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Mangan BL, DuMontier C, Hopkins JO, Abel GA, McCurdy SR. Tailoring Therapy in Older Adults With Hematologic Malignancies. Am Soc Clin Oncol Educ Book 2024; 44:e432220. [PMID: 38788182 DOI: 10.1200/edbk_432220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Hematologic malignancies most often present in the sixth or seventh decade of life. Even so, many older adults may be unable to tolerate standard chemotherapy or require supplementary care or dose adjustments to do so. Both in community and academic centers, geriatric assessment (GA) can be used to improve the care of older adults with blood cancers. For example, hematologic oncologists can use GA to guide treatment selection, adjusting for patient frailty and goals, as well as prompt initiation of enhanced supportive care. After initial therapy, GA can improve the identification of older adults with aggressive myeloid malignancies who would benefit from hematopoietic cell transplantation (HCT), inform shared decision making, as well as allow transplanters to tailor conditioning regimen, donor selection, graft-versus-host disease prophylaxis, and pre- and post-HCT treatments. As in HCT, GA can improve the care of older patients with relapsed lymphoma or multiple myeloma eligible for chimeric antigen receptor-T therapy, identifying patients at higher risk for toxicity and providing a baseline for subsequent neurocognitive testing. Here, we review the data supporting GA for the care of older adults with blood cancers, from the community to the academic center. In addition, we explore future directions to optimize outcomes for older adults with hematologic malignancies.
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Affiliation(s)
- Brendan L Mangan
- Department of Pharmacy, University of Pennsylvania, Philadelphia, PA
| | - Clark DuMontier
- Brigham and Women's Hospital, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
| | | | - Gregory A Abel
- Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Shannon R McCurdy
- Division of Hematology-Oncology/Department of Medicine, University of Pennsylvania, Philadelphia, PA
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Sung AD, Koll T, Gier SH, Racioppi A, White G, Lew M, Free M, Agarwal P, Bohannon LM, Johnson EJ, Selvan B, Babushok DV, Frey NV, Gill SI, Hexner EO, Martin M, Perl AE, Pratz KW, Luger SM, Chao NJ, Fisher AL, Stadtmauer EA, Porter DL, Loren AW, Bhatt VR, Gimotty PA, McCurdy SR. Preconditioning Frailty Phenotype Influences Survival and Relapse for Older Allogeneic Transplantation Recipients. Transplant Cell Ther 2024; 30:415.e1-415.e16. [PMID: 38242440 PMCID: PMC11009062 DOI: 10.1016/j.jtct.2024.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/21/2024]
Abstract
Hematologic malignancies disproportionately affect older adults. Hematopoietic cell transplantation (HCT) is potentially curative, but poor overall survival (OS) has limited its use in older adults. Fried's frailty phenotype (FFP) is a geriatric assessment tool that combines objective and subjective performance measures: gait speed, grip strength, activity level, exhaustion, and weight loss. People meeting ≥3 criteria are classified as frail; 1 or 2 criteria, as pre-frail; and 0 criteria, as fit. To evaluate the association of pre-HCT FFP with post-HCT outcomes, we assessed FFP prior to conditioning for 280 HCT recipients age ≥60 years with acute leukemia or a myeloid neoplasm at 3 institutions. When analyzing survival by age group, patients age ≥70 years had inferior OS compared to patients age 60 to 69 years (P = .002), with corresponding OS estimates of 38.9% (95% confidence interval [CI], 27.8% to 49.9%) and 59.3% (95% CI, 51.9% to 65.9%). Nonrelapse mortality (NRM) also was significantly higher in the older patients (P = .0005); the 2-year cumulative incidences of NRM were 38.5% (95% CI, 27.5% to 49.2%) and 17.2% (95% CI, 12.3% to 22.8%), for older and younger recipients, respectively. The cumulative incidences of relapse did not differ by age group (P = .3435). Roughly one-third (35.5%) of the patients were fit, 57.5% were pre-frail, and 7.5% were frail, with corresponding 2-year OS estimates of 68.4% (95% CI, 57.9% to 76.8%), 45.5% (95% CI, 37.4% to 53.2%), and 45.8% (95% CI, 23.4% to 65.8%) (P = .013). FFP was not significantly associated with NRM, but being frail or pre-frail was associated with a higher rate of disease-related deaths (33.3% and 27.3%, respectively, compared with 17.4% for fit patients; P = .043). In univariate modeling of restricted mean survival time with a 3-year horizon (RMST_3y), the factors that were significantly associated were FFP, age, Karnofsky Performance Status (KPS), Disease Risk Index (DRI), and HCT-specific Comorbidity Index (HCT-CI). Of those factors, only FFP (P = .006), age (P = .006), KPS (P = .004), and DRI (P = .005) were significantly associated in multivariate modeling of RMST_3y. Estimates of RMST_3y were computed and 5 risk-groups were created with survival ranging from 31.4 months for those who were age 60 to 69 years, fit, had KPS 90 to 100, and low/intermediate-risk DRI compared to 10.5 months for those who had high-risk features for all the evaluated factors. In univariate and multivariate analyses for restricted mean time to relapse with a 3-year horizon (RMRT_3y), FFP (pre-frail versus fit, P = .007; frail versus fit, P = .061) and DRI (P = .001) were the only significant factors. Predicted RMRT_3y was longest (30.6 months) for those who were fit and had low/intermediate-risk DRI scores and shortest (19.1 months) for those who were frail and had high-risk or very high-risk DRI scores. Both age and FFP impact survival after HCT. Incorporation of FFP into pre-HCT evaluations may improve decision-making and counseling regarding HCT risk for older adults. Our findings support future trials designed to reverse frailty, such as pre-HCT supervised exercise programs, and correlative analyses to unravel the connection of frailty and relapse to generate future targets for intervention. Finally, exploration of novel HCT platforms to reduce relapse in pre-frail and frail patients, as well as reduce NRM in adults age >70 years, are warranted.
