s)
- Katarzyna Duda
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Agata Wieczorkiewicz-Kabut
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anna Koclęga
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Patrycja Zielińska
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krzysztof Woźniczka
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Helena Krzemień
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Anna Armatys
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, Faculty of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.
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4
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Rotz SJ, Ryan TD, Hayek SS. Cardiovascular disease and its management in children and adults undergoing hematopoietic stem cell transplantation. J Thromb Thrombolysis 2021; 51:854-869. [PMID: 33230704 PMCID: PMC8085022 DOI: 10.1007/s11239-020-02344-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/12/2020] [Indexed: 02/07/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for many malignancies, hemoglobinopathies, metabolic diseases, bone marrow failure syndromes, and primary immune deficiencies. Despite the significant improvement in survival afforded by HSCT, the therapy is associated with major short and long-term morbidity and mortality. Cardiovascular complications such as cardiomyopathy, arrhythmias, pulmonary hypertension, and pericardial effusions are increasingly recognized as potential outcomes following HSCT. The incidence of cardiac complications is related to various factors such as age, co-morbid medical conditions, whether patients received cardiotoxic chemotherapy prior to HSCT, the type of HSCT (autologous versus allogeneic), and the specific conditioning regimen. Thus, the cardiovascular evaluation has become a core component of the pre-transplant assessment, however, the practice differs from center to center as national guidelines and contemporary high-quality studies are lacking. We review the incidence of cardiotoxicity in pediatric and adult HSCT, potential mechanisms of injury, and effects on long-term outcomes. We also discuss the possible therapeutic approaches when disease arises, as well as the indications and need for surveillance before, during, and after transplantation.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine, and Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
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5
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Isobe M, Konuma T, Masuko M, Uchida N, Miyakoshi S, Sugio Y, Yoshida S, Tanaka M, Matsuhashi Y, Hattori N, Onizuka M, Aotsuka N, Kouzai Y, Wake A, Kimura T, Ichinohe T, Atsuta Y, Yanada M. Single cord blood transplantation for acute myeloid leukemia patients aged 60 years or older: a retrospective study in Japan. Ann Hematol 2021; 100:1849-1861. [PMID: 33624134 DOI: 10.1007/s00277-021-04464-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
The availability of alternative donor sources could allow elderly patients to receive allogeneic hematopoietic cell transplantation (HCT). We retrospectively evaluated the outcomes of single-unit cord blood transplantation (CBT) in 1577 patients aged ≥60 years with acute myeloid leukemia (AML) in Japan between 2002 and 2017. In total, 990 (63%) patients were not in complete remission (CR) at the time of CBT. A myeloablative conditioning regimen (52%) and calcineurin inhibitor (CI) + mycophenolate mofetil (MMF)-based graft-versus-host disease (GVHD) prophylaxis (45%) were more commonly used. With a median follow-up for survivors of 31 months, the probability of overall survival and the cumulative incidence of leukemia-related mortality at 3 years was 31% and 29%, respectively. The cumulative incidence of non-relapse mortality (NRM) at 100 days and 3 years were 24% and 41%, respectively. The cumulative incidences of grade II-IV and grade III-IV acute GVHD at 100 days and extensive chronic GVHD at 2 years were 44%, 16%, and 14%, respectively. The cumulative incidence of neutrophil engraftment was 80% at 42 days. Results of multivariate analysis indicated that the following factors were significantly associated with higher overall mortality: performance status ≥1, hematopoietic cell transplantation-specific comorbidity index ≥3, adverse cytogenetics, extramedullary disease at diagnosis, and non-CR status at CBT. By contrast, female sex, HLA disparities ≥2, mycophenolate mofetil-based GVHD prophylaxis, and recent CBT were significantly associated with lower overall mortality. In conclusion, single CBT offers a curative option for AML patients aged ≥60 years with careful patient selection.
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Affiliation(s)
- Masamichi Isobe
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan.
| | - Masayoshi Masuko
- Department of Hematopoietic Cell Transplantation, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Yasuhiro Sugio
- Department of Internal Medicine, Kitakyushu City Hospital Organization, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Shuro Yoshida
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshiko Matsuhashi
- Department of Hematology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Nobuyuki Aotsuka
- Division of Hematology-Oncology, Japanese Red Cross Society Narita Hospital, Narita, Japan
| | - Yasushi Kouzai
- Department of Transfusion Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Atsushi Wake
- Department of Hematology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Takafumi Kimura
- Preparation Department, Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamitsu Yanada
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
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6
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Hsu J, Chen Z, Shore T, Gergis U, Mayer S, Phillips A, Guarner D, Hsu YM, Cushing MM, Van Besien K. Outcomes of Allogeneic Stem Cell Transplant for Elderly Patients with Hematologic Malignancies. Biol Blood Marrow Transplant 2019; 26:789-797. [PMID: 31891814 DOI: 10.1016/j.bbmt.2019.12.766] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 11/03/2019] [Accepted: 12/26/2019] [Indexed: 12/23/2022]
Abstract
Reduced-intensity conditioning (RIC) regimens, improved HLA matching, and better supportive care allow allogeneic stem cell transplant (alloSCT) to be offered to older patients. Only a small percentage of eligible patients between ages 65 and 74 years actually undergo alloSCT, and comprehensive outcome data from the aging population are still lacking. We examined the outcome of older patients who underwent alloSCT using melphalan-based RIC for hematologic malignancies at our institution. We identified 125 patients older than 65 years (median, 69; range, 66 to 77) who underwent matched related donor, matched unrelated donor, or combined haploidentical/umbilical cord alloSCT between 2012 through November, 2017. Among them, 52 (41.6%) and 70 (56%) had, respectively, intermediate and high/very high Center for International Blood and Marrow Transplant Research (CIBMTR) disease risk index (DRI). One hundred six patients (85%) received fludarabine/melphalan-based RIC regimen with either antithymocyte globulin (ATG) or alemtuzumab. The median time to neutrophil engraftment was 13 days (range, 8 to 37) and platelet engraftment 17 days (range, 9 to 169). The cumulative incidence of nonrelapse mortality was 11.5% at 100 days and 30.1% and 34.8% at 1 and 2 years, respectively. The cumulative incidence of relapse was 35% and 40% at 1 and 2 years. The cumulative incidence of grades II to IV acute graft-versus-host disease (GVHD) at day 100 and 6 months was 29.5% and 34.5%, and chronic GVHD at 6, 12, and 24 months was 2.5%, 5.2%, and 6.3%, respectively. With a median follow-up of 32 months, the 1-, 2-, and 3-year progression-free survival (PFS) was 34.6%, 24.4%, and 16.5%, respectively. The graft GVHD-free survival was 24.6%, 16.1%, and 9.3%, respectively. The 1-, 2-, and 3-year overall survival (OS) was 44.5%, 30.7%, and 26.5%, respectively. In multivariable analysis, low albumin was predictive of poor PFS and OS and high hematopoietic cell transplantation-specific comorbidity index, and CIBMTR DRI was predictive of worse graft GVHD-free survival. Among long-term survivors the median Karnofsky performance status was 80. Older patients, even when referred with advanced disease, can benefit from melphalan-based alloSCT with HLA-matched or alternative donor sources without discernible impact of donor source on outcome. Using alemtuzumab- or ATG-based in vivo T cell depletion, the incidence of chronic GVHD is extremely low. Performance status in survivors is excellent. Better predictors for outcome in this patient population need to be identified.
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Affiliation(s)
- Jingmei Hsu
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York.
| | - Zhengming Chen
- Biostatistics and Epidemiology, Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Tsiporah Shore
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Usama Gergis
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Sebastian Mayer
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Adrienne Phillips
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Danielle Guarner
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Yen-Michael Hsu
- Department of Pathology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Melissa M Cushing
- Department of Pathology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
| | - Koen Van Besien
- Department of Medicine, Division of Hematology/Oncology, Weill Cornell Medical Center/New York Presbyterian Hospital, New York, New York
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7
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Ustun C, Le-Rademacher J, Wang HL, Othus M, Sun Z, Major B, Zhang MJ, Storrick E, Lafky JM, Chow S, Mrózek K, Attar EC, Nand S, Bloomfield CD, Cripe LD, Tallman MS, Appelbaum F, Larson RA, Marcucci G, Roboz GJ, Uy GL, Stone RM, Jatoi A, Shea TC, de Lima M, Foran JM, Sandmaier BM, Litzow MR, Erba HP, Hurria A, Weisdorf DJ, Artz AS. Allogeneic hematopoietic cell transplantation compared to chemotherapy consolidation in older acute myeloid leukemia (AML) patients 60-75 years in first complete remission (CR1): an alliance (A151509), SWOG, ECOG-ACRIN, and CIBMTR study. Leukemia 2019; 33:2599-2609. [PMID: 31073153 PMCID: PMC6842042 DOI: 10.1038/s41375-019-0477-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/17/2019] [Accepted: 03/20/2019] [Indexed: 01/21/2023]
Abstract
The preferred post-remission therapy for older patients with acute myeloid leukemia (AML) in first complete remission (CR1) remains uncertain. In this retrospective, multicenter study, we compared the outcomes for older AML patients (age 60-77 years) receiving allogeneic hematopoietic cell transplantation (alloHCT) (n = 431) with those treated on prospective National Clinical Trials Network induction and nontransplantation chemotherapy (CT) consolidation trials (n = 211). AlloHCT patients were younger (median age: 64.2 versus 67.9 years, p < 0.001), but more frequently had high-risk AML (high WBC, secondary AML, and unfavorable cytogenetics). Overall survival (OS) was worse in alloHCT during the first 9 months after CR1 (HR = 1.52, p = 0.02), but was significantly better thereafter (HR = 0.53, p < 0.0001) relative to CT. Treatment-related mortality (TRM) following HCT was worse in the first 9 months (HR = 2.8, 95% CI: 1.5-5.2, p = 0.0009), while post-HCT relapse was significantly less frequent beyond 9 months (HR = 0.42, 95% CI: 0.29-0.61, p < 0.0001). Despite higher early TRM, alloHCT recipients had superior long-term OS [29% (24-34%) versus CT 13.8% (9-21%) at 5 years]. Although this is a retrospective analysis with potential biases, it indicates that alloHCT led to heightened early risks from TRM, yet reduced relapse and superior long-term survival relative to CT in older AML patients in CR1.
