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Ashok Kumar P, Ghimire K, Haroun E, Kassab J, Saba L, Gentile T, Dutta D, Lim SH. Utilization and outcome disparities in allogeneic hematopoietic stem cell transplant in the United States. Eur J Haematol 2024; 112:328-338. [PMID: 37899652 DOI: 10.1111/ejh.14129] [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: 09/29/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023]
Abstract
Allogeneic hematopoietic stem cell transplant (allo-HSCT) is increasingly being used in the United States (US) and across the world as a curative therapeutic option for patients with certain high-risk hematologic malignancies and non-malignant diseases. However, racial and ethnic disparities in utilization of the procedure and in outcome following transplant remain major problems. Racial and ethnic minority patients are consistently under-represented in the proportion of patients who undergo allo-HSCT in the US. The transplant outcomes in these patients are also inferior. The interrelated driving forces responsible for the differences in the utilization and transplant outcome of the medical intervention are socioeconomic status, complexity of the procedure, geographical barriers, and the results of differences in the genetics and comorbidities across different races. Bridging the disparity gaps is important not only to provide equity and inclusion in the utilization of this potentially life-saving procedure but also in ensuring that minority groups are well represented for research studies about allo-HSCT. This is required to determine interventions that may be more efficacious in particular racial and ethnic groups. Various strategies at the Federal, State, and Program levels have been designed to bridge the disparity gaps with varying successes. In this review paper, we will examine the disparities and discuss the strategies currently available to address the utilization and outcome gaps between patients of different races in the US.
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Affiliation(s)
- Prashanth Ashok Kumar
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Krishna Ghimire
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Elio Haroun
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Joseph Kassab
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Ludovic Saba
- Department of Medicine, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Teresa Gentile
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Dibyendu Dutta
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Seah H Lim
- Division of Hematology and Oncology, State University of New York Upstate Medical University, Syracuse, New York, USA
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2
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Majhail NS, Miller B, Dean R, Manghani R, Shin H, Sivaraman S, Maziarz RT. Hospitalization and Healthcare Resource Utilization of Omidubicel-Onlv versus Umbilical Cord Blood Transplantation for Hematologic Malignancies: Secondary Analysis from a Pivotal Phase 3 Clinical Trial. Transplant Cell Ther 2023; 29:749.e1-749.e5. [PMID: 37703995 DOI: 10.1016/j.jtct.2023.09.004] [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: 06/15/2023] [Revised: 08/17/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
A phase 3 trial (ClincialTrials.gov identifier NCT02730299) of omidubicel-onlv, a nicotinamide-modified allogeneic hematopoietic progenitor cell therapy manufactured from a single umbilical cord blood (UCB) unit, showed faster hematopoietic recovery, reduced rate of infections, and shorter hospital stay compared with patients randomized to standard UCB. This prospective secondary analysis of the phase 3 trial characterized resource utilization in the first 100 days post-transplantation with omidubicel-onlv compared with UCB. This analysis examined resource utilization, including hospital length of stay, hospital care setting, visits by provider type, rate of transfusions, and readmissions, among the 108 treated patients (omidubicel-onlv, n = 52; UCB, n = 56) from day 0 to day 100 post-transplantation. Demographics were generally balanced between the 2 arms, except a higher proportion of females (52% versus 37%) and older median age (40 years versus 36 years) were noted in the omidubicel-onlv arm. Compared with patients receiving UCB transplantation, patients receiving omidubicel-onlv had a shorter average total hospital length of stay (mean, 41.2 days versus 50.8 days; P = .027) in the first 100 days post-transplantation and more days alive and out of the hospital (mean, 55.8 days versus 43.7 days; P = .023). Fewer patients died in the omidubicel-onlv arm compared with the UCB arm (12% vs 16%) before day 100 post-transplantation. During primary hospitalization (ie, time from transplantation to discharge), fewer patients receiving omidubicel-onlv required intensive care unit (ICU) admission (10% versus 23%) and spent fewer days in the ICU (mean, .4 day versus 4.7 days; P = .028) and transplant unit (mean, 25.3 days versus 32.9 days; P = .022) compared with those receiving UCB. Patients receiving omidubicel-onlv required fewer outpatient consultant and nonconsultant visits and fewer platelet or other transfusions within 100 days from transplantation. Our findings suggest that faster hematopoietic recovery in omidubicel-onlv patients is associated with significantly shorter hospital stay and reduced healthcare resource use compared with UCB.
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Affiliation(s)
- Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, Tennessee.
| | | | | | | | | | | | - Richard T Maziarz
- Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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3
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Gupta A, Hay AE, Crump M, Djurfeldt MS, Zhu L, Cheung MC, Shepherd LE, Chen BE, Booth CM. Contact Days Associated With Cancer Treatments in the CCTG LY.12 Trial. Oncologist 2023; 28:799-803. [PMID: 37226534 PMCID: PMC10485297 DOI: 10.1093/oncolo/oyad128] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 04/18/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND When cancer treatments have similar oncologic outcomes, the number of days with in-person healthcare contact (""contact days'') can help contextualize expected time use with each treatment. We assessed contact days in a completed randomized clinical trial. PATIENTS AND METHODS We conducted a secondary analysis of the CCTG LY.12 RCT that evaluated 2-3 cycles of gemcitabine, dexamethasone, and cisplatin (GDP) vs. dexamethasone, cytarabine, and cisplatin (DHAP) in 619 patients with relapsed/refractory lymphoma prior to stem cell transplant. Primary analyses reported similar response rates and survival. We calculated patient-level "contact days" by analyzing trial forms. The study period was from assignment to progression or transplant. Days without healthcare contact were considered "home days''. We compared measures of contact days across arms. RESULTS The study period was longer in the GDP arm (median 50, vs. 47 days, P = .007). Contact days were comparable in both arms (median 18 vs 19, P = 0.79), but home days were higher in the GDP arm (median 33 vs 28, P < .001). The proportion of contact days was lower in the GDP arm (34%, vs. 38%, P = .009). The GDP arm experienced more contact days related to planned outpatient chemotherapy (median, 10 vs. 8 days), but the DHAP arm experienced many more inpatient contact days (median, 11 vs. 0 days). CONCLUSIONS Measures of time use, such as contact days, can be extracted from RCTs. In LY.12, despite comparable oncologic outcomes, GDP was associated with fewer contact days. Such information can guide decision-making for patients with hematological cancers, who already face significant healthcare contact.
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Affiliation(s)
- Arjun Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, MN, USA
| | - Annette E Hay
- Canadian Cancer Trials Group, Kingston, ON, Canada
- Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Michael Crump
- Canadian Cancer Trials Group, Kingston, ON, Canada
- Division of Hematology, Princess Margaret Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Liting Zhu
- Canadian Cancer Trials Group, Kingston, ON, Canada
| | - Matthew C Cheung
- Canadian Cancer Trials Group, Kingston, ON, Canada
- Division of Hematology, Odette Cancer Centre, Toronto, ON, Canada
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4
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Resource utilization in patients with large B-cell lymphoma receiving tisagenlecleucel and axicabtagene ciloleucel. Bone Marrow Transplant 2023; 58:590-593. [PMID: 36774431 DOI: 10.1038/s41409-023-01934-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
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Klein OR, Bonfim C, Abraham A, Ruggeri A, Purtill D, Cohen S, Wynn R, Russell A, Sharma A, Ciccocioppo R, Prockop S, Boelens JJ, Bertaina A. Transplant for non-malignant disorders: an International Society for Cell & Gene Therapy Stem Cell Engineering Committee report on the role of alternative donors, stem cell sources and graft engineering. Cytotherapy 2023; 25:463-471. [PMID: 36710227 DOI: 10.1016/j.jcyt.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 01/30/2023]
Abstract
Hematopoietic stem cell transplantation (HSCT) is curative for many non-malignant disorders. As HSCT and supportive care technologies improve, this life-saving treatment may be offered to more and more patients. With the development of new preparative regimens, expanded alternative donor availability, and graft manipulation techniques, there are many options when choosing the best regimen for patients. Herein the authors review transplant considerations, transplant goals, conditioning regimens, donor choice, and graft manipulation strategies for patients with non-malignant disorders undergoing HSCT.