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Affiliation(s)
- Anthony D Sung
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Thuy Koll
- Division of Geriatrics, Gerontology, and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Shannon H Gier
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alessandro Racioppi
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Griffin White
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Meagan Lew
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Marcia Free
- Division of Geriatrics, Gerontology, and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Priyal Agarwal
- Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Lauren M Bohannon
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Ernaya J Johnson
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Bharathi Selvan
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Daria V Babushok
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Noelle V Frey
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Saar I Gill
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth O Hexner
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - MaryEllen Martin
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alexander E Perl
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Keith W Pratz
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Selina M Luger
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nelson J Chao
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Alfred L Fisher
- Division of Geriatrics, Gerontology, and Palliative Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Edward A Stadtmauer
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David L Porter
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alison W Loren
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Vijaya R Bhatt
- Division of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Phyllis A Gimotty
- Department of Biostatistics, Epidemiology and Informatics Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shannon R McCurdy
- Division of Hematology and Oncology, Perelman School of Medicine, Philadelphia, Pennsylvania.
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Bala R, Madaan R, Chauhan S, Gupta M, Dubey AK, Zahoor I, Brijesh H, Calina D, Sharifi-Rad J. Revitalizing allicin for cancer therapy: advances in formulation strategies to enhance bioavailability, stability, and clinical efficacy. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:703-724. [PMID: 37615709 DOI: 10.1007/s00210-023-02675-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/12/2023] [Indexed: 08/25/2023]
Abstract
The main objective of this review is to highlight the therapeutic potential of allicin, a defense molecule in garlic known for its diverse health benefits, and address the key challenges of its bioavailability and stability. The research further aims to evaluate various formulation strategies and nanotechnology-based delivery systems that can resolve these issues and improve allicin's clinical efficacy, especially in cancer therapy. We conducted a comprehensive review of the available literature and previous studies, focusing on the therapeutic properties of allicin, its bioavailability, stability issues, and novel formulation strategies. We assessed the mechanism of action of allicin in cancer, including its effects on signaling pathways, cell cycle, apoptosis, autophagy, and tumor development. We also evaluated the outcomes of both in vitro and in vivo studies on different types of cancers, such as breast, cervical, colon, lung, and gastric cancer. Despite allicin's significant therapeutic benefits, including cardiovascular, antihypertensive, cholesterol-lowering, antimicrobial, antifungal, anticancer, and immune-modulatory activity, its clinical utility is limited due to poor stability and unpredictable bioavailability. Allicin's bioavailability in the gastrointestinal tract is dependent on the activity of the enzyme alliinase, and its stability can be affected by various conditions like gastric acid and intestinal enzyme proteases. Recent advances in formulation strategies and nanotechnology-based drug delivery systems show promise in addressing these challenges, potentially improving allicin's solubility, stability, and bioavailability. Allicin offers substantial potential for cancer therapy, yet its application is hindered by its instability and poor bioavailability. Novel formulation strategies and nanotechnology-based delivery systems can significantly overcome these limitations, enhancing the therapeutic efficacy of allicin. Future research should focus on refining these formulation strategies and delivery systems, ensuring the safety and efficacy of these new allicin formulations. Clinical trials and long-term studies should be carried out to determine the optimal dosage, assess potential side effects, and evaluate their real-world applicability. The comparative analysis of different drug delivery approaches and the development of targeted delivery systems can also provide further insight into enhancing the therapeutic potential of allicin.