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Affiliation(s)
- Celalettin Ustun
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA.
- Division of Hematology, Oncology and Cellular Therapy, Rush University, Chicago, IL, USA.
| | | | - Hai-Lin Wang
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Zhuoxin Sun
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brittny Major
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Mei-Jie Zhang
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | - Selina Chow
- University of Chicago Comprehensive Cancer Center, Chicago, IL, USA
| | - Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Eyal C Attar
- Massachusetts General Hospital, Boston, MA, USA
- Agios Pharmaceuticals, Inc, Cambridge, MA, USA
| | - Such Nand
- Loyola University Medical Center, Chicago, IL, USA
| | - Clara D Bloomfield
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Larry D Cripe
- Indiana University Simon Cancer Center, Indianapolis, IN, USA
| | | | - Frederick Appelbaum
- Fred Hutchinson Cancer Research Center and Division of Oncology, University of Washington, Seattle, WA, USA
| | - Richard A Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Guido Marcucci
- Department of Hematological Malignancies Translational Science, Gehr Family Center for Leukemia Research, Hematologic Malignancies and Stem Cell Transplantation Institute, Beckman Research Institute, City of Hope, Duarte, CA, USA
| | - Gail J Roboz
- Weill-Cornell Medical College, New York, NY, USA
| | - Geoffrey L Uy
- Washington University School of Medicine, Saint Louis, MO, USA
| | | | | | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Marcos de Lima
- Adult Hematologic Malignancies & Stem Cell Transplant Section, University Hospitals Seidman Cancer Center, Cleveland, OH, USA
| | - James M Foran
- Division of Hematology and Medical Oncology, Department of Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center and Division of Oncology, University of Washington, Seattle, WA, USA
| | - Mark R Litzow
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Daniel J Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, MN, USA
- CIBMTR (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Andrew S Artz
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
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8
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Ringdén O, Boumendil A, Labopin M, Canaani J, Beelen D, Ehninger G, Niederwieser D, Finke J, Stelljes M, Gerbitz A, Ganser A, Kröger N, Kantz L, Brecht A, Savani B, Sadeghi B, Mohty M, Nagler A. Outcome of Allogeneic Hematopoietic Stem Cell Transplantation in Patients Age >69 Years with Acute Myelogenous Leukemia: On Behalf of the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:1975-1983. [DOI: 10.1016/j.bbmt.2019.05.037] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/30/2019] [Accepted: 05/29/2019] [Indexed: 11/15/2022]
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9
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Mau LW, Meyer C, Burns LJ, Saber W, Steinert P, Vanness DJ, Preussler JM, Silver A, Leppke S, Murphy EA, Denzen E. Reimbursement, Utilization, and 1-Year Survival Post-Allogeneic Transplantation for Medicare Beneficiaries With Acute Myeloid Leukemia. JNCI Cancer Spectr 2019; 3:pkz048. [PMID: 31750417 PMCID: PMC6845850 DOI: 10.1093/jncics/pkz048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 05/21/2019] [Accepted: 07/08/2019] [Indexed: 12/18/2022] Open
Abstract
Background The economics of allogeneic hematopoietic cell transplantation (alloHCT) for older patients with acute myeloid leukemia (AML) affects clinical practice and public policy. To assess reimbursement, utilization, and overall survival (OS) up to 1 year post-alloHCT for Medicare beneficiaries aged 65 years or older with AML, a unique merged dataset of Medicare claims and national alloHCT registry data was analyzed. Methods Patients diagnosed with AML undergoing alloHCT from 2010 to 2011 were included for a retrospective cohort analysis with generalized linear model adjustment. One-year post-alloHCT reimbursement included Medicare, secondary payer, and beneficiary copayments (no coinsurance) (inflation adjusted to 2017 dollars). Cost-to-charge ratios were applied to estimate department-specific inpatient costs. Cox proportional hazards regression models were utilized to identify risk factors of 1-year OS post-alloHCT. Results A total of 250 patients met inclusion criteria. Mean total reimbursement was $230 815 (95% confidence interval [CI] = $214 381 to $247 249) 1 year after alloHCT. Pharmacy was the most- costly inpatient service category. Adjusted mean total reimbursement was statistically higher for patients who received cord blood grafts (P = .01), myeloablative conditioning (P < .0001), and alloHCT in the Northeast and West (P = .03). Mortality increased with age (hazard ratio [HR] = 1.08, 95% CI = 1.0 to 1.17), poorer Karnofsky performance score (<90% vs ≥90%, HR = 1.60, 95% CI = 1.08 to 2.35), and receipt of myeloablative conditioning (HR = 1.88, 95% CI = 1.21 to 2.92). Conclusions This merged dataset allowed adjustment for a richer set of patient- and HCT-related characteristics than claims data alone. The finding that nonmyeloablative conditioning was associated with lower reimbursement and improved OS 1 year post-alloHCT warrants further investigation.
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Affiliation(s)
- Lih-Wen Mau
- See the Notes section for the full list of authors' affiliations
| | - Christa Meyer
- See the Notes section for the full list of authors' affiliations
| | - Linda J Burns
- See the Notes section for the full list of authors' affiliations
| | - Wael Saber
- See the Notes section for the full list of authors' affiliations
| | | | - David J Vanness
- See the Notes section for the full list of authors' affiliations
| | | | - Alicia Silver
- See the Notes section for the full list of authors' affiliations
| | - Susan Leppke
- See the Notes section for the full list of authors' affiliations
| | | | - Ellen Denzen
- See the Notes section for the full list of authors' affiliations
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Hematopoietic Cell Transplant (HCT) in the Elderly: Myths, Controversies and Unknowns. Drugs Aging 2019; 35:1055-1064. [PMID: 30302674 DOI: 10.1007/s40266-018-0596-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The incidence of most hematological malignancies increases with age. Despite the higher incidence of hematological malignancies in the elderly, the geriatric population is poorly represented in the early oncology clinical trials that established the current standards of care. Hematopoietic cell transplant (HCT), either upfront or at relapse, provides a potentially life-prolonging, often curative option for many patients with hematological malignancies and is considered the standard of care, at least for younger patients. Historically, the concern that older adults undergoing HCT may experience higher morbidity and transplant-related complications has limited the use of this potentially curative option to younger adults, particularly in allogeneic (allo-) HCT. There is growing evidence to support the feasibility, tolerability, and relatively similar effectiveness of both autologous and allo-HCT in the geriatric population. In the allo-HCT setting, nonmyeloablative/reduced-intensity conditioning (NMA/RIC) has expanded the spectrum of patients that can be considered for this approach. Overall survival is largely affected by disease stage, performance status, and comorbidities rather than by chronological age per se. Comprehensive geriatric assessment (CGA) is a promising tool that can uncover frequently undocumented vulnerabilities in an elderly transplant-eligible patient. Serial study of CGA throughout the peri-HCT period may help predict the short- and long-term impact of HCT on an older adult's functional status and quality of life. Further research is needed to evaluate whether early intervention to improve such vulnerabilities can improve survival and quality of life of these older patients.
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11
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Hecker J, Miller I, Götze KS, Verbeek M. Bridging Strategies to Allogeneic Transplant for Older AML Patients. Cancers (Basel) 2018; 10:cancers10070232. [PMID: 29997333 PMCID: PMC6071045 DOI: 10.3390/cancers10070232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/27/2018] [Accepted: 07/06/2018] [Indexed: 11/28/2022] Open
Abstract
Treatment options for older patients with intermediate or high-risk acute myeloid leukemia (AML) remain unsatisfactory. Allogeneic stem cell transplantation, the treatment of choice for the majority of younger AML patients, has been hampered in elderly patients by higher treatment related mortality, comorbidities and lack of a suitable donor. With the higher availability of suitable donors as well as of reduced intensity conditioning regimens, novel low intensity treatments prior to transplantation and optimized supportive care, the number of older AML patients being successfully transplanted is steadily increasing. Against this background, we review current treatment strategies for older AML patients planned for allogeneic stem cell transplantation based on clinical trial data, discussing differences between approaches with advantages and pitfalls of each. We summarize pre-treatment considerations that need to be taken into account in this highly heterogeneous older population. Finally, we offer an outlook on areas of ongoing clinical research, including novel immunotherapeutic approaches that may improve access to curative therapies for a larger number of older AML patients.
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Affiliation(s)
- Judith Hecker
- Department of Medicine III, Hematology and Oncology, Technische Universität München, 80333 Munich, Germany.
| | - Isabella Miller
- Department of Medicine III, Hematology and Oncology, Technische Universität München, 80333 Munich, Germany.
| | - Katharina S Götze
- Department of Medicine III, Hematology and Oncology, Technische Universität München, 80333 Munich, Germany.
| | - Mareike Verbeek
- Department of Medicine III, Hematology and Oncology, Technische Universität München, 80333 Munich, Germany.