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Affiliation(s)
- Orly R Klein
- Division of Hematology, Oncology and Stem Cell Transplant and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA.
| | - Carmem Bonfim
- Pediatric Blood and Marrow Transplantation Division and Pele Pequeno Principe Research Institute, Hospital Pequeno Principe, Curitiba, Brazil
| | - Allistair Abraham
- Center for Cancer and Immunology Research, Cell Enhancement and Technologies for Immunotherapy, Children's National Hospital, Washington, DC, USA
| | - Annalisa Ruggeri
- Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Duncan Purtill
- Department of Hematology, Fiona Stanley Hospital, Perth, Australia
| | - Sandra Cohen
- Université de Montréal and Maisonneuve Rosemont Hospital, Montréal, Canada
| | - Robert Wynn
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Athena Russell
- Center for Cellular Immunotherapies, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Rachele Ciccocioppo
- Gastroenterology Unit, Department of Medicine, Azienda Ospedaliera Universitaria Integrata Policlinico G.B. Rossi and University of Verona, Verona, Italy
| | - Susan Prockop
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Jaap Jan Boelens
- Stem Cell Transplantation and Cellular Therapies, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Pediatrics, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Alice Bertaina
- Division of Hematology, Oncology and Stem Cell Transplant and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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Cooper DL, Manago J, Patel V, Schaar D, Tyno A, Lin Y, Strair R. Universal posttransplant cyclophosphamide after allogeneic transplant, a retrospective single institution study. Leuk Res 2022; 122:106934. [PMID: 36084368 DOI: 10.1016/j.leukres.2022.106934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The excellent results of posttransplant cyclophosphamide in decreasing graft-versus-host disease (GVHD) after haploidentical (HI) allogeneic transplant have challenged current donor selection algorithms. PATIENTS AND METHODS We compared outcomes after matched sibling (MSD) versus alternative donor transplant using identical graft-versus-host disease (GVHD) prophylaxis including posttransplant cyclophosphamide (PTCy. Endpoints included engraftment, time outside of the hospital in the first 100 days after transplant, overall survival (OS), non-relapse mortality (NRM) and percentage of patients disease-free and off immunosuppression (DFOI) at one year and at the last follow-up. RESULTS There were significant differences at baseline between matched donor versus HI donor transplants with higher disease-risk index (DRI), more female-to-male donor recipient pairs and a higher percentage of Black patients in the HI group. Engraftment and time out of the hospital favored MSD and matched unrelated donor transplants. Multivariate analysis showed that high DRI and Black race were associated with decreased survival and Black race was associated with a higher NRM. CONCLUSIONS With the use of PTCy, our results support current donor selection algorithms. The finding of decreased survival and increased NRM in Black patients requires confirmation in a larger number of patients as well as the development of mitigation strategies.
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Affiliation(s)
| | | | | | | | - Anne Tyno
- Rutgers Cancer Institute of New Jersey, USA
| | - Yong Lin
- Rutgers Cancer Institute of New Jersey, USA
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7
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Gupta A, Eisenhauer EA, Booth CM. The Time Toxicity of Cancer Treatment. J Clin Oncol 2022; 40:1611-1615. [PMID: 35235366 DOI: 10.1200/jco.21.02810] [Citation(s) in RCA: 86] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Arjun Gupta
- Division of Hematology, Oncology & Transplantation, University of Minnesota, Minneapolis, MN
| | | | - Christopher M Booth
- Department of Oncology, Queen's University, Kingston, Canada.,Cancer Care and Epidemiology, Cancer Research Institute, Queen's University, Kingston, Canada
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Omidubicel vs standard myeloablative umbilical cord blood transplantation: results of a phase 3 randomized study. Blood 2021; 138:1429-1440. [PMID: 34157093 PMCID: PMC9710469 DOI: 10.1182/blood.2021011719] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/22/2021] [Indexed: 01/16/2023] Open
Abstract
Omidubicel is an ex vivo expanded hematopoietic progenitor cell and nonexpanded myeloid and lymphoid cell product derived from a single umbilical cord blood unit. We report results of a phase 3 trial to evaluate the efficacy of omidubicel compared with standard umbilical cord blood transplantation (UCBT). Between January 2017 and January 2020, 125 patients age 13 to 65 years with hematologic malignancies were randomly assigned to omidubicel vs standard UCBT. Patients received myeloablative conditioning and prophylaxis with a calcineurin inhibitor and mycophenolate mofetil for graft-versus-host disease (GVHD). The primary end point was time to neutrophil engraftment. The treatment arms were well balanced and racially diverse. Median time to neutrophil engraftment was 12 days (95% confidence interval [CI], 10-14 days) for the omidubicel arm and 22 days (95% CI, 19-25 days) for the control arm (P < .001). The cumulative incidence of neutrophil engraftment was 96% for patients receiving omidubicel and 89% for patients receiving control transplants. The omidubicel arm had faster platelet recovery (55% vs 35% recovery by 42 days; P = .028), had a lower incidence of first grade 2 to 3 bacterial or invasive fungal infection (37% vs 57%; P = .027), and spent more time out of hospital during the first 100 days after transplant (median, 61 vs 48 days; P = .005) than controls. Differences in GVHD and survival between the 2 arms were not statistically significant. Transplantation with omidubicel results in faster hematopoietic recovery and reduces early transplant-related complications compared with standard UCBT. The results suggest that omidubicel may be considered as a new standard of care for adult patients eligible for UCBT. The trial was registered at www.clinicaltrials.gov as #NCT02730299.
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9
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Lage DE, El-Jawahri A, Fuh CX, Newcomb RA, Jackson VA, Ryan DP, Greer JA, Temel JS, Nipp RD. Functional Impairment, Symptom Burden, and Clinical Outcomes Among Hospitalized Patients With Advanced Cancer. J Natl Compr Canc Netw 2021; 18:747-754. [PMID: 32502982 DOI: 10.6004/jnccn.2019.7385] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 12/04/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND National guidelines recommend regular measurement of functional status among patients with cancer, particularly those who are elderly or high-risk, but little is known about how functional status relates to clinical outcomes among hospitalized patients with advanced cancer. The goal of this study was to investigate how functional impairment is associated with symptom burden and healthcare utilization and clinical outcomes. PATIENTS AND METHODS We conducted a prospective observational study of patients with advanced cancer with unplanned hospitalizations at Massachusetts General Hospital from September 2014 through March 2016. Upon admission, nurses assessed patients' activities of daily living (ADLs; mobility, feeding, bathing, dressing, and grooming). Patients with any ADL impairment on admission were classified as having functional impairment. We used the revised Edmonton Symptom Assessment System (ESAS-r) and Patient Health Questionnaire-4 to assess physical and psychological symptoms, respectively. Multivariable regression models were used to assess the relationships between functional impairment, hospital length of stay, and survival. RESULTS Among 971 patients, 390 (40.2%) had functional impairment. Those with functional impairment were older (mean age, 67.18 vs 60.81 years; P<.001) and had a higher physical symptom burden (mean ESAS physical score, 35.29 vs 30.85; P<.001) compared with those with no functional impairment. They were also more likely to report moderate-to-severe pain (74.9% vs 63.1%; P<.001) and symptoms of depression (38.3% vs 23.6%; P<.001) and anxiety (35.9% vs 22.4%; P<.001). Functional impairment was associated with longer hospital length of stay (β = 1.29; P<.001) and worse survival (hazard ratio, 1.73; P<.001). CONCLUSIONS Hospitalized patients with advanced cancer who had functional impairment experienced a significantly higher symptom burden and worse clinical outcomes compared with those without functional impairment. These findings provide evidence supporting the routine assessment of functional status on hospital admission and using this to inform discharge planning, discussions about prognosis, and the development of interventions addressing patients' symptoms and physical function.
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Affiliation(s)
- Daniel E Lage
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Areej El-Jawahri
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Richard A Newcomb
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - David P Ryan
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joseph A Greer
- 4Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jennifer S Temel
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan D Nipp
- 1Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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10
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Agarwal N, Citla Sridhar D, Malay S, Patil N, Shekar A, Ahuja S, Dalal J. Wiskott Aldrich syndrome: healthcare utilizations and disparities in transplant care. Sci Rep 2021; 11:4654. [PMID: 33633315 PMCID: PMC7907136 DOI: 10.1038/s41598-021-84328-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 02/15/2021] [Indexed: 11/09/2022] Open
Abstract
Wiskott Aldrich syndrome (WAS) is a rare disease and hematopoietic stem cell transplant (HCT) is considered the treatment modality of choice for WAS. We conducted a cross-sectional analysis on the KIDS' pediatric inpatient database and compared hospitalization rates, complications and healthcare utilizations in the transplant and non-transplant arms. Of the 383 pediatric admissions with diagnosis of WAS between 2006-2012, 114 underwent transplant and 269 did not. The non-transplant arm included older children, female patients and more African Americans. Death rates, income and payer source were similar in both arms, however the total charge for each admission was higher in the transplant arm. Emergency room visits were similar but non-elective admissions were more in the non-transplant arm. Length of stay was prolonged in the transplant arm. When comparing morbidities, lymphomas, ulcerative colitis and autoimmune complications of WAS were seen only in the non-transplant arm. Our study shows that transplant is the largest contributor to healthcare utilization in WAS patients. We identified healthcare disparities based on race and socioeconomic status and found that this rare disease is being appropriately directed to centers with HCT expertise. We noted a change in practice moving away from splenectomy in WAS patients.