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Affiliation(s)
- Rajni Bala
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Reecha Madaan
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Samrat Chauhan
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Malika Gupta
- Chitkara College of Pharmacy, Chitkara University, Rajpura, Punjab, India
| | - Ankit Kumar Dubey
- iGlobal Research and Publishing Foundation, New Delhi, India
- Institute of Scholars, Chikmagalur, India
| | - Ishrat Zahoor
- Maharishi Markandeshwar College of Pharmacy, Maharishi Markandeshwar (Deemed to Be University), Mullana-Ambala, Haryana, 133207, India
| | - Hemavathi Brijesh
- Department of Biotechnology, School of Applied Sciences, REVA University, Bengaluru, Karnataka, India
| | - Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349, Craiova, Romania.
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Jayani RV. How old is too old? Frailty and geriatric assessments of older patients undergoing allogeneic HCT. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:709-714. [PMID: 38066893 PMCID: PMC10727072 DOI: 10.1182/hematology.2023000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is a curative-intent treatment for many hematologic malignancies but carries a significant risk of morbidity and mortality. An increasing number of older adults are receiving HCT, but current pretransplant evaluations overlook the unique vulnerabilities that older adults face. Oncology-specific geriatric and frailty assessments provide a comprehensive evaluation of older adults, help better weigh the risks of HCT with patients, and guide personalized optimization strategies to minimize vulnerabilities. Geriatric assessments evaluate seven domains: comorbidities, physical function, mental health, cognition, nutrition, medications, and social support. Frailty indices provide unique evaluations into a patient's overall status. Various standardized measures have been used to evaluate these areas in older adults prior to HCT. Different care models exist for the integration of geriatrics and geriatric principles into HCT evaluation: a multidisciplinary consultative clinic, a geriatrician alongside the HCT clinic, or a primary geriatric hematologist/transplant physician. Future studies are needed to investigate the use of geriatric assessments in selecting the conditioning regimen and intensity and measuring the impact of geriatric assessment-driven interventions on quality of life and toxicities post transplant.
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Affiliation(s)
- Reena V. Jayani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Salas MQ, Atenafu EG, Pasic I, Bascom O, Wilson L, Lam W, Law AD, Chen C, Novitzky-Basso I, Kim DDH, Gerbitz A, Viswabandya A, Michelis FV, Lipton JH, Mattsson J, Alibhai SMH, Kumar R. HCT frailty scale for younger and older adults undergoing allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2023; 58:1237-1246. [PMID: 37620424 DOI: 10.1038/s41409-023-02088-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 07/19/2023] [Accepted: 08/14/2023] [Indexed: 08/26/2023]
Abstract
The HCT Frailty Scale is an easy prognostic tool composed of (a) Clinical Frailty Scale; (b) Instrumental Activities of Daily Living; (c) Timed-up-and-Go test; (d) Grip Strength; (e) Self-Health Rated Questionnaire; (f) Falls tests; (g) Albumin and C-reactive protein levels. This scale was designed to classify allogeneic hematopoietic cell transplant (alloHCT) candidates into fit, pre-frail and frail groups, irrespective of age. This study evaluates the ability of this frailty classification to predict overall survival (OS) and non-relapse mortality (NRM) in adult patients of all ages, in a prospective sample of 298 patients transplanted between 2018 and 2020. At first consultation, 103 (34.6%) patients were fit, 148 (49.7%) pre-frail, and 47 (15.8%) were frail. The 2-year OS and NRM of the three groups were 82.9%, 67.4%, and 48.3% (P < 0.001), and 5.4%, 19.2%, and 37.7% (P < 0.001). For patients younger than 60 years (n = 174), the 2-year OS and NRM of fit, pre-frail, and frail groups were 88.4%, 69.3% and 53.1% (P = 0.002), and 5.8%, 22.8%, and 34.8% (P = 0.005), respectively; and in patients older than 60 (n = 124), OS and NRM were 75.5%, 63.8% and 41.4% (P = 0.006), and 4.9%, 16.4%, and 42.1% (P = 0.001). In conclusion, frailty predicted worse transplant outcomes in both younger and older adults.