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12
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Luskin MR, Abel GA. Management of older adults with myelodysplastic syndromes (MDS). J Geriatr Oncol 2018; 9:302-307. [DOI: 10.1016/j.jgo.2017.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/17/2017] [Accepted: 12/13/2017] [Indexed: 01/09/2023]
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13
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Bhatt VR, Chen B, Gyawali B, Lee SJ. Socioeconomic and health system factors associated with lower utilization of hematopoietic cell transplantation in older patients with acute myeloid leukemia. Bone Marrow Transplant 2018; 53:1288-1294. [PMID: 29588500 DOI: 10.1038/s41409-018-0164-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 12/21/2022]
Abstract
Receipt of hematopoietic cell transplantation (HCT) can improve overall survival in older patients with intermediate or high-risk acute myeloid leukemia (AML); however, utilization of HCT is poor. It is important to understand the factors that affect the receipt of HCT in a real-world setting among the older patients. We utilized the National Cancer Database to determine receipt of HCT in older patients (61-75 years) with intermediate or high-risk AML reported between 2003 and 2012. Multivariate logistic regression analysis was used to determine factors associated with receipt of HCT. Only 5.5% of older patients (n = 17,555) underwent HCT. Factors associated with a lower likelihood of receiving HCT included receipt of care in a non-academic hospital, race other than white, older age, Charlson comorbidity score of ≥1, uninsured status, Medicaid or Medicare insurance, and lower educational status. The receipt of HCT in older patients is low and varies based on biological as well as non-biologic factors, such as hospital type, insurance, and educational status. Nationwide efforts to improve access to HCT for appropriate patients are necessary.
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Affiliation(s)
- Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Baojiang Chen
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, School of Public Health in Austin, Austin, TX, USA
| | - Bishal Gyawali
- Department of Hematology-Oncology, Nobel Hospital, Kathmandu, Nepal
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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14
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Koreth J, Antin JH, Cutler C. Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia and Myelodysplastic Syndrome in Adults. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00061-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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15
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Frailty: the missing piece of the pre- hematopoietic cell transplantation assessment? Bone Marrow Transplant 2017; 53:3-10. [PMID: 29084201 DOI: 10.1038/bmt.2017.192] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/03/2017] [Accepted: 07/22/2017] [Indexed: 12/20/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) represents a curative option for those afflicted with numerous hematologic malignancies and bone marrow failure syndromes. Advances and refinement of the HSCT process have resulted in increasing number of transplants performed on older patients in the recent years. Pre-transplant assessments (PTA) function to risk stratify patients prior to undergoing HSCT in an effort to predict those at higher risk of treatment-related toxicity, to inform risk/benefit assessments and to aid clinical decision making. Traditionally used risk stratification parameters such as chronologic age, comorbidity and performance status may not fully capture physical function, physiologic fitness, highlighting a need for improvement in PTA. Incorporation of frailty measurements in pre-HSCT assessments, particularly in elderly transplant candidates, may result in improving predictive ability of existing tools such as the Hematopoietic Cell Transplantation Comorbidity Index and Karnofsky performance status. Here, we review existing pre-HSCT assessment tools, measures of frailty that may aid in risk stratification for patients undergoing HSCT and directions for future research using frailty in the pre-HSCT setting.
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16
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Impact of Allogeneic Stem Cell Transplantation in First Complete Remission in Acute Myeloid Leukemia: A National Population-Based Cohort Study. Biol Blood Marrow Transplant 2017; 24:314-323. [PMID: 29051022 DOI: 10.1016/j.bbmt.2017.10.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 10/10/2017] [Indexed: 11/23/2022]
Abstract
To examine the outcomes of allogeneic stem cell transplantation (HSCT) in first complete remission (CR1) compared with chemotherapy alone in a population-based setting, we identified a cohort of patients with acute myeloid leukemia (AML) aged 15 to 70 years diagnosed between 2000 and 2014 in Denmark. Using the Danish National Acute Leukemia Registry, we compared relapse risk, relapse-free survival (RFS), and overall survival (OS) between patients with unfavorable cytogenetic features receiving postremission therapy with conventional chemotherapy only versus those undergoing HSCT in CR1. To minimize immortal time bias, we performed Cox proportional hazards regression, included date of allogeneic HSCT as a time-dependent covariate, and stratified the results by age (<60 or ≥60 years) and cytogenetic risk group. Overall, 1031 patients achieved a CR1. Of these, 196 patients (19%) underwent HSCT. HSCT was associated with a lower relapse rate (24% versus 49%) despite a similar median time to relapse (287 days versus 265 days). In all subgroups, the risk of relapse was lower and both RFS and OS were superior in recipients of HSCT (OS, adjusted mortality ratios: all patients, .54 [95% confidence interval (CI), .42-.71]; patients age <60 years, .58 [95% CI, .42-.81]; patients age ≥60 years, .42 [95% CI, .26-.69]; patients with intermediate-risk cytogenetics, .63 [95% CI, .43-.87]; patients with adverse-risk cytogenetics, .40 [95% CI, .24-.67]). In conclusion, in this population-based nationwide cohort study, HSCT was associated with improved survival in both younger and older patients and in patients with both intermediate and adverse cytogenetic risk.
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17
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Jakubowski AA, Petrlik E, Maloy M, Hilden P, Papadopoulos E, Young JW, Boulad F, Castro-Malaspina H, Tamari R, Dahi PB, Goldberg J, Koehne G, Perales MA, Sauter CS, O'Reilly RJ, Giralt S. T Cell Depletion as an Alternative Approach for Patients 55 Years or Older Undergoing Allogeneic Stem Cell Transplantation as Curative Therapy for Hematologic Malignancies. Biol Blood Marrow Transplant 2017; 23:1685-1694. [PMID: 28734876 PMCID: PMC10715069 DOI: 10.1016/j.bbmt.2017.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 06/28/2017] [Indexed: 12/27/2022]
Abstract
T cell-depleted (TCD) allogeneic hematopoietic stem cell transplantation (HSCT) is curative treatment for hematologic malignancies in adults, shown to reduce graft-versus-host disease (GVHD) without increased relapse. We retrospectively reviewed a single-center, 11-year experience of 214 patients aged ≥ 55 years to determine tolerability and efficacy in the older adult. Most patients (70%) had myeloid diseases, and most acute leukemias were in remission. Median age was 61 years, with related and unrelated donors ≥8/10 HLA matched. Hematopoietic cell transplantation-specific comorbidity index scores were intermediate and high for 84%. Conditioning regimens were all myeloablative. Grafts were peripheral blood stem cells (97%) containing CD3 dose ≤103-4/kg body weight, without pharmacologic GVHD prophylaxis. With median follow-up of 70 months among survivors, Kaplan-Meier estimates of overall and relapse-free survival were 44% and 41%, respectively (4 years). Cumulative incidence of nonrelapse mortality at day +100 was only 10%. Incidence of GVHD for acute (grades II to IV) was 9% at day +100 and for chronic was 7% at 2 and 4 years (8 extensive, 1 overlap). Median Karnofsky performance status for patients > 2 years post-transplant was 90%. As 1 of the largest reports for patients ≥2 aged ≥55 years receiving TCD HSCTs, it demonstrates curative therapy with minimal GVHD, similar to that observed in a younger population.
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Affiliation(s)
- Ann A Jakubowski
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York.
| | - Erica Petrlik
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick Hilden
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Esperanza Papadopoulos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - James W Young
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Farid Boulad
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hugo Castro-Malaspina
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Roni Tamari
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Parastoo B Dahi
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Jenna Goldberg
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Guenther Koehne
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Craig S Sauter
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
| | - Richard J O'Reilly
- Weill Cornell Medical College, Cornell University, New York, New York; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Weill Cornell Medical College, Cornell University, New York, New York
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18
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Age does not adversely influence outcomes among patients older than 60 years who undergo allogeneic hematopoietic stem cell transplant for AML and myelodysplastic syndrome. Bone Marrow Transplant 2017; 52:1530-1536. [PMID: 28869613 DOI: 10.1038/bmt.2017.182] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/15/2017] [Accepted: 07/12/2017] [Indexed: 12/20/2022]
Abstract
Allogeneic hematopoietic stem cell transplant (AHSCT) outcomes data of older AML/myelodysplastic syndrome (MDS) patients are limited. We retrospectively evaluated consecutive patients ⩾60 years old with AML/MDS who underwent AHSCT between January 2005 and December 2014. The primary objectives were to determine nonrelapse mortality (NRM), relapse, relapse-free survival (RFS) and overall survival (OS) at 1 year post AHSCT. A total of 159 patients underwent AHSCT with a median age of 64 (range, 60-75) years. Of these, 103 patients (65%) had AML and 56 patients (35%) had MDS. At 1 year post AHSCT, grade III-IV acute GvHD and chronic GvHD occurred in 20.8% (95% confidence interval (CI), 14.9-27.5%) and 54.1% (95% CI, 46.0-61.5%) of patients, respectively. NRM, RFS, relapse rate and OS at 1 year post AHSCT were 25.3% (95% CI, 18.8-32.3%), 53.3% (95% CI, 46.1-61.7%), 21.4% (95% CI, 15.4-28.1%) and 56.4% (95% CI, 49.2-54.7%), respectively. High disease risk index was associated with poor RFS, OS and higher relapse rate (P<0.03), whereas non-thymoglobulin-based GvHD prophylaxis, higher comorbidity index (⩾3) and MDS were associated with higher NRM (P<0.03). Importantly, age did not have an adverse effect on NRM, relapse, RFS and OS. AHSCT was well tolerated. Hence, older age alone should not be considered a contraindication to AHSCT.