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Affiliation(s)
- Nikki Agarwal
- Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Divyaswathi Citla Sridhar
- Rainbow Babies and Children Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sindhoosha Malay
- School of Medicine, Case Western Reserve University, 1200 Wolstein Research Building, Cleveland, OH, 44106, USA
| | - Nirav Patil
- University Hospitals Cleveland Medical Center, 1200 Wolstein Research Building, Cleveland, OH, 44106, USA
| | - Anjali Shekar
- Rainbow Babies and Children Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sanjay Ahuja
- Rainbow Babies and Children Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Jignesh Dalal
- Rainbow Babies and Children Hospital, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
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11
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Grey W, Chauhan R, Piganeau M, Huerga Encabo H, Garcia-Albornoz M, McDonald NQ, Bonnet D. Activation of the receptor tyrosine kinase RET improves long-term hematopoietic stem cell outgrowth and potency. Blood 2020; 136:2535-2547. [PMID: 32589703 PMCID: PMC7714096 DOI: 10.1182/blood.2020006302] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/08/2020] [Indexed: 12/21/2022] Open
Abstract
Expansion of human hematopoietic stem cells (HSCs) is a rapidly advancing field showing great promise for clinical applications. Recent evidence has implicated the nervous system and glial family ligands (GFLs) as potential drivers of hematopoietic survival and self-renewal in the bone marrow niche; how to apply this process to HSC maintenance and expansion has yet to be explored. We show a role for the GFL receptor, RET, at the cell surface of HSCs in mediating sustained cellular growth, resistance to stress, and improved cell survival throughout in vitro expansion. HSCs treated with the key RET ligand/coreceptor complex, glial-derived neurotrophic factor and its coreceptor, exhibit improved progenitor function at primary transplantation and improved long-term HSC function at secondary transplantation. Finally, we show that RET drives a multifaceted intracellular signaling pathway, including key signaling intermediates protein kinase B, extracellular signal-regulated kinase 1/2, NF-κB, and p53, responsible for a wide range of cellular and genetic responses that improve cell growth and survival under culture conditions.
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Affiliation(s)
- W Grey
- Hematopoietic Stem Cell Laboratory and
| | - R Chauhan
- Signalling and Structural Biology Laboratory, Francis Crick Institute, London, United Kingdom; and
| | | | | | | | - N Q McDonald
- Signalling and Structural Biology Laboratory, Francis Crick Institute, London, United Kingdom; and
- Institute of Structural and Molecular Biology, Department of Biological Sciences, Birkbeck College, University of London, London, United Kingdom
| | - D Bonnet
- Hematopoietic Stem Cell Laboratory and
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12
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Days Alive Outside Hospital and Readmissions in Patients Undergoing Allogeneic Transplants from Identical Siblings or Alternative Donors. Mediterr J Hematol Infect Dis 2020; 12:e2020055. [PMID: 32952966 PMCID: PMC7485463 DOI: 10.4084/mjhid.2020.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
We have studied the number of days alive outside the Hospital (DAOH) and the number of readmissions within the first 100 days after transplant in 185 patients who received an allogeneic hemopoietic stem cell transplant (HSCT). The donors were matched siblings (SIB; n=61), or alternative donors (ALT; n=124). The median number of DAOH for SIB transplants (78 days, range 21–84) was significantly greater than DAOH for ALT donor grafts (73 days, range 2–87) (p=0.0003). Other positive predictors of DAOH were the use of reduced-intensity regimens (p=0.01), grade 0-I acute graft versus host disease (GvHD) (p=0.0006), and a comorbidity index equal or less than two (p=0.04). Fifty-one patients required readmission (22%), which was predicted by grade II–IV acute GvHD (p=0.009), higher comorbidity index (p=0.06), and ALT donors as compared to SIBS (p=0.08). The CI of readmission was 18% (95%CI 10–31) for SIB and 30% (95%CI 23–39) for ALT donor grafts. The non relapse mortality (NRM) for patients re-admitted was 25% (95%CI 15–43%), compared to 5% (95%CI 2–12%) for patients not readmitted (p=0.0001). In a multivariate analysis, readmission was the strongest predictor of non-relapse mortality (NRM) (HR 2.0) (p=0.0006) and survival (HR 3.4) (p<0.0001).
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13
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Rhéaume MÈ, Rouleau P, Tremblay T, Paré I, Loubaki L. Short-Term exposure of umbilical cord blood CD34+ cells to human platelet lysate and cytokines enhances engraftment. Transfusion 2020; 60:2348-2358. [PMID: 32757244 DOI: 10.1111/trf.15991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 06/08/2020] [Accepted: 06/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intra bone marrow (IBM) injection has been proposed as a strategy to bypass homing inefficiencies associated with intravenous (IV) hematopoietic progenitor stem cell (HSPC) transplantation and thus increases the number of HSPC that engraft. Despite physical delivery into the bone marrow cavity, many donor cells are rapidly redistributed by vascular perfusion. Thus, the objective of our study was to evaluate the ability of human platelet lysates (hPL) to improve HSPC retention into the bone marrow and consequently to improve engraftment. STUDY DESIGN AND METHODS HSPC were isolated from human umbilical cord blood. HSPC were seeded in the wells of a 24-well microplate and exposed to increasing concentrations of hPL with or without cytokines for 24 hours. Following priming, HSPC cells chemotaxis to rhSDF-1 was determined in vitro and engraftment in NSG mice was evaluated. RESULTS Priming of cord blood CD34+ cells to a combination of hPL and cytokines resulted in a significant increase (up to 3-fold) in the expression of the CD34 antigen on HSPC. This effect was closely correlated to a significantly increased (up to 7-fold) migration toward a rhSDF-1 concentration gradient. In addition, IBM injection of CD34+ cells previously primed with hPL+cytokines into NSG mice showed significantly increased engraftment as measured by human platelet numbers, human CD45 and human CD34+ cells for unprimed and primed cells, respectively. CONCLUSION The use of hPL + cytokines as a short-term priming treatment for UCB could be an advantageous strategy to improve clinical outcomes following IBM injection.
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Affiliation(s)
| | - Pascal Rouleau
- Medical Affairs and Innovation, Héma-Québec, Québec, Quebec, Canada
| | - Tony Tremblay
- Medical Affairs and Innovation, Héma-Québec, Québec, Quebec, Canada
| | - Isabelle Paré
- Medical Affairs and Innovation, Héma-Québec, Québec, Quebec, Canada
| | - Lionel Loubaki
- Medical Affairs and Innovation, Héma-Québec, Québec, Quebec, Canada.,Department of Biochemistry, Microbiology and Bioinformatics, Laval University, Québec, Quebec, Canada
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14
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Godara A, Siddiqui NS, Munigala S, Dhawan R, Kansagra AJ, Rapoport AP, Yared JA, Dahiya S. Length of Stay and Hospital Costs for Patients Undergoing Allogeneic Stem-Cell Transplantation. JCO Oncol Pract 2020; 17:e355-e368. [PMID: 32735507 DOI: 10.1200/op.20.00170] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Patients who undergo allogeneic hematopoietic stem-cell transplantation (allo-HSCT) usually require a prolonged hospital stay that varies greatly across patients. Limited information exists on the factors associated with hospital length of stay (LOS) after allo-HSCT and the impact on transplant-related costs. The objective of this study was to determine predictors for longer LOS for allo-HSCT and to assess their impact on the cost of transplant stay. METHODS Using the National Inpatient Sample database, adult patients hospitalized for allo-HSCT were identified using International Classification of Diseases, Ninth Revision, primary and secondary procedure codes. RESULTS Between 2002 and 2015, 68,296 hospitalizations for allo-HSCT were identified. Peripheral blood was the most common stem-cell source (80%) followed by bone marrow (15%) and cord blood (5%). Median LOS was 25.8 days (interquartile range [IQR], 21-34.0 days), and the overall inpatient mortality rate was 8%. Stem-cell source was a significant predictor for longer LOS, being significantly longer for cord blood (median, 36.9 days; IQR, 26.7-49.9 days) compared with bone marrow (median, 27.2 days; IQR, 21.5-35.2 days) and peripheral blood (median 25.4 days; IQR, 20.8-32.7 days). Other predictors for longer LOS were patient characteristics such as age and race, transplant/post-transplant characteristics, and complications such as total body irradiation use, acute graft-versus-host disease, and infections. Longer LOS was also found to be associated with higher hospital costs. CONCLUSION In patients who undergo allo-HSCT, LOS can be predicted using patient- and transplant-related characteristics as well as post-transplant complications. LOS is also a driver for increased cost, and further efforts are needed to mitigate transplant complications and resource utilization.