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Affiliation(s)
- Maria Queralt Salas
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
- HCT Unit, Hospital Clinic de Barcelona, ICHMO, Barcelona, Spain
| | - Eshetu G Atenafu
- Department of Biostatistics, Princes Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ivan Pasic
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ora Bascom
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Leeann Wilson
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Wilson Lam
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Arjun Datt Law
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Carol Chen
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Igor Novitzky-Basso
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Dennis Dong Hwan Kim
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Armin Gerbitz
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Auro Viswabandya
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Fotios V Michelis
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jeffrey Howard Lipton
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jonas Mattsson
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Rajat Kumar
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology. Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
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Ho F, Kow A, Lim WC, Chen MZ, Mohd Rais NC, Ling NMW, Ooi M, Ng JY, Ng YS, Chun M, Yao Y, Mohd Said N, Eng WN, Chen WM, Luah V, Loy Y, Ong J, Wong WY, Korc-Grodzicki B, Lichtman SM, Pang A. Feasibility of a Geriatric Oncology Longitudinal End to End (GOLDEN) Program in a Tertiary Cancer Center in Singapore. Oncologist 2023; 28:e198-e204. [PMID: 36779537 PMCID: PMC10078895 DOI: 10.1093/oncolo/oyac276] [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: 08/05/2022] [Accepted: 12/13/2022] [Indexed: 02/14/2023] Open
Abstract
INTRODUCTION In the National University Cancer Institute, Singapore (NCIS), 2 pilot programs providing (i) surgical prehabilitation before cancer surgery and (ii) geriatric oncology support for older adults planned for chemotherapy and/or radiotherapy were merged to form the Geriatric Oncology Longitudinal End to eNd (GOLDEN) program in 2019 to support patients from the time of their cancer diagnosis, through their treatment process, to cancer survivorship. METHODS AND MATERIALS Older adults aged ≥65 years were enrolled in either surgical prehabilitation, the geriatric medical oncology (GO) arm, or both. All patients undergo a geriatric assessment. We assessed if patients had a change in treatment plans based on GOLDEN recommendations, and the impact on patient related outcomes. RESULTS There were 777 patients enrolled in the GOLDEN program over 2 years; 569 (73%) were enrolled in surgical prehabilitation, 308 (40%) were enrolled in the GO arm, with 100 (12.8%) enrolled in both. 56.9% were females. Median age was 73. Lower gastrointestinal (51.2%) and hepatobiliary cancers (24.1%) were the most common cancer types. 43.4% were pre-frail and 11.7% were frail. Of the 308 patients in the GO arm, 86.0% had geriatric syndromes, while 60.7% had a change in their treatment plans based on GOLDEN recommendations. 31.5% reported an improved global health status, while 38.3% maintained their global health status. 226 (73%) responded that they had benefited from the GOLDEN. CONCLUSION More than half of the population was either pre-frail or frail. Amongst those in the GO arm, the majority had geriatric syndromes and had a change in their treatment plans based on GOLDEN recommendations. Majority reported either improvement or maintenance in global health status, with most feeling they have benefited from the program. Further evaluation of the longitudinal geriatric hematology-oncology program for cancer-related outcomes and sustainability should be carried out.
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Affiliation(s)
- Francis Ho
- Department of Radiation Oncology, National University Cancer Institute, Singapore
| | - Alfred Kow
- Department of Surgery, National University Hospital, Singapore
| | - Wan Chin Lim
- Department of Surgery, National University Hospital, Singapore
| | - Matthew Zhixuan Chen
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore
| | - Nydia Camelia Mohd Rais
- Division of Geriatric Medicine, Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Natalie Mun Wai Ling
- Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore
| | - Melissa Ooi
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Jing Yu Ng
- Department of Surgery, Ng Teng Fong General Hospital, Singapore
| | - Yean Shin Ng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Meiling Chun
- Department of Surgery, Ng Teng Fong General Hospital, Singapore
| | - Yao Yao
- Department of Pharmacy, National University Hospital, Singapore
| | - Noorhanah Mohd Said
- Department of Oncology Nursing, National University Cancer Institute, Singapore
| | - Wan Nghee Eng
- Department of Oncology Nursing, National University Cancer Institute, Singapore
| | - Wen Meei Chen
- Department of Nursing, Ng Teng Fong General Hospital, Singapore
| | - Vivian Luah
- Department of Medical Social Work, National University Hospital, Singapore
| | - Yijun Loy
- Department of Rehabilitation, National University Hospital, Singapore
| | - Jiexin Ong
- Department of Rehabilitation, National University Hospital, Singapore
| | - Wei Yee Wong
- Department of Dietetics, National University Hospital, Singapore
| | | | | | - Angela Pang
- Department of Haematology-Oncology, National University Cancer Institute, Singapore
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7
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Cooperrider JH, Shukla N, Nawas MT, Patel AA. The Cup Runneth Over: Treatment Strategies for Newly Diagnosed Acute Myeloid Leukemia. JCO Oncol Pract 2023; 19:74-85. [PMID: 36223559 PMCID: PMC10476749 DOI: 10.1200/op.22.00342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022] Open
Abstract
Since 2017, the number of agents for acute myeloid leukemia (AML) has rapidly expanded. Given the increased therapeutic options, better identification of high-risk subsets of AML and more refined approaches to patient fitness assessment, the decisions surrounding selection of intensive chemotherapy versus lower-intensity treatment have grown increasingly more nuanced. In this review, we present available data for both standard and investigational approaches in the initial treatment of AML using an intensive chemotherapy backbone or a lower-intensity approach. We summarize management strategies