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19
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Wall SA, Devine S, Vasu S. The who, how and why: Allogeneic transplant for acute myeloid leukemia in patients older than 60years. Blood Rev 2017; 31:362-369. [PMID: 28802907 DOI: 10.1016/j.blre.2017.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 05/26/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
Acute myelogenous leukemia (AML) is primarily a disease of the elderly, and as such, our approach to treatment needs to be tailored to address an aging population. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only potentially curative treatment for intermediate and high risk AML, and until recently, its use had been limited to a younger population and dependent on availability of a donor. Advances in conditioning regimens, supportive care, and the use of alternative donor sources have greatly expanded access to this therapy. In this review, we summarize the challenges and unique biological aspects of treatment with allogeneic stem cell transplantation in this group of patients older than 60years. We also highlight areas of ongoing research including measurement of residual disease prior to and following transplant, post-remission maintenance therapy, and natural killer cell immunotherapy. Finally, we propose future directions for AML treatment in an elderly and aging population.
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Affiliation(s)
- Sarah A Wall
- Division of Hematology, Ohio State University, Columbus, OH, USA
| | - Steven Devine
- Division of Hematology, Ohio State University, Columbus, OH, USA
| | - Sumithira Vasu
- Division of Hematology, Ohio State University, Columbus, OH, USA.
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20
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Patterns of Care and Survival for Elderly Acute Myeloid Leukemia—Challenges and Opportunities. Curr Hematol Malig Rep 2017; 12:290-299. [DOI: 10.1007/s11899-017-0388-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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21
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Preussler JM, Meyer CL, Mau LW, Majhail NS, Denzen EM, Edsall KC, Farnia SH, Saber W, Burns LJ, Vanness DJ. Healthcare Costs and Utilization for Patients Age 50 to 64 Years with Acute Myeloid Leukemia Treated with Chemotherapy or with Chemotherapy and Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1021-1028. [PMID: 28263920 DOI: 10.1016/j.bbmt.2017.02.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
The primary aim of this study was to describe healthcare costs and utilization during the first year after a diagnosis of acute myeloid leukemia (AML) for privately insured non-Medicare patients in the United States aged 50 to 64 years who were treated with either chemotherapy or chemotherapy and allogeneic hematopoietic cell transplantation (alloHCT). MarketScan (Truven Health Analytics) adjudicated total payments for inpatient, outpatient, and prescription drug claims from 2007 to 2011 were used to estimate costs from the health system perspective. Stabilized inverse propensity score weights were constructed using logistic regression to account for differential selection of alloHCT over chemotherapy. Weighted generalized linear models adjusted costs and utilization (hospitalizations, inpatient days, and outpatient visit-days) for differences in age, sex, diagnosis year, region, insurance plan type, Elixhauser Comorbidity Index), and 60-day prediagnosis costs. Because mortality data were not available, models could not be adjusted for survival times. Among 29,915 patients with a primary diagnosis of AML, 985 patients met inclusion criteria (774 [79%] receiving chemotherapy alone and 211 [21%] alloHCT). Adjusted mean 1-year costs were $280,788 for chemotherapy and $544,178 for alloHCT. Patients receiving chemotherapy alone had a mean of 4 hospitalizations, 52.9 inpatient days, and 52.4 outpatient visits in the year after AML diagnosis; patients receiving alloHCT had 5 hospitalizations, 92.5 inpatient days, and 74.5 outpatient visits. Treating AML in the first year after diagnosis incurs substantial healthcare costs and utilization with chemotherapy alone and with alloHCT. Our analysis informs healthcare providers, policymakers, and payers so they can better understand treatment costs and utilization for privately insured patients aged 50 to 64 with AML.
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Affiliation(s)
| | - Christa L Meyer
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Lih-Wen Mau
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Ellen M Denzen
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - Kristen C Edsall
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Linda J Burns
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | - David J Vanness
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin.
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22
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Michelis FV, Gupta V, Zhang MJ, Wang HL, Aljurf M, Bacher U, Beitinjaneh A, Chen YB, DeFilipp Z, Gale RP, Kebriaei P, Kharfan-Dabaja M, Lazarus HM, Nishihori T, Olsson RF, Oran B, Rashidi A, Rizzieri DA, Tallman MS, de Lima M, Khoury HJ, Sandmaier BM, Weisdorf D, Saber W. Cytogenetic risk determines outcomes after allogeneic transplantation in older patients with acute myeloid leukemia in their second complete remission: A Center for International Blood and Marrow Transplant Research cohort analysis. Cancer 2017; 123:2035-2042. [PMID: 28117898 DOI: 10.1002/cncr.30567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/06/2016] [Accepted: 12/19/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation (HCT) offers curative potential to a number of older patients with acute myeloid leukemia (AML) in their first complete remission. However, there are limited data in the literature concerning post-HCT outcomes for older patients in their second complete remission (CR2). METHODS The purpose of the current study was to retrospectively investigate within the Center for International Blood and Marrow Transplant Research database parameters influencing posttransplant outcomes for patients 60 years of age or older undergoing HCT for AML in CR2. RESULTS In total, 196 patients from 78 centers were identified; the median age was 64 years (range, 60-78 years). Seventy-one percent had a Karnofsky performance status ≥ 90 at the time of HCT. Reduced-intensity conditioning regimens were used in 159 patients (81%). A univariate analysis demonstrated a 3-year overall survival (OS) rate of 42% (95% confidence interval [CI], 35%-49%), a leukemia-free survival rate of 37% (95% CI, 30%-44%), a cumulative incidence of nonrelapse mortality of 25% (95% CI, 19%-32%), and a cumulative incidence of relapse (CIR) of 38% (95% CI, 31%-45%). A multivariate analysis demonstrated that cytogenetic risk was the only independent risk factor for OS (P = .023) with a hazard ratio (HR) of 1.14 (95% CI, 0.59-2.19) for intermediate-risk cytogenetics and an HR of 2.32 (95% CI, 1.05-5.14) for unfavorable-risk cytogenetics. For CIR, cytogenetic risk was also the only independent prognostic factor (P = .01) with an HR of 1.10 (95% CI, 0.47-2.56) for intermediate-risk cytogenetics and an HR of 2.98 (95% CI, 1.11-8.00) for unfavorable-risk cytogenetics. CONCLUSIONS Allogeneic HCT is a curative treatment option for older patients with AML in CR2, particularly for those with favorable or intermediate cytogenetic risk. Cancer 2017;123:2035-2042. © 2017 American Cancer Society.
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Affiliation(s)
- Fotios V Michelis
- Allogeneic Blood and Marrow Transplant Program, Princes Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Vikas Gupta
- Allogeneic Blood and Marrow Transplant Program, Princes Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hai-Lin Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Ulrike Bacher
- Department of Hematology/Oncology, University Medicine Gottingen, Gottingen, Germany
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg, Hamburg, Germany
| | | | - Yi-Bin Chen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hillard M Lazarus
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Betul Oran
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Armin Rashidi
- Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Brenda M Sandmaier
- Division of Medical Oncology, University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Fujiwara SI, Muroi K, Yamamoto C, Hatano K, Okazuka K, Sato K, Oh I, Ohmine K, Suzuki T, Ozawa K. CD25 as an adverse prognostic factor in elderly patients with acute myeloid leukemia. ACTA ACUST UNITED AC 2017; 22:347-353. [PMID: 28097942 DOI: 10.1080/10245332.2016.1276240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES CD25 has been reported to be highly expressed in leukemia stem cells and correlated with adverse outcomes in young patients with acute myeloid leukemia (AML). However, the significance of CD25 expression in elderly patients with AML has not yet been investigated. METHODS We retrospectively analyzed 154 newly diagnosed AML patients aged 60 years or over by flow cytometry. RESULTS CD25-positive AML was characterized by high white blood cell counts, secondary AML, rare favorable karyotypes, and positivity for CD34 and CD7 antigens, compared with CD25-negative AML. CD25 positivity was significantly correlated with an inferior complete remission (CR), event-free survival (EFS), and overall survival. Multivariate analysis showed CD25 positivity to be a significant prognostic predictor of CR and EFS. A regimen of low-dose cytarabine and aclarubicin combined with granulocyte-colony-stimulating factor (CAG) led to higher CR rates in the CD25-positive AML patients than intensive chemotherapies. CD25 expression was increased at relapse and in the development of leukemic status from myelodysplastic syndrome or myeloproliferative neoplasm. DISCUSSION An effective treatment strategy for elderly patients with CD25-positive AML has not been established. Further studies are needed to evaluate the effect of a CAG regimen and allogenic stem cell transplantation in patients. CONCLUSION CD25 is an independent prognostic factor in elderly AML patients. Alternative therapies for CD25-positive elderly AML patients are needed.