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Affiliation(s)
- Amandeep Godara
- Division of Hematology-Oncology, Department of Medicine, Tufts Medical Center, Boston, MA
| | - Nauman S Siddiqui
- Division of Hematology/Oncology, University of Wisconsin, Madison, WI
| | - Satish Munigala
- St Louis University Center for Outcomes Research, St Louis University School of Medicine, St Louis, MO
| | - Rishi Dhawan
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit J Kansagra
- Division of Hematology and Bone Marrow Transplant, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Aaron P Rapoport
- Division of Hematology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Jean A Yared
- Division of Hematology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
| | - Saurabh Dahiya
- Division of Hematology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD
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15
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Kindwall-Keller TL, Ballen KK. Umbilical cord blood: The promise and the uncertainty. Stem Cells Transl Med 2020; 9:1153-1162. [PMID: 32619330 PMCID: PMC7519764 DOI: 10.1002/sctm.19-0288] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 05/05/2020] [Accepted: 05/10/2020] [Indexed: 12/16/2022] Open
Abstract
Unfortunately, many patients referred for hematopoietic cell transplant will not have a fully matched related donor, and finding matched unrelated donors through the registry may be difficult, especially if the recipient is not of Northern European descent [N Engl J Med 2014;371:339‐348]. Umbilical cord blood (UCB) has been an available graft source for hematopoietic cell transplant for more than 30 years, since the first UCB transplant was performed in the late 1980s [N Engl J Med 1989;321:1174‐1178]. UCB is readily available, has low immunogenicity, and does not require as strict of human leukocyte antigen (HLA) matching compared to other graft sources [N Engl J Med 2004;351:2265‐2275]. According to data from the Center for International Blood and Marrow Transplant Research (CIBMTR), an estimated 500 patients in the US will have received a UCB transplant in 2018. Since 2014, haploidentical transplants have surpassed UCB transplants performed in the United States (CIBMTR Summary Slides, 2018, available at https://www.cibmtr.org). Increased use of haploidentical transplants has brought to light concerns about UCB transplants, including delayed engraftment and graft failure, increased nonrelapse mortality, increased infection risk, and UCB acquisition costs [Lancet Oncol 2010;11:653‐660; Biol Blood Marrow Transplant 2019;1456‐1464]. These concerns will need to be addressed for UCB to remain a viable option as a graft source for hematopoietic cell transplant. Other promising therapeutic benefits for UCB, in addition to hematopoietic cell transplant, is its use in regenerative medicine and immune modulation, which is currently being evaluated in ongoing clinical trials.
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Affiliation(s)
| | - Karen K Ballen
- Division of Hematology/Oncology, University of Virginia, Charlottesville, Virginia, USA
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16
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Zhou J, Nutescu EA, Han J, Calip GS. Clinical trajectories, healthcare resource use, and costs of long-term hematopoietic stem cell transplantation survivors: a latent class analysis. J Cancer Surviv 2020; 14:294-304. [PMID: 31897877 DOI: 10.1007/s11764-019-00842-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 11/28/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE To identify patterns of healthcare utilization in allogeneic and autologous hematopoietic stem cell transplantation (HSCT) recipients and evaluate factors associated with high-need and high-cost post-transplantation care. METHODS Latent class analysis of a retrospective cohort of long-term allogeneic (n = 436) and autologous (n = 888) HSCT survivors within the Truven MarketScan database (2009-2014). We assessed factors associated with the latent classes by comparing post-transplantation healthcare utilization including inpatient admissions and length of stay, emergency room visits, specialist visits, and primary care provider visits. RESULTS Four utilization classes were identified in allogeneic and autologous HSCT recipients: (i) outpatient specialist care dominant (51.8% and 57.3%), (ii) outpatient primary care dominant (10.3% and 25.7%), (iii) outpatient/inpatient balanced (20.6% and 13.5%), and (iv) inpatient dominant (17.2% and 3.5%). Mean monthly healthcare expenditures in the inpatient dominant utilization class were $41,097 and $25,556 for allogeneic and autologous survivors, respectively, which were two to five times higher compared with other classes during the 2-year post-transplantation period. Factors associated with the high utilization class were transfusion (OR = 1.87, 95% CI 1.06-3.30) and 100-day post-transplant graft-versus-host-disease (OR = 1.76, 95% CI 1.05-2.94) in allogeneic HSCT; higher baseline Charlson comorbidity index (OR = 1.45, 95% CI 1.19-1.76) in autologous HSCT. CONCLUSION Based on distinct patterns of healthcare utilization following HSCT, we identified factors associated with higher resource utilization and greater healthcare related expenditures. IMPLICATIONS FOR CANCER SURVIVORS Earlier identification of high-cost and high-need HSCT long-term survivors could pave the way for clinicians to offer more continuous engagement in survivorship care delivery.
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Affiliation(s)
- Jifang Zhou
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Jin Han
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
- Comprehensive Sickle Cell Center, Section of Hematology/Oncology, Department of Medicine, University of Illinois at Chicago, Chicago, IL, 60607, USA
| | - Gregory S Calip
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, IL, USA.
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA.
- Division of Public Health Sciences, Epidemiology Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
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17
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Unlicensed Umbilical Cord Blood Units Provide a Safe and Effective Graft Source for a Diverse Population: A Study of 2456 Umbilical Cord Blood Recipients. Biol Blood Marrow Transplant 2019; 26:745-757. [PMID: 31756539 DOI: 10.1016/j.bbmt.2019.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 12/16/2022]
Abstract
Umbilical cord blood (UCB) transplantation (UCBT) is a curative procedure for patients with hematologic malignancies and genetic disorders and expands access to transplantation for non-Caucasian patients unable to find a fully matched unrelated donor. In 2011, the US Food and Drug Administration required that unrelated UCBT be performed using either licensed UCB or unlicensed UCB under the Investigational New Drug (IND) program. The National Marrow Donor Program manages an IND under which 2456 patients (1499 adults and 957 children, 564 with malignant diseases and 393 with nonmalignant diseases) underwent single or double UCBT between October 2011 and December 2016. The median patient age was 31 years (range, <1 to 81 years), and 50% of children and 36% of adults were non-Caucasian. The median time to neutrophil engraftment (ie, absolute neutrophil count ≥500/mm3) was 22 days for adults, 20 days for pediatric patients with malignant diseases, and 19 days for pediatric patients with nonmalignant diseases, with corresponding rates of engraftment at 42 days of 89%, 88%, and 90%. In these 3 groups of patients, the incidence of acute graft-versus-host disease (GVHD) grade II-IV was 35%, 32%, and 24%; the incidence of chronic GVHD was 24%, 26%, and 24%; and 1-year overall survival (OS) was 57%, 71%, and 79%, respectively. In multivariate analysis, younger age, lower Hematopoietic Cell Transplantation-Specific Comorbidity Index, early-stage chemotherapy-sensitive disease, and higher performance score were predictive of improved OS for adults. In a subset analysis of children with malignancies undergoing single UCBT, the use of either licensed UCB (n = 48) or unlicensed UCB (n = 382) was associated with similar engraftment and survival. The use of unlicensed UCB units is safe and effective and provides an important graft source for a diverse population.
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18
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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: 6] [Impact Index Per Article: 1.2] [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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19
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Prediction of clinical outcome by controlling nutritional status (CONUT) before allogeneic hematopoietic stem cell transplantation in myeloid malignancies. Int J Hematol 2019; 110:599-605. [DOI: 10.1007/s12185-019-02723-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 10/26/2022]
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20
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Dhakal B, Giri S, Levin A, Rein L, Fenske TS, Chhabra S, Shah NN, Szabo A, D'Souza A, Pasquini M, Hari P, Hamadani M. Factors Associated With Unplanned 30-Day Readmissions After Hematopoietic Cell Transplantation Among US Hospitals. JAMA Netw Open 2019; 2:e196476. [PMID: 31276175 DOI: 10.1001/jamanetworkopen.2019.6476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hematopoietic cell transplantation (HCT) is a therapeutic strategy in the management of several hematological cancers. Limited data exist on the incidence and predictors of 30-day readmission after HCT. OBJECTIVE To measure the incidence of and risk factors associated with 30-day readmission following HCT in the United States. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined patient data from the US population-based Nationwide Readmissions Database. All adults (age ≥18 years) who underwent autologous (auto-) or allogenic (allo-) HCT in US hospitals between January 1, 2012, and November 30, 2014, were included. The analysis was performed from June 2018 to February 2019. MAIN OUTCOMES AND MEASURES The main outcome was 30-day readmission rates for auto-HCT and allo-HCT. Factors associated with readmission, including baseline demographic characteristics and disease- and hospital-related characteristics (including annual case volume), were measured. RESULTS A total of 28 356 index admissions for auto-HCT in 244 centers (191 low-volume, 38 medium-volume, and 15 high-volume centers) and 17 217 index admissions for allo-HCT in 211 centers (161 low-volume, 37 medium-volume, and 13 high-volume centers) were identified during the study period. The overall 30-day readmission rates were 11.6% for auto-HCT and 24.4% for allo-HCT. The odds of readmission were significantly higher in low-volume hospitals compared with high-volume hospitals (adjusted odds ratio [aOR], 1.69; 95% CI, 1.08-2.64 for auto-HCT and aOR, 1.41; 95% CI, 1.09-1.82 for allo-HCT) but comparable to medium-volume hospitals (aOR, 1.06; 95% CI, 0.62-1.83 for auto-HCT and aOR, 1.19; 95% CI, 0.90-1.57 for allo-HCT). Other factors associated with readmission for auto-HCT included younger age (aOR for age ≥50 vs <49 years, 0.82; 95% CI, 0.68-0.98), female sex (aOR, 1.21; 95% CI, 1.06-1.36), disease type (aOR for other vs myeloma, 1.37; 95% CI, 1.06-1.77), and Elixhauser comorbidity index score (aOR for ≥20 vs 0, 1.5; 95% CI, 1.17-1.93). For allo-HCT, factors associated with readmission included disease type (aOR for acute lymphoblastic leukemia vs acute myelogenous leukemia, 1.30; 95% CI, 1.04-1.62), insurance (aOR for Medicare vs private, 1.18; 95% CI, 1.02-1.36), and Elixhauser comorbidity index score (aOR for 1-9 vs 0, 1.2; 95% CI, 1.04-1.39). Infections, neutropenic fever, and gastrointestinal symptoms were the most common reasons for readmission for both types of HCT. CONCLUSIONS AND RELEVANCE This study found substantial rates of readmission for both types of HCT and an inverse association between hospital HCT volume and 30-day readmission. These results may provide guidance when developing quality indicators and policies penalizing hospitals for HCT readmission.
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Affiliation(s)
- Binod Dhakal
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Smith Giri
- Division of Hematology and Oncology, Yale University, New Haven, Connecticut
| | - Adam Levin
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Timothy S Fenske
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Saurabh Chhabra
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Nirav N Shah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Anita D'Souza
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Marcelo Pasquini
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Parameswaran Hari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
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21
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Rangarajan HG, Smith LC, Stanek JR, Hall M, Abu-Arja R, Auletta JJ, O'Brien SH. Increased Health Care Utilization and Costs during Allogeneic Hematopoietic Cell Transplantation for Acute Leukemia and Myelodysplastic Syndromes in Adolescents and Young Adults Compared with Children: A Multicenter Study. Biol Blood Marrow Transplant 2019; 25:1031-1038. [DOI: 10.1016/j.bbmt.2019.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/01/2019] [Indexed: 12/11/2022]
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22
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Huang YT, Su Y, Kim SJ, Nichols P, Burack D, Maloy M, Giralt S, Perales MA, Jakubowski AA, Papanicolaou GA. Cytomegalovirus Infection in Allogeneic Hematopoietic Cell Transplantation Managed by the Preemptive Approach: Estimating the Impact on Healthcare Resource Utilization and Outcomes. Biol Blood Marrow Transplant 2018; 25:791-799. [PMID: 30476551 DOI: 10.1016/j.bbmt.2018.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/12/2018] [Indexed: 12/16/2022]
Abstract
We quantified cytomegalovirus (CMV) antiviral use and hospital length of stay (LOS) associated with CMV infection in a contemporary cohort of conventional (CONV) and CD34-selected (T cell-depleted) hematopoietic cell transplantation (HCT) recipients managed by preemptive therapy (PET) in a single US center. Adults who received first allogeneic HCT at Memorial Sloan Kettering Cancer Center from June 2010 through December 2014 were analyzed. Days on PET, number of readmissions, and readmission LOS by day 180 post-HCT were summarized. Estimated unit value (EUV) was defined as the expected number of PET days for a cohort of 100 HCT with characteristics as the analyzed cohort. Standardized incidence ratio was calculated as the ratio of observed outcomes of patients with CMV viremia over the outcomes of patients without CMV viremia. Of 318 patients, 88 received CONV and 230 CD34-selected HCT. Rates of CMV viremia were 26.3% for CONV and 41.9% for CD34-selected (P = .003). Among patients with viremia 68.2% CONV and 97.9% CD34-selected received PET. EUV for PET was 852 days and 2821 days for CONV and CD34-selected, respectively. The standardized incidence ratios for number of readmission and readmission LOS were 1.7 (95% confidence interval [CI], 1.4 to 2.1) and 1.2 (95% CI, 1.1 to 1.3), respectively, for CONV HCT and 1.7 (95% CI, 1.3 to 2.1) and 1.6 (95% CI, 1.5 to 1.7), respectively, for CD34-selected HCT. Overall survival was similar between patients with and without CMV viremia by HCT type. CMV end-organ disease was associated with lower overall survival only in CD34-selected HCT (P = .0007). CMV infection managed by PET requires substantial antiviral use and is associated with longer readmission LOS more, particularly among CD34-selected HCT.
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Affiliation(s)
- Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yiqi Su
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paige Nichols
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Burack
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ann A Jakubowski
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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Risk factors and survival impact of readmission after single-unit cord blood transplantation for adults. Int J Hematol 2018; 109:115-124. [PMID: 30302739 DOI: 10.1007/s12185-018-2539-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 12/31/2022]
Abstract
Hospital readmissions have been used as a prognostic indicator for patients receiving allogeneic hematopoietic cell transplantation (HCT). However, the impact of readmission during early and mid-phase of cord blood transplantation (CBT) on long-term outcomes has not been fully investigated. We retrospectively analyzed 156 adult patients who received single-unit CBT in our institute. Among this cohort, thirteen patients (8%) were readmitted within 30 days after discharge, and 27 (17%) were readmitted within 90 days after discharge. The most common causes for readmission within 30 and 90 days of discharge were infection, chronic graft-versus-host disease, and relapse. Higher cryopreserved cord blood CD34+ cell count was only significantly associated with lower readmission within 90 days after discharge. The probabilities of overall survival were significantly lower in patients readmitted within 90 days after discharge compared with those who were not readmitted within 90 days after discharge in univariate and multivariate analysis. These data suggest that readmission within 90 days after discharge may have a significant impact on long-term mortality after single-unit CBT.
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24
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Impact of hospital length of stay on the risk of readmission and overall survival after allogeneic stem cell transplantation. Int J Hematol 2018; 108:290-297. [DOI: 10.1007/s12185-018-2477-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 12/16/2022]
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25
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Buggy DJ, Freeman J, Johnson MZ, Leslie K, Riedel B, Sessler DI, Kurz A, Gottumukkala V, Short T, Pace N, Myles PS. Systematic review and consensus definitions for standardised endpoints in perioperative medicine: postoperative cancer outcomes. Br J Anaesth 2018; 121:38-44. [PMID: 29935592 DOI: 10.1016/j.bja.2018.03.020] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/22/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance. METHODS We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician-researchers was then used to refine a recommended list of endpoints. RESULTS We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival). CONCLUSION Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia-analgesia technique on oncological outcomes.