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Affiliation(s)
- Shin-Ichiro Fujiwara
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Kazuo Muroi
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan.,b Division of Cell Transplantation and Transfusion , Jichi Medical University , Tochigi , Japan
| | - Chihiro Yamamoto
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Kaoru Hatano
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Kiyoshi Okazuka
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Kazuya Sato
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Iekuni Oh
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Ken Ohmine
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Takahiro Suzuki
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
| | - Keiya Ozawa
- a Division of Hematology, Department of Medicine , Jichi Medical University , Tochigi , Japan
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Myeloablative versus Reduced-Intensity Conditioning in Patients with Myeloid Malignancies: A Propensity Score-Matched Analysis. Biol Blood Marrow Transplant 2016; 22:2270-2275. [DOI: 10.1016/j.bbmt.2016.08.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/31/2016] [Indexed: 12/14/2022]
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Fedele R, Salooja N, Martino M. Recommended screening and preventive evaluation practices of adult candidates for hematopoietic stem cell transplantation. Expert Opin Biol Ther 2016; 16:1361-1372. [DOI: 10.1080/14712598.2016.1229773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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26
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Lu Y, Wu T, Liu DY, Cao XY, Xiong M, Zhang JP, Zhou JR, Lu DP. [Clinical studies of myeloablative dose conditioning prior to allogeneic hematopoietic stem cell transplantation for treatment of 12 patients over 55 years with high- risk malignant blood diseases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:708-11. [PMID: 27587256 PMCID: PMC7348528 DOI: 10.3760/cma.j.issn.0253-2727.2016.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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27
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Allogeneic hematopoietic cell transplantation in patients ⩾70 years: which patients may benefit? Blood Cancer J 2016; 6:e443. [PMID: 27391575 PMCID: PMC5030379 DOI: 10.1038/bcj.2016.54] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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28
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El Cheikh J, Sfumato P, Sobh M, Fegueux N, Mohty M, Vigouroux S, Beguin Y, Yakoub-Agha I, Socié G, Cornillon J, Mercier M, Bay JO, Blaise D, Michallet M, Peffault de Latour R. Allogeneic hematopoietic stem cell transplantation after reduced intensity conditioning regimen for elderly patients (60 years and older) with hematologic malignancies using unrelated donors: a retrospective study from the French society for stem cell transplantation (SFGM-TC). Haematologica 2016; 101:e262-5. [PMID: 26992946 DOI: 10.3324/haematol.2015.139345] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Jean El Cheikh
- Hematology and Oncology Bone Marrow Transplantation Program, American University of Beirut, Medical Center Beirut, Lebanon
| | - Patrick Sfumato
- Clinical Trial Office and Biostatistics Unit, Paoli Calmettes Institute, Marseille, France
| | - Mohamad Sobh
- Hematology Department, University Hospital Center, Lyon, France
| | - Nathalie Fegueux
- Hematology Department, University Hospital Center, Montpellier, France
| | - Mohamad Mohty
- Hematology and cellular therapy unit, AP-HP, Université Paris 6, Hôpital Saint Antoine, Paris, France
| | - Stephane Vigouroux
- Hematology Department, Haut-Leveque Hospital and Bordeaux University Hospital Center, Pessac, France
| | - Yves Beguin
- Hematology department, Centre Hospitalier Universitaire de Liège, Liège University, Liège, Belgium
| | | | - Gerard Socié
- Hematology and cellular therapy unit, AP-HP, Hôpital Saint Louis, Paris, France
| | - Jerome Cornillon
- Hematology Department, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Melanie Mercier
- Hematology Department, University Hospital Center, Angers, France
| | | | - Didier Blaise
- Hematology Department, transplantation unit, Paoli Calmettes Institute, Marseille, France
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Aoki J, Kanamori H, Tanaka M, Yamasaki S, Fukuda T, Ogawa H, Iwato K, Ohashi K, Okumura H, Onizuka M, Maesako Y, Teshima T, Kobayashi N, Morishima Y, Hirokawa M, Atsuta Y, Yano S, Takami A. Impact of age on outcomes of allogeneic hematopoietic stem cell transplantation with reduced intensity conditioning in elderly patients with acute myeloid leukemia. Am J Hematol 2016; 91:302-7. [PMID: 26663096 DOI: 10.1002/ajh.24270] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/30/2015] [Accepted: 12/01/2015] [Indexed: 11/11/2022]
Abstract
Previous studies have repeatedly reported that increasing age is a significant risk factor for worse outcomes after allogeneic hematopoietic stem cell transplantation (allo-HSCT) among patients with acute myeloid leukemia (AML). However, more recent studies reported conflicting results regarding the association between age and outcomes in elderly patients. Therefore, we conducted a large-scale, nationwide retrospective study to examine the impact of age on outcomes of allo-HSCT with reduced intensity conditioning (RIC) for AML patients who were older than 50 years. Of the 757 patients, 89 patients (11.8%) were 50-54, 249 patients (32.9%) were 55-59, 301 patients (39.8%) were 60-64 and 118 patients (15.6%) were ≥65 years old. The 3-year overall survival (OS) (47.8, 45.2, 37.9, and 36.6% for patients aged 50-54, 55-59, 60-64, and ≥65 years, respectively, P = 0.24) and nonrelapse mortality (NRM) (24.0, 22.8, 29.2, and 27.6% for patients aged 50-54, 55-59, 60-64, and ≥65 years, respectively, P = 0.49) were not significantly different among the four age groups. Multivariate analysis revealed that increased age had no significant effect on OS or NRM after adjusting for covariates. These results suggested that advanced patient age is not a contraindication for RIC allo-HSCT in elderly AML patients.
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Affiliation(s)
- Jun Aoki
- Department of Hematology; Kanagawa Cancer Center; Yokohama Japan
| | - Heiwa Kanamori
- Department of Hematology; Kanagawa Cancer Center; Yokohama Japan
| | - Masatsugu Tanaka
- Department of Hematology; Kanagawa Cancer Center; Yokohama Japan
| | - Satoshi Yamasaki
- Department of Hematology and Clinical Research Institute; National Hospital Organization Kyushu Medical Center; Fukuoka Japan
| | - Takahiro Fukuda
- Division of Hematopoietic Stem Cell Transplantation; National Cancer Center Hospital; Tokyo Japan
| | - Hiroyasu Ogawa
- Division of Hematology; Department of Internal Medicine; Hyogo College of Medicine; Hyogo Japan
| | - Koji Iwato
- Department of Hematology; Hiroshima Red Cross Hospital and Atomic-Bomb Survivors Hospital; Hiroshima Japan
| | - Kazuteru Ohashi
- Department of Hematology; Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital; Tokyo Japan
| | - Hirokazu Okumura
- Department of Internal Medicine; Toyama Prefectural Central Hospital; Toyama Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology; Tokai University School of Medicine; Isehara Japan
| | | | - Takanori Teshima
- Department of Hematology; Hokkaido University Hospital; Sapporo Japan
| | - Naoki Kobayashi
- Department of Hematology; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Yasuo Morishima
- Division of Epidemiology and Prevention; Aichi Cancer Center Research Institute; Aichi Japan
| | - Makoto Hirokawa
- Department of General Internal Medicine and Clinical Laboratory Medicine; Akita University Graduate School of Medicine; Akita Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation; Nagoya Japan
- Department of Healthcare Administration; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology; Department of Internal Medicine; Jikei University School of Medicine; Tokyo Japan
| | - Akiyoshi Takami
- Division of Hematology; Department of Internal Medicine; Aichi Medical University; Aichi Japan
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Sharma SK, Choudhary D, Kaul E, Kharya G, Khandelwal V, Kothari S, Doval D, Handoo A, Setia R, Dadu T, Pessi K. Hematopoietic Stem Cell Transplant in Elderly Patients: Experience from a Tertiary Care Centre in Northern India. Indian J Hematol Blood Transfus 2015; 32:205-7. [PMID: 27408392 DOI: 10.1007/s12288-015-0624-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/26/2015] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sanjeev Kumar Sharma
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Dharma Choudhary
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Esha Kaul
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Gaurav Kharya
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Vipin Khandelwal
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Sweta Kothari
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Divya Doval
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Anil Handoo
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Rasika Setia
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Tina Dadu
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
| | - Kirti Pessi
- Department of Hemato-Oncology and Bone Marrow Transplantation, BLK Superspeciality Hospital, New Delhi, 110005 India
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Devine SM, Owzar K, Blum W, Mulkey F, Stone RM, Hsu JW, Champlin RE, Chen YB, Vij R, Slack J, Soiffer RJ, Larson RA, Shea TC, Hars V, Sibley AB, Giralt S, Carter S, Horowitz MM, Linker C, Alyea EP. Phase II Study of Allogeneic Transplantation for Older Patients With Acute Myeloid Leukemia in First Complete Remission Using a Reduced-Intensity Conditioning Regimen: Results From Cancer and Leukemia Group B 100103 (Alliance for Clinical Trials in Oncology)/Blood and Marrow Transplant Clinical Trial Network 0502. J Clin Oncol 2015; 33:4167-75. [PMID: 26527780 DOI: 10.1200/jco.2015.62.7273] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE Long-term survival rates for older patients with newly diagnosed acute myeloid leukemia (AML) are extremely low. Previous observational studies suggest that allogeneic hematopoietic stem-cell transplantation (HSCT) may improve overall survival (OS) because of lower rates of relapse. We sought to prospectively determine the value of HSCT for older patients with AML in first complete remission. PATIENTS AND METHODS We conducted a prospective multicenter phase II study to assess the efficacy of reduced-intensity conditioning HSCT for patients between the ages of 60 and 74 years with AML in first complete remission. The primary end point was disease-free survival at 2 years after HSCT. Secondary end points included nonrelapse mortality (NRM), graft-versus-host disease (GVHD), relapse, and OS. RESULTS In all, 114 patients with a median age of 65 years received transplantations. The majority (52%) received transplantations from unrelated donors and were given antithymocyte globulin for GVHD prophylaxis. Disease-free survival and OS at 2 years after transplantation were 42% (95% CI, 33% to 52%) and 48% (95% CI, 39% to 58%), respectively, for the entire group and 40% (95% CI, 29% to 55%) and 50% (95% CI, 38% to 64%) for the unrelated donor group. NRM at 2 years was 15% (95% CI, 8% to 21%). Grade 2 to 4 acute GVHD occurred in 9.6% (95% CI, 4% to 15%) of patients, and chronic GVHD occurred in 28% (95% CI, 19% to 36%) of patients. The cumulative incidence of relapse at 2 years was 44% (95% CI, 35% to 53%). CONCLUSION Reduced-intensity conditioning HSCT to maintain remission in selected older patients with AML is relatively well tolerated and appears to provide superior outcomes when compared with historical patients treated without HSCT. GVHD and NRM rates were lower than expected. Future transplantation studies in these patients should focus on further reducing the risk of relapse.
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Affiliation(s)
- Steven M Devine
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA.
| | - Kouros Owzar
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - William Blum
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Flora Mulkey
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Richard M Stone
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Jack W Hsu
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Richard E Champlin
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Yi-Bin Chen
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Ravi Vij
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - James Slack
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Robert J Soiffer
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Richard A Larson
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Thomas C Shea
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Vera Hars
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Alexander B Sibley
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Sergio Giralt
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Shelly Carter
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Mary M Horowitz
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Charles Linker
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
| | - Edwin P Alyea
- Steven M. Devine and William Blum, Ohio State University, Columbus, OH; Kouros Owzar, Flora Mulkey, Vera Hars, and Alexander B. Sibley, Alliance Statistics and Data Center, Duke University, Durham; Thomas C. Shea, University of North Carolina, Chapel Hill, NC; Richard M. Stone, Robert J. Soiffer, and Edwin P. Alyea, Dana-Farber Cancer Institute; Yi-Bin Chen, Massachusetts General Hospital, Boston, MA; Jack W. Hsu, University of Florida, Gainesville, FL; Richard E. Champlin, MD Anderson Cancer Research Center, Houston, TX; Ravi Vij, Washington University, St. Louis, MO; James Slack, Mayo Clinic, Scottsdale, AZ; Richard A. Larson, University of Chicago, Chicago, IL; Sergio Giralt, Memorial Sloan Kettering Cancer Center, New York, NY; Shelly Carter, The EMMES Corporation, Bethesda, MD; Mary M. Horowitz, Medical College of Wisconsin, Milwaukee, WI; and Charles Linker, University of California at San Francisco, San Francisco, CA
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Abstract
PURPOSE OF REVIEW Significant advances have been made in the treatment of younger patients with acute myeloid leukemia over the past 3 decades, but prognosis in the elderly has remained dismal, with median survival times of only a few months. Although a small percentage of older patients may be cured by standard chemotherapy, it is clear that several aspects of frontline management require improvement and novel approaches are urgently needed. This review focuses on treatment options currently available to older patients with acute myeloid leukemia, with an emphasis on new therapeutics. RECENT FINDINGS Developing risk-assessment tools is critical to identify older patients who are most likely to benefit from intensive chemotherapy, but optimal induction and postremission therapies have yet to be determined in this population. New strategies and treatments are emerging and under current assessment. In particular, investigations of monoclonal antibodies, hypomethylating agents, signal transduction inhibitors, and novel cytotoxics hold promise for improving outcomes in older patients with acute myeloid leukemia, including those for whom traditional chemotherapy is not considered appropriate. SUMMARY Acute myeloid leukemia remains a therapeutic challenge in elderly patients, but, following a period of paucity in discoveries, several new treatments are finally emerging that may offer future improvement for these patients.
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Federmann B, Faul C, Meisner C, Vogel W, Kanz L, Bethge WA. Influence of age on outcome after allogeneic hematopoietic cell transplantation: a single center study in patients aged ⩾60. Bone Marrow Transplant 2015; 50:427-31. [DOI: 10.1038/bmt.2014.292] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 10/17/2014] [Accepted: 10/21/2014] [Indexed: 11/09/2022]
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Interpreting outcome data in hematopoietic cell transplantation for leukemia: tackling common biases. Bone Marrow Transplant 2015; 50:324-33. [DOI: 10.1038/bmt.2014.270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/15/2014] [Accepted: 07/03/2014] [Indexed: 11/08/2022]
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Impact of pre-transplant co-morbidities on outcome after alemtuzumab-based reduced intensity conditioning allo-SCT in elderly patients: a British Society of Blood and Marrow Transplantation study. Bone Marrow Transplant 2014; 50:82-6. [PMID: 25285801 DOI: 10.1038/bmt.2014.215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 08/27/2014] [Accepted: 08/28/2014] [Indexed: 11/12/2022]
Abstract
The advent of reduced intensity conditioning (RIC) regimens has permitted the extension of allo-SCT to selected patients into their eighth decade but GVHD remains a major cause of morbidity and mortality. Alemtuzumab is increasingly used to reduce the risk of severe GVHD, but there are concerns that T-cell depletion may compromise outcome particularly in older patients. We therefore studied the impact of pre-transplant factors on the outcome of 187 patients with a haematological malignancy over the age of 60 transplanted using an alemtuzumab-based RIC regimen of whom co-morbidity scoring was possible in 169. Of the patients, 120 had a haematopoietic cell transplantation co-morbidity index (HCT-CI) of 0 or 1 and 49 had a score of 2 or more. The 5-year OS was 33%. In multivariable analysis, OS was determined by co-morbidity score (P=0.001) and disease status at transplant (P=0.004) but not by patient age. Non-relapse mortality was determined by co-morbidity score (P=0.001). Two-year OS for patients with a HCT-CI of 0-1 was 59 versus 6% for patients with a higher score. Alemtuzumab-based RIC allografts can be delivered safely in patients aged over 60 but co-morbidity scoring is mandatory to identify patients who will benefit.
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Wildes TM, Stirewalt DL, Medeiros B, Hurria A. Hematopoietic stem cell transplantation for hematologic malignancies in older adults: geriatric principles in the transplant clinic. J Natl Compr Canc Netw 2014; 12:128-36. [PMID: 24453296 DOI: 10.6004/jnccn.2014.0010] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Hematopoietic cell transplantation (HCT) provides a life-prolonging or potentially curative treatment option for patients with hematologic malignancies. Given the high transplant-related morbidity, these treatment strategies were initially restricted to younger patients, but are increasingly being used in older adults. The incidence of most hematologic malignancies increases with age; with the aging of the population, the number of potential older candidates for HCT increases. Autologous HCT (auto-HCT) in older patients may confer a slightly increased risk of specific toxicities (such as cardiac toxicities and mucositis) and have modestly lower effectiveness (in the case of lymphoma). However, auto-HCT remains a feasible, safe, and effective therapy for selected older adults with multiple myeloma and lymphoma. Similarly, allogeneic transplant (allo-HCT) is a potential therapeutic option for selected older adults, although fewer data exist on allo-HCT in older patients. Based on currently available data, age alone is not the best predictor of toxicity and outcomes; rather, the comorbidities and functional status of the older patient are likely better predictors of toxicity than chronologic age in both the autologous and allogeneic setting. A comprehensive geriatric assessment (CGA) in older adults being considered for either an auto-HCT or allo-HCT may identify additional problems or geriatric syndromes, which may not be detected during the standard pretransplant evaluation. Further research is needed to establish the utility of CGA in predicting toxicity and to evaluate the quality of survival in older adults undergoing HCT.
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Affiliation(s)
- Tanya M Wildes
- From aWashington University School of Medicine, St. Louis, Missouri; bFred Hutchinson Cancer Research Center, Seattle, Washington; cStanford University School of Medicine, Stanford, California; and dCity of Hope Comprehensive Cancer Center, Duarte, California
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Quality of life and outcomes in patients⩾60 years of age after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2014; 49:1426-31. [PMID: 25068430 DOI: 10.1038/bmt.2014.166] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Revised: 05/03/2014] [Accepted: 06/10/2014] [Indexed: 11/08/2022]
Abstract
Hematopoietic cell transplantation (HCT) has become an established standard of care for many older patients with hematologic malignancies. The effect of transplantation on the quality of life (QOL) of older patients, however, has not been well studied. We thus analyzed QOL in patients ⩾60 undergoing an allogeneic HCT compared with patients <60 years. Prospective psychometric instruments were administered to 351 patients who underwent HCT from 2003 to 2010. Psychometric data were assessed longitudinally by validated questionnaires: Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT), Coping Inventory and the Profile of Mood State-Short Form. Patients ⩾60 reported better social (P=0.006) and functional well-being (P=0.05) with FACT assessment, and had better total scores, (P=0.043) across all time points. When adjusted for baseline QOL scores as a covariate, social well-being remained significantly better, whereas the other scores became non-significant. With a median follow-up of 49 months, there were no significant differences in OS, relapse-free survival, relapse or chronic GVHD. This study provides further evidence that advanced age should not be a barrier in the decision to pursue allogeneic HCT. Older patients achieved comparable QOL when compared with younger patients.