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Affiliation(s)
- D J Buggy
- Department of Anaesthesia, Mater Misericordiae University Hospital, School of Medicine, University College Dublin, Ireland; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - J Freeman
- Department of Anaesthesia, Mater Misericordiae University Hospital, School of Medicine, University College Dublin, Ireland
| | - M Z Johnson
- Department of Anaesthesia, Mater Misericordiae University Hospital, School of Medicine, University College Dublin, Ireland
| | - K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne Medical School, University of Melbourne, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - B Riedel
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre and University of Melbourne, Australia
| | - D I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A Kurz
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - V Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - T Short
- Auckland City Hospital, Auckland, New Zealand
| | - N Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - P S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
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Lage DE, Nipp RD, D'Arpino SM, Moran SM, Johnson PC, Wong RL, Pirl WF, Hochberg EP, Traeger LN, Jackson VA, Cashavelly BJ, Martinson HS, Greer JA, Ryan DP, Temel JS, El-Jawahri A. Predictors of Posthospital Transitions of Care in Patients With Advanced Cancer. J Clin Oncol 2017; 36:76-82. [PMID: 29068784 DOI: 10.1200/jco.2017.74.0340] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Patients with advanced cancer experience potentially burdensome transitions of care after hospitalizations. We examined predictors of discharge location and assessed the relationship between discharge location and survival in this population. Methods We conducted a prospective study of 932 patients with advanced cancer who experienced an unplanned hospitalization between September 2014 and March 2016. Upon admission, we assessed patients' physical symptoms (Edmonton Symptom Assessment System) and psychological distress (Patient Health Questionnaire-4). The primary outcome was discharge location (home without hospice, postacute care [PAC], or hospice [any setting]). The secondary outcome was survival. Results Of 932 patients, 726 (77.9%) were discharged home without hospice, 118 (12.7%) were discharged to PAC, and 88 (9.4%) to hospice. Those discharged to PAC and hospice reported high rates of severe symptoms, including dyspnea, constipation, low appetite, fatigue, depression, and anxiety. Using logistic regression, patients discharged to PAC or hospice versus home without hospice were more likely to be older (odds ratio [OR], 1.03; 95% CI, 1.02 to 1.05; P < .001), live alone (OR, 1.95; 95% CI, 1.25 to 3.02; P < .003), have impaired mobility (OR, 5.08; 95% CI, 3.46 to 7.45; P < .001), longer hospital stays (OR, 1.15; 95% CI, 1.11 to 1.20; P < .001), higher Edmonton Symptom Assessment System physical symptoms (OR, 1.02; 95% CI, 1.003 to 1.032; P < .017), and higher Patient Health Questionnaire-4 depression symptoms (OR, 1.13; 95% CI, 1.01 to 1.25; P < .027). Patients discharged to hospice rather than PAC were more likely to receive palliative care consultation (OR, 4.44; 95% CI, 2.12 to 9.29; P < .001) and have shorter hospital stays (OR, 0.84; 95% CI, 0.77 to 0.91; P < .001). Patients discharged to PAC versus home had lower survival (hazard ratio, 1.53; 95% CI, 1.22 to 1.93; P < .001). Conclusion Patients with advanced cancer who were discharged to PAC facilities and hospice had substantial physical and psychological symptom burden, impaired physical function, and inferior survival compared with those discharged to home. These patients may benefit from interventions to enhance their quality of life and care.
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Affiliation(s)
- Daniel E Lage
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Ryan D Nipp
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Sara M D'Arpino
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Samantha M Moran
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - P Connor Johnson
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Risa L Wong
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - William F Pirl
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Ephraim P Hochberg
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Lara N Traeger
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Vicki A Jackson
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Barbara J Cashavelly
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Holly S Martinson
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Joseph A Greer
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - David P Ryan
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Jennifer S Temel
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
| | - Areej El-Jawahri
- Daniel E. Lage, Ryan D. Nipp, Sara M. D'Arpino, Samantha M. Moran, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Barbara J. Cashavelly, Holly S. Martinson, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Massachusetts General Hospital Cancer Center; Daniel E. Lage, Ryan D. Nipp, P. Connor Johnson, Risa L. Wong, Ephraim P. Hochberg, Lara N. Traeger, Vicki A. Jackson, Joseph A. Greer, David P. Ryan, Jennifer S. Temel, and Areej El-Jawahri, Harvard Medical School; Lara N. Traeger, Vicki A. Jackson, and Joseph A. Greer, Massachusetts General Hospital, Boston, MA; and William F. Pirl, Sylvester Comprehensive Cancer Center and University of Miami, Miami, FL
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Anand S, Thomas S, Corbet K, Gasparetto C, Long GD, Lopez R, Morris AK, Rizzieri DA, Sullivan KM, Sung AD, Sarantopoulos S, Chao NJ, Horwitz ME. Adult Umbilical Cord Blood Transplantation Using Myeloablative Thiotepa, Total Body Irradiation, and Fludarabine Conditioning. Biol Blood Marrow Transplant 2017; 23:1949-1954. [PMID: 28729147 DOI: 10.1016/j.bbmt.2017.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/26/2017] [Indexed: 12/16/2022]
Abstract
Treatment-related mortality (TRM) remains elevated in adult patients undergoing umbilical cord blood transplantation (UCBT), including an early rise in TRM suggestive of excessive toxicity associated with the standard myeloablative total body irradiation (TBI), fludarabine, and cyclophosphamide regimen. In an attempt to reduce regimen-related toxicity, we previously studied a modified myeloablative regimen with TBI (1350 cGy) and fludarabine (160 mg/m2); TRM was decreased, but neutrophil engraftment was suboptimal. Therefore, to improve engraftment while still minimizing regimen-related toxicity, we piloted a myeloablative regimen with the addition of thiotepa (10 mg/kg) to TBI and fludarabine conditioning. Thirty-one adult patients (median age, 46 years; range, 19 to 65) with hematologic malignancies (acute leukemia/myelodysplastic syndrome, 77%; lymphoid malignancy, 23%) underwent single (n = 1) or double (n = 30) UCBT from 2010 to 2015 at our institution. The cumulative incidence of neutrophil engraftment was 90% (95% confidence interval [CI], 70% to 97%) by 60 days, with a median time to engraftment of 21 days (95% CI, 19 to 26). The cumulative incidence of platelet engraftment was 77% (95% CI, 57% to 89%) by 100 days, with a median time to engraftment of 47 days (95% CI, 37 to 73). Cumulative incidences of grades II to IV and grades III to IV acute graft-versus-host disease (GVHD) at day 100 were 45% (95% CI, 27% to 62%) and 10% (95% CI, 2% to 23%), respectively. The overall incidence of chronic GVHD at 2 years was 40% (95% CI, 22% to 57%), with 17% of patients (95% CI, 6% to 33%) experiencing moderate to severe chronic GVHD by 2 years. TRM at 180 days was 13% (95% CI, 4% to 27%), at 1 year 24% (95% CI, 10% to 41%), and at 3 years 30% (95% CI, 13% to 49%). Relapse at 1 year was 13% (95% CI, 4% to 27%) and at 3 years 19% (95% CI, 6% to 38%). With a median follow-up of 35.5 months (95% CI, 12.7 to 52.2), disease-free and overall survival at 3 years were 51% (95% CI, 29% to 69%) and 57% (95% CI, 36% to 73%), respectively. This regimen represents a reasonable alternative to myeloablative conditioning with TBI, fludarabine, and cyclophosphamide and warrants further study.
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Affiliation(s)
- Sarah Anand
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Kelly Corbet
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Cristina Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Gwynn D Long
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Richard Lopez
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Ashley K Morris
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Keith M Sullivan
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina.
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Huang YT, Kim SJ, Lee YJ, Burack D, Nichols P, Maloy M, Perales MA, Giralt SA, Jakubowski AA, Papanicolaou GA. Co-Infections by Double-Stranded DNA Viruses after Ex Vivo T Cell-Depleted, CD34 + Selected Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:1759-1766. [PMID: 28668490 DOI: 10.1016/j.bbmt.2017.06.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 06/14/2017] [Indexed: 12/16/2022]
Abstract
Recipients of ex vivo T cell-depleted (TCD) hematopoietic cell transplantation (HCT) are at risk of infection by double-stranded (ds) DNA viruses. We report rates of dsDNA viremia, end-organ disease (EOD), infection-related mortality, and overall survival (OS) in a contemporary cohort of adult TCD HCT recipients routinely monitored for cytomegalovirus (CMV), adenovirus (ADV), human herpesvirus 6 (HHV6), and Epstein-Barr virus (EBV). Healthcare utilization in the first 6 months post-HCT was compared between patients with dsDNA viremia versus no viremia. This was an observational study of adult patients with acute leukemia and myelodysplastic syndrome who received CD34+ selected, peripheral blood HCT at Memorial Sloan Kettering Cancer Center from March 2012 through December 2014. Patients were prospectively monitored by quantitative PCR assays for CMV, ADV, HHV6, and EBV in whole blood or plasma. The cumulative incidence of viremia(s) at day +180, EOD at 1 year, and OS at 1 year were estimated by the Kaplan-Meier method and compared by the log-rank test among patient with and without viremia/EOD. Standardized incidence ratios were used to compare overall length of hospital stay (LOS), number of readmissions after HCT, and length of readmissions through day +180. Of 156 patients, 96 (62%) were CMV recipient seropositive. Forty-two patients received grafts from matched related (27%), 86 from matched unrelated (55%), and 28 from mismatched (18%) donors. Overall, 132 patients (85%) had ≥1 viremia and 52 (33%) ≥2 viremias by day +180. The cumulative incidences for CMV, HHV6, ADV, and EBV viremia were 44%, 61%, 7%, and 16%, respectively, with median times of onset 28 days (interquartile range [IQR], 25 to 33), 33 days (IQR, 25 to 47), 60 days (IQR, 19 to 84), and 79 days (IQR, 54 to 106) post-HCT, respectively. Twenty-eight patients (18%) developed EOD by dsDNA viruses at 1 year post-HCT. Treatment for CMV accounted for 91% total antiviral treatment-days. Compared with patients with no viremia, patients with CMV viremia, HHV6 viremia, or ≥2 viremias experienced longer LOS (P <.001) and a higher number of readmissions (P <.001) by day +180. OS rate at 1 year was 79% and was similar between patients with or without dsDNA viremias. EOD was associated with lower 1-year OS rates (63.4%) versus without EOD (81.1%) (P = .02). Of 33 patients who died, 10 died due to infection, and 7 of these infection-related deaths were due to dsDNA viruses. Viremia by dsDNA viruses occurred in 85% of TCD HCT recipients by day +100 and 33% of patients experienced ≥2 viremias by day +180. CMV accounted for most antiviral use. CMV, HHV6, or ≥2 viremias were associated with more readmissions and longer LOS. One year OS rate was 78%. EOD by dsDNA viruses was associated with decreased 1-year OS. Infections by dsDNA viruses pose a substantial burden after TCD HCT.
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Affiliation(s)
- Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Seong Jin Kim
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yeon Joo Lee
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Daniel Burack
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paige Nichols
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Molly Maloy
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Miguel-Angel Perales
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sergio A Giralt
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann A Jakubowski
- Department of Medicine, Weill Cornell Medical College, New York, New York; Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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Kindwall-Keller TL, Ballen KK. Alternative Donor Graft Sources for Adults with Hematologic Malignancies: A Donor for All Patients in 2017! Oncologist 2017; 22:1125-1134. [PMID: 28546462 DOI: 10.1634/theoncologist.2017-0009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/13/2017] [Indexed: 12/21/2022] Open
Abstract
Hematopoietic stem cell transplant (HSCT) is potentially curative for a wide variety of malignant diseases, including acute and leukemias, lymphoma, and myelodysplasia. Choice of a stem cell donor is dependent on donor availability, donor compatibility and health, recipient disease type, and recipient condition. Current sources of stem cell donation for HSCT are matched sibling donors (MSDs), matched unrelated donors (MUDs), 1-antigen mismatched unrelated donors (MMUDs), haploidentical donors (haplo), and umbilical cord blood (UCB) units. Historically, preferred donors for HSCT have been human leukocyte antigen (HLA)-matched sibling donors; however, only about 30% of U.S. patients will have a MSD available. The majority of patients referred for HSCT will require an alternative donor graft: MUD, MMUD, UCB, or haplo. The likelihood of finding a MUD varies depending on the ethnicity of the recipient. White Caucasians of European descent have the greatest chance of finding a MUD. Chances of finding a MUD are significantly less for African-American or Hispanic recipients due to HLA polymorphisms. Therefore, MMUD, UCB, and haplo donor graft sources expand the donor pool for recipients who do not have a MSD or MUD available. Given the variety of different donor stem cell sources available today, nearly every patient who needs an allogeneic HSCT has a potential donor in 2017. All transplant-eligible patients with hematologic malignancies should be evaluated by a transplant center to determine if HSCT is a viable treatment option for their underlying disease process. IMPLICATIONS FOR PRACTICE The goal of this review is to increase the awareness of oncology practitioners to the availability of alternative donor stem cell transplants for patients with hematologic malignancies. Despite new agents, stem cell transplant remains the only curative therapy for many patients with acute and chronic leukemia, myelodysplasia, and lymphoma. Given the variety of different donor stem cell sources available today, nearly every patient who needs an allogeneic stem cell transplant will have a donor.
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Affiliation(s)
- Tamila L Kindwall-Keller
- Department of Medicine, University of Virginia School of Medicine, and Stem Cell Transplant Program, University of Virginia Cancer Center, Charlottesville, Virginia, USA
| | - Karen K Ballen
- Department of Medicine, University of Virginia School of Medicine, and Stem Cell Transplant Program, University of Virginia Cancer Center, Charlottesville, Virginia, USA
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Ballen K. Umbilical Cord Blood Transplantation: Challenges and Future Directions. Stem Cells Transl Med 2017; 6:1312-1315. [PMID: 28456009 PMCID: PMC5442719 DOI: 10.1002/sctm.17-0069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 03/30/2017] [Indexed: 01/05/2023] Open
Abstract
Since the first successful allogeneic transplants performed in Seattle 50 years ago, the field of transplantation has evolved considerably, with improvements in human leukocyte antigen typing, patient selection, reduced intensity regimens, and graft-versus-host disease prophylaxis. A major breakthrough has been the availability of more donor options, first via the National Marrow Donor Program-Be the Match [Biol Blood Marrow Transplant 2008;14:2-7]. Then, in the 1990s, unrelated umbilical cord blood transplantation became available, first for children and then for adults [New Engl J Med 1996;35:157-166]. More recently mismatched unrelated transplants and haploidentical donor options became available [Blood 2011;118:282-288]. In 2017, there is a donor for almost every patient who needs a transplant. In this review, we will discuss the state of the science (and art) of cord blood transplant, focusing on successes, challenges, and future directions. Stem Cells Translational Medicine 2017;6:1312-1315.
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Anand S, Thomas S, Hyslop T, Adcock J, Corbet K, Gasparetto C, Lopez R, Long GD, Morris AK, Rizzieri DA, Sullivan KM, Sung AD, Sarantopoulos S, Chao NJ, Horwitz ME. Transplantation of Ex Vivo Expanded Umbilical Cord Blood (NiCord) Decreases Early Infection and Hospitalization. Biol Blood Marrow Transplant 2017; 23:1151-1157. [PMID: 28392378 DOI: 10.1016/j.bbmt.2017.04.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/04/2017] [Indexed: 02/07/2023]
Abstract
Delayed hematopoietic recovery contributes to increased infection risk following umbilical cord blood (UCB) transplantation. In a Phase 1 study, adult recipients of UCB stem cells cultured ex vivo for 3 weeks with nicotinamide (NiCord) had earlier median neutrophil recovery compared with historical controls. To evaluate the impact of faster neutrophil recovery on clinically relevant early outcomes, we reviewed infection episodes and hospitalization during the first 100 days in an enlarged cohort of 18 NiCord recipients compared with 86 standard UCB recipients at our institution. The median time to neutrophil engraftment was shorter in NiCord recipients compared with standard UCB recipients (12.5 days versus 26 days; P < .001). Compared with standard UCB recipients, NiCord recipients had a significantly reduced risk for total infection (RR, 0.69; P = .01), grade 2-3 (moderate to severe) infection (RR, 0.36; P < .001), bacterial infection (RR, 0.39; P = .003), and grade 2-3 bacterial infection (RR, 0.21; P = .003) by Poisson regression analysis; this effect persisted after adjustment for age, disease stage, and grade II-IV acute GVHD. NiCord recipients also had significantly more time out of the hospital in the first 100 days post-transplantation after adjustment for age and Karnofsky Performance Status (69.9 days versus 49.7 days; P = .005). Overall, transplantation of NiCord was associated with faster neutrophil engraftment, fewer total and bacterial infections, and shorter hospitalization in the first 100 days compared with standard UCB transplantation. In conclusion, rapid hematopoietic recovery from an ex vivo expanded UCB transplantation approach is associated with early clinical benefit.