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Isidori A, Venditti A, Maurillo L, Buccisano F, Loscocco F, Manduzio P, Sparaventi G, Amadori S, Visani G. Alternative novel therapies for the treatment of elderly acute myeloid leukemia patients. Expert Rev Hematol 2014; 6:767-84. [PMID: 24219553 DOI: 10.1586/17474086.2013.858018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
With a median age at diagnosis of approximately 65-70 years, acute myeloid leukemia (AML) represents a major therapeutic challenge in the elderly. Only 30-35% of elderly patients with AML are considered eligible for intensive chemotherapy and do actually receive it. However, the long-term benefit associated with intensive chemotherapy remains marginal, and the overall outcome for this population remains poor. The remaining 60-65% of elderly AML patients receives supportive care only. Nevertheless, several studies have indicated that patients who receive any therapy had a better outcome if compared with patients who receive supportive care only. Thus, the development of novel, less toxic, targeted agents is offering new options to older AML patients who are unfit for intensive approaches. In the present review, we will report on the results achieved using intensive chemotherapy and novel agents, and will describe some of the new strategies under development for treating older AML patients.
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Affiliation(s)
- Alessandro Isidori
- Haematology and Haematopoietic Stem Cell Transplant Center, AORMN, Marche Nord Hospital, Via Lombroso, 61100 Pesaro, Italy
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Chantepie S, Gac A, Reman O. Feasibility of the fludarabine busulfan 3 days and ATG 2 days reduced toxicity conditioning in 51 allogeneic hematopoietic stem cell transplantation: A single-center experience. Leuk Res 2014; 38:569-74. [DOI: 10.1016/j.leukres.2014.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 02/21/2014] [Accepted: 02/24/2014] [Indexed: 10/25/2022]
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40
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Weisdorf D, Eapen M, Ruggeri A, Zhang MJ, Zhong X, Brunstein C, Ustun C, Rocha V, Gluckman E. Alternative donor transplantation for older patients with acute myeloid leukemia in first complete remission: a center for international blood and marrow transplant research-eurocord analysis. Biol Blood Marrow Transplant 2014; 20:816-22. [PMID: 24582782 DOI: 10.1016/j.bbmt.2014.02.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 02/22/2014] [Indexed: 12/27/2022]
Abstract
We studied patients with acute myeloid leukemia (AML) over age 50 and in first complete remission (CR1) after adult unrelated donor (URD) (n = 441, 8/8 HLA matched; n = 94, 7/8 HLA matched) or umbilical cord blood (UCB; n = 205) transplantations. UCB recipients achieved CR1 within 8 weeks less often, and received reduced-intensity conditioning and cyclosporine-based graft-versus-host disease (GVHD) prophylaxis more often. Neutrophil recovery was slower in UCB (69% by day 28) compared with 8/8 HLA-matched URD (97%) and 7/8 HLA-matched (91%) (P < .001) recipients. Three-year transplantation-related mortality (TRM) was higher and leukemia-free survival (LFS) lower with UCB (35% and 28%, respectively) versus 8/8 HLA-matched URD (27% and 39%, respectively). TRM was higher in 7/8 HLA-matched URD (41%, P = .01), but LFS was similar at 34% (P = .39). Three-year chronic GVHD was the lowest in UCB (28%) versus 53% and 59% in 8/8 and 7/8 HLA-matched URD recipients, respectively. Three-year survival was 43% in 8/8 HLA-matched URD (95% confidence interval [CI], 38% to 48%), 30% in UCB (95% CI, 23% to 37%) (P = .002) and 37% in 7/8 URD (95% CI, 27 to 46). Allotransplantation for AML in CR1 with any of these grafts extends LFS for over one third of older patients. In the absence of an 8/8 HLA-matched URD or when transplantation is needed urgently, UCB can provide extended survival. Less frequent chronic GVHD with UCB transplantation may be of particular value for older patients.
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Affiliation(s)
- Daniel Weisdorf
- Department of Medicine, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Annalisa Ruggeri
- Eurocord, Hopital Saint Louis, Paris, France; Service d Hematologie et Therapie Cellulaire, Hopital Saint Antoine, Paris, France
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Eurocord, Hopital Saint Louis, Paris, France; Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaobo Zhong
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claudio Brunstein
- Department of Medicine, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Celalettin Ustun
- Department of Medicine, Blood and Marrow Transplant Program, University of Minnesota, Minneapolis, Minnesota
| | - Vanderson Rocha
- Eurocord, Hopital Saint Louis, Paris, France; Oxford University Hospitals NHS Trust, Department of Clinical Haematology, Churchill Hospital, Oxford, United Kingdom
| | - Eliane Gluckman
- Eurocord, Hopital Saint Louis, Paris, France; Université Paris Diderot, Paris, France
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41
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Martner A, Thorén FB, Aurelius J, Söderholm J, Brune M, Hellstrand K. Immunotherapy with histamine dihydrochloride for the prevention of relapse in acute myeloid leukemia. Expert Rev Hematol 2014; 3:381-91. [DOI: 10.1586/ehm.10.30] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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42
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Zeidan AM, Gore SD. Should elderly patients with higher-risk myelodysplastic syndromes undergo allogeneic hematopoietic stem cell transplantation? Expert Rev Hematol 2013; 6:539-42. [PMID: 24093972 DOI: 10.1586/17474086.2013.827097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Myelodysplastic syndromes (MDS) include a group of hematopoietic malignancies characterized by dysplastic changes, ineffective hematopoiesis and variable risk of leukemic progression. At diagnosis, 86% of MDS patients are ≥60 years. Azacitidine, the only drug that prolongs life in high-risk (HR)-MDS patients, adds a median of only 9.5 months to life. Allogeneic stem cell transplantation (alloSCT) remains the only potentially curative approach. Despite recent improvements including use of reduced intensity conditioning (RIC) that decrease transplant-related mortality, alloSCT continues to be used rarely in elderly MDS. There is paucity of data regarding outcomes of RIC alloSCT in elderly MDS patients, especially in direct comparison with azanucleosides. In this paper, the authors discuss the recent Markov decision analysis by Koreth et al. in which investigators demonstrated superior survival of patients with HR-MDS aged 60-70 years who underwent RIC alloSCT in comparison with those who were treated with azanucleosides.
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Affiliation(s)
- Amer M Zeidan
- Department of Oncology, The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, CRB1 Building, Room 186, Baltimore, MD 21287, USA
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43
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Grunwald MR. Allogeneic hematopoietic cell transplantation in septuagenarians. Biol Blood Marrow Transplant 2013; 19:1276-8. [PMID: 23871779 PMCID: PMC4476526 DOI: 10.1016/j.bbmt.2013.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Michael R Grunwald
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, North Carolina 28204, USA.
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44
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Abstract
PURPOSE OF REVIEW We summarize recent advances for acute myeloid leukemia (AML) in older patients, with a focus on immunotherapeutics. Although the recently updated US SEER data still show that the majority of older AML patients do not receive any therapy, this reality is slowly changing. Advances in our understanding of the biology of AML and in the field of immunology are facilitating the development of alternative therapeutic options for patients, affording more and novel opportunities for potentially curative treatment. RECENT FINDINGS Data from multiple cooperative groups show that older patients benefit from the incorporation of gemtuzumab ozogamicin, an anti-CD33 mAb toxin, into induction regimens. The first prospective study for reduced-intensity conditioning allogeneic hematopoietic stem cell transplantation in older AML patients was reported at the American Society of Hematology Annual Meeting, 2012; the approach was feasible and improved disease-free survival over conventional chemotherapy. Proof-of-concept trials targeting specific antigens such as WT1 or novel unique leukemia-associated antigens are currently underway, as well as other trials using chimeric antigen receptor T cells or (natural killer/effector cells in nontransplantation settings. SUMMARY Wider application of immunotherapies such as allogeneic hematopoietic stem cell transplantation with reduced-intensity conditioning have altered the landscape and offer potential for cure of an increasing number of older AML patients.
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45
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Koreth J, Pidala J, Perez WS, Deeg HJ, Garcia-Manero G, Malcovati L, Cazzola M, Park S, Itzykson R, Ades L, Fenaux P, Jadersten M, Hellstrom-Lindberg E, Gale RP, Beach CL, Lee SJ, Horowitz MM, Greenberg PL, Tallman MS, DiPersio JF, Bunjes D, Weisdorf DJ, Cutler C. Role of reduced-intensity conditioning allogeneic hematopoietic stem-cell transplantation in older patients with de novo myelodysplastic syndromes: an international collaborative decision analysis. J Clin Oncol 2013; 31:2662-70. [PMID: 23797000 DOI: 10.1200/jco.2012.46.8652] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Myelodysplastic syndromes (MDS) are clonal hematopoietic disorders that are more common in patients aged ≥ 60 years and are incurable with conventional therapies. Reduced-intensity conditioning (RIC) allogeneic hematopoietic stem-cell transplantation is potentially curative but has additional mortality risk. We evaluated RIC transplantation versus nontransplantation therapies in older patients with MDS stratified by International Prognostic Scoring System (IPSS) risk. PATIENTS AND METHODS A Markov decision model with quality-of-life utility estimates for different MDS and transplantation states was assessed. Outcomes were life expectancy (LE) and quality-adjusted life expectancy (QALE). A total of 514 patients with de novo MDS aged 60 to 70 years were evaluated. Chronic myelomonocytic leukemia, isolated 5q- syndrome, unclassifiable, and therapy-related MDS were excluded. Transplantation using T-cell depletion or HLA-mismatched or umbilical cord donors was also excluded. RIC transplantation (n = 132) stratified by IPSS risk was compared with best supportive care for patients with nonanemic low/intermediate-1 IPSS (n = 123), hematopoietic growth factors for patients with anemic low/intermediate-1 IPSS (n = 94), and hypomethylating agents for patients with intermediate-2/high IPSS (n = 165). RESULTS For patients with low/intermediate-1 IPSS MDS, RIC transplantation LE was 38 months versus 77 months with nontransplantation approaches. QALE and sensitivity analysis did not favor RIC transplantation across plausible utility estimates. For intermediate-2/high IPSS MDS, RIC transplantation LE was 36 months versus 28 months for nontransplantation therapies. QALE and sensitivity analysis favored RIC transplantation across plausible utility estimates. CONCLUSION For patients with de novo MDS aged 60 to 70 years, favored treatments vary with IPSS risk. For low/intermediate-1 IPSS, nontransplantation approaches are preferred. For intermediate-2/high IPSS, RIC transplantation offers overall and quality-adjusted survival benefit.