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Affiliation(s)
- Sarah Anand
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Samantha Thomas
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Terry Hyslop
- Department of Biostatistics and Bioinformatics, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Janet Adcock
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Kelly Corbet
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Cristina Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Richard Lopez
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Gwynn D Long
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Ashley K Morris
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Keith M Sullivan
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina.
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El-Jawahri A, Chen YB, Brazauskas R, He N, Lee SJ, Knight JM, Majhail N, Buchbinder D, Schears RM, Wirk BM, Wood WA, Ahmed I, Aljurf M, Szer J, Beattie SM, Battiwalla M, Dandoy C, Diaz MA, D'Souza A, Freytes CO, Gajewski J, Gergis U, Hashmi SK, Jakubowski A, Kamble RT, Kindwall-Keller T, Lazarus HM, Malone AK, Marks DI, Meehan K, Savani BN, Olsson RF, Rizzieri D, Steinberg A, Speckhart D, Szwajcer D, Schoemans H, Seo S, Ustun C, Atsuta Y, Dalal J, Sales-Bonfim C, Khera N, Hahn T, Saber W. Impact of pre-transplant depression on outcomes of allogeneic and autologous hematopoietic stem cell transplantation. Cancer 2017; 123:1828-1838. [PMID: 28102896 DOI: 10.1002/cncr.30546] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/23/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the impact of depression before autologous and allogeneic hematopoietic cell transplantation (HCT) on clinical outcomes post-transplantation. METHODS We analyzed data from the Center for International Blood and Marrow Transplant Research to compare outcomes after autologous (n = 3786) or allogeneic (n = 7433) HCT for adult patients with hematologic malignancies with an existing diagnosis of pre-HCT depression requiring treatment versus those without pre-HCT depression. Using Cox regression models, we compared overall survival (OS) between patients with or without depression. We compared the number of days alive and out of the hospital in the first 100 days post-HCT using Poisson models. We also compared the incidence of grade 2-4 acute and chronic graft-versus-host disease (GVHD) in allogeneic HCT. RESULTS The study included 1116 (15%) patients with pre-transplant depression and 6317 (85%) without depression who underwent allogeneic HCT between 2008 and 2012. Pre-transplant depression was associated with lower OS (hazard ratio [HR], 1.13; 95% confidence interval [CI], 1.04-1.23; P = 0.004) and a higher incidence of grade 2-4 acute GVHD (HR, 1.25; 95% CI, 1.14-1.37; P < 0.0001), but similar incidence of chronic GVHD. Pre-transplant depression was associated with fewer days-alive-and-out-of-the hospital (means ratio [MR] = 0.97; 95% CI, 0.95-0.99; P = 0.004). There were 512 (13.5%) patients with Pre-transplant depression and 3274 (86.5%) without depression who underwent autologous HCT. Pre-transplant depression in autologous HCT was not associated with OS (HR, 1.15; 95% CI, 0.98-1.34; P = 0.096) but was associated with fewer days alive and out of the hospital (MR, 0.98; 95% CI, 0.97-0.99; P = 0.002). CONCLUSION Pre-transplant depression was associated with lower OS and higher risk of acute GVHD among allogeneic HCT recipients and fewer days alive and out of the hospital during the first 100 days after autologous and allogeneic HCT. Patients with pre-transplant depression represent a population that is at risk for post-transplant complications. Cancer 2017;123:1828-1838. © 2017 American Cancer Society.
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Affiliation(s)
| | - Yi-Bin Chen
- Massachusetts General Hospital, Boston, Massachusetts
| | - Ruta Brazauskas
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin.,Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Naya He
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Jennifer M Knight
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | | | - William A Wood
- University of North Carolina, Chapel Hill, North Carolina
| | - Ibrahim Ahmed
- The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Jeff Szer
- Royal Melbourne Hospital, Victoria, Australia
| | | | | | | | | | - Anita D'Souza
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Cesar O Freytes
- University of Texas Health Science Center San Antonio, San Antonio, Texas
| | | | - Usama Gergis
- New York Presbyterian Hospital, New York, New York
| | | | - Ann Jakubowski
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | | | | | | | | | - David I Marks
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Kenneth Meehan
- Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard F Olsson
- Karolinska Institute, Stockholm, Sweden.,Uppsala University, Uppsala, Sweden
| | | | | | | | | | | | | | | | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jignesh Dalal
- The Children's Mercy Hospitals and Clinics, Kansas City, Missouri
| | | | | | - Theresa Hahn
- Roswell Park Cancer Institute, Buffalo, New York
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
OBJECTIVE Chemotherapy-induced intestinal toxicity is a common adverse effect of cancer treatment. We hypothesized that a milk diet containing bovine colostrum (BC) would reduce intestinal toxicity in doxorubicin-treated piglets. METHODS "Study 1" investigated intestinal parameters 9 days after a single dose of doxorubicin (1 × 75 mg/m) in piglets fed bovine milk enriched with whey protein (BM). In "study 2," responses to doxorubicin treatment were investigated in piglets receiving either 7 BC feedings per day (Only-BC, n = 13), 4 BC feedings (High-BC, n = 13), 2 BC feedings (Low-BC, n = 14), or no BC (only BM, n = 13). RESULTS Doxorubicin treatment induced clinical signs of intestinal toxicity with diarrhea and weight loss, relative to controls (P < 0.05). White blood cells, hexose absorptive function, plasma citrulline, weights of intestine, colon, and spleen were reduced, whereas gut permeability and plasma C-reactive protein levels were increased (all P < 0.05). Limited or no effects were observed for digestive enzymes, proinflammatory cytokines, or tight-junction proteins in the intestine. Increasing BC supplementation to doxorubicin-treated piglets (study 2) had no consistent effects on plasma C-reactive protein and citrulline levels, intestinal morphology, digestive enzymes, permeability, or proinflammatory cytokines. Only-BC pigs, however, had lower diarrhea severity toward the end of the experiment (P < 0.05 vs BM) and across the BC groups, intestinal toxicity was reduced (P < 0.01). CONCLUSIONS Doxorubicin-treated piglets are relevant for studying chemotherapy-induced gut toxicity. Colostrum supplementation had limited effects on doxorubicin-induced toxicity in milk-fed piglets suggesting that colostrum and a bovine milk diet enriched with whey protein provided similar protection of the developing intestine from chemotherapy-induced toxicity.
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Rathe M, Thomassen M, Shen RL, Pontoppidan PE, Husby S, Müller K, Kruse TA, Sangild PT. Chemotherapy Modulates Intestinal Immune Gene Expression Including Surfactant Protein-D and Deleted in Malignant Brain Tumors 1 in Piglets. Chemotherapy 2016; 61:204-16. [DOI: 10.1159/000442938] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/30/2015] [Indexed: 11/19/2022]
Abstract
Background: Information about chemotherapy-induced intestinal gene expression may provide insight into the mechanisms underlying gut toxicity and help identify biomarkers and targets for intervention. Methods: We analyzed jejunal tissue from piglets subjected to two different, clinically relevant chemotherapy regimens: (1) busulfan plus cyclophosphamide (BUCY) and (2) doxorubicin (DOX). Results: Gene expression analysis identified 1,328 differentially expressed genes in the BUCY piglets and 594 in the DOX piglets, compared to controls. Similar changes in expression were found for 137 genes across the BUCY and DOX piglets. Selected genes of potential biological significance with a similar change in expression across the treatments were controlled by real-time polymerase chain reaction. Key innate defense molecules, including surfactant protein-D and deleted in malignant brain tumors 1, were among the upregulated genes for both treatments. Conclusion: In the developing intestine, chemotherapy increases the expression of genes related to innate immune functions involved in surveillance, protection, and homeostasis of mucosal surfaces.
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Blackburn R, Presson K, Laufman R, Tomczak N, Brassil K. Establishing an Inpatient Gym for Recipients of Stem Cell Transplantation: A Multidisciplinary Collaborative. Clin J Oncol Nurs 2016; 20:66-71. [DOI: 10.1188/16.cjon.66-71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Ballen KK. Is there a best graft source of transplantation in acute myeloid leukemia? Best Pract Res Clin Haematol 2015; 28:147-54. [DOI: 10.1016/j.beha.2015.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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