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Affiliation(s)
- John Koreth
- Dana-Farber Cancer Institute, D1B05, 450 Brookline Ave, Boston, MA 02215, USA.
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46
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Brunner AM, Kim HT, Coughlin E, Alyea EP, Armand P, Ballen KK, Cutler C, Dey BR, Glotzbecker B, Koreth J, McAfee SL, Spitzer TR, Soiffer RJ, Antin JH, Ho VT, Chen YB. Outcomes in patients age 70 or older undergoing allogeneic hematopoietic stem cell transplantation for hematologic malignancies. Biol Blood Marrow Transplant 2013; 19:1374-80. [PMID: 23791626 DOI: 10.1016/j.bbmt.2013.06.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 06/10/2013] [Indexed: 12/16/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) can achieve durable remissions in a number of patients with advanced hematologic malignancies. Little is known about the safety of HSCT in patients age 70 or older. Consecutive patients (n = 54) age 70 or older underwent HSCT between 2007 and 2012. Diseases included acute myelogenous leukemia (n = 25), myelodysplastic syndrome (n = 12), chronic lymphocytic leukemia (n = 5), non-Hodgkin lymphoma (n = 4), acute lymphoblastic leukemia (n = 3), myeloproliferative neoplasm (n = 4), and chronic myelogenous leukemia (n = 1). Median follow-up for survivors was 21 months. All patients received reduced-intensity conditioning regimens, primarily busulfan/fludarabine. All patients received unmanipulated peripheral blood stem cell grafts: 44 from 8/8 matched unrelated donors, 8 from matched related donors, and 2 from 7/8 matched unrelated donors. Graft-versus-host disease (GVHD) prophylaxis was calcineurin inhibitor-based in all patients. The median age at transplantation was 71 years (range, 70 to 76); the median HCT comorbidity index score was 1 (range, 0 to 5). Two patients died before hematopoietic recovery (1 with graft failure and 1 with disease progression), and 1 patient relapsed before hematopoietic recovery; otherwise, all engrafted with median donor chimerism of 94% at 1 month. Cumulative incidence of grades II to IV acute GVHD was 13% and of grades III to IV acute GVHD, 9.3%. At 2 years, the cumulative incidence of chronic GVHD was 36%, progression-free survival was 39%, overall survival was 39%, and relapse was 56%. Nonrelapse mortality was 3.7% at day +100 and 5.6% at 2 years. We conclude that allogeneic HSCT is a safe and effective option for carefully selected patients age 70 or older.
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Affiliation(s)
- Andrew M Brunner
- Bone Marrow Transplant Unit, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
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47
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To transplant or not: a dilemma for treatment of elderly AML patients in the twenty-first century. Bone Marrow Transplant 2013; 48:1497-505. [DOI: 10.1038/bmt.2013.67] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/04/2013] [Indexed: 12/14/2022]
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48
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Brandwein JM, Geddes M, Kassis J, Kew AK, Leber B, Nevill T, Sabloff M, Sandhu I, Schuh AC, Storring JM, Ashkenas J. Treatment of older patients with acute myeloid leukemia (AML): a Canadian consensus. AMERICAN JOURNAL OF BLOOD RESEARCH 2013; 3:141-64. [PMID: 23675565 PMCID: PMC3649813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 03/23/2013] [Indexed: 06/02/2023]
Abstract
Patients over age 60 comprise the majority of those diagnosed with acute myeloid leukemia (AML), but treatment approaches in this population are variable, with many uncertainties and controversies. Our group conducted a literature review to summarize the latest information and to develop a consensus document with practical treatment recommendations. We addressed five key questions: selection criteria for patients to receive intensive induction chemotherapy; optimal induction and post-remission regimens; allogeneic hematopoietic stem cell transplantation (HSCT); treatment of patients not suitable for induction chemotherapy; and treatment of patients with prior hematological disorders or therapy-related AML. Relevant literature was identified through a PubMed search of publications from 1991 to 2012. Key findings included the recognition that cytogenetics and molecular markers are major biologic determinants of treatment outcomes in the older population, both during induction therapy and following HSCT. Although disease-specific and patient-specific risk factors for poor outcomes are more common in the older population, age is not in itself sufficient grounds for withholding established treatments, including induction and consolidation chemotherapy. The role of HSCT and use of hypomethylating agents are discussed. Finally, suggested treatment algorithms are outlined, based on these recommendations.
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Affiliation(s)
- Joseph M Brandwein
- Department of Medical Oncology and Hematology, Princess Margaret Cancer CentreToronto, Ontario
| | - Michelle Geddes
- Division of Hematology and Hematologic Malignancy, Department of Medicine, University of CalgaryCalgary, Alberta
| | - Jeannine Kassis
- Department of Hematolgy, Hôpital Maisonneuve-Rosemont, University of MontrealMontreal, Québec
| | - Andrea K Kew
- Division of Hematology, Queen Elizabeth II Health Sciences CentreHalifax, Nova Scotia
| | - Brian Leber
- Juravinski Cancer Centre, Hamilton Health Sciences: McMaster UniversityHamilton, Ontario
| | - Thomas Nevill
- Vancouver General HospitalVancouver, British Columbia
| | - Mitchell Sabloff
- Department of Medicine, Division of Hematology, The Ottawa Hospital, University of OttawaOttawa, Ontario
| | - Irwindeep Sandhu
- Division of Clinical Hematology, Department of Medicine, Faculty of Medicine & Dentistry, University of AlbertaAlberta
| | - Andre C Schuh
- Department of Medical Oncology and Hematology, Princess Margaret Cancer CentreToronto, Ontario
| | - John M Storring
- Division of Hematology, McGill University Health CentreMontreal, Quebec
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49
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Optimal positioning of hematopoietic stem cell transplantation for older patients with myelodysplastic syndromes. Curr Opin Hematol 2013; 20:150-6. [DOI: 10.1097/moh.0b013e32835d8e8e] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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Keating A, DaSilva G, Pérez WS, Gupta V, Cutler CS, Ballen KK, Cairo MS, Camitta BM, Champlin RE, Gajewski JL, Lazarus HM, Lill M, Marks DI, Nabhan C, Schiller GJ, Socie G, Szer J, Tallman MS, Weisdorf DJ. Autologous blood cell transplantation versus HLA-identical sibling transplantation for acute myeloid leukemia in first complete remission: a registry study from the Center for International Blood and Marrow Transplantation Research. Haematologica 2012; 98:185-92. [PMID: 22983587 DOI: 10.3324/haematol.2012.062059] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The optimal post-remission treatment for acute myeloid leukemia in first complete remission remains uncertain. Previous comparisons of autologous versus allogeneic hematopoietic cell transplantation noted higher relapse, but lower treatment-related mortality though using bone marrow grafts, with treatment-related mortality of 12-20%. Recognizing lower treatment-related mortality using autologous peripheral blood grafts, in an analysis of registry data from the Center for International Blood and Transplant Research, we compared treatment-related mortality, relapse, leukemia-free survival, and overall survival for patients with acute myeloid leukemia in first complete remission (median ages 36-44, range 19-60) receiving myeloablative HLA-matched sibling donor grafts (bone marrow, n=475 or peripheral blood, n=428) versus autologous peripheral blood (n=230). The 5-year cumulative incidence of treatment-related mortality was 19% (95% confidence interval, 16-23%), 20% (17-24%) and 8% (5-12%) for allogeneic bone marrow, allogeneic peripheral blood and autologous peripheral blood stem cell transplant recipients, respectively. The corresponding figures for 5-year cumulative incidence of relapse were 20% (17-24%), 26% (21-30%) and 45% (38-52%), respectively. At 5 years, leukemia-free survival and overall survival rates were similar: allogeneic bone marrow 61% (56-65%) and 64% (59-68%); allogeneic peripheral blood 54% (49-59%) and 59% (54-64%); autologous peripheral blood 47% (40-54%) and 54% (47-60%); P=0.13 and P=0.19, respectively. In multivariate analysis the incidence of treatment-related mortality was lower after autologous peripheral blood transplantation than after allogeneic bone marrow/peripheral blood transplants [relative risk 0.37 (0.20-0.69); P=0.001], but treatment failure (death or relapse) after autologous peripheral blood was significantly more likely [relative risk 1.32 (1.06-1.64); P=0.011]. The 5-year overall survival, however, was similar in patients who received autologous peripheral blood (n=230) [relative risk 1.23 (0.98-1.55); P=0.071] or allogeneic bone marrow/peripheral blood (n=903). In the absence of an HLA-matched sibling donor, autologous peripheral blood may provide acceptable alternative post-remission therapy for patients with acute myeloid leukemia in first complete remission.
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Affiliation(s)
- Armand Keating
- Princess Margaret Hospital, University of Toronto, Ontario, Canada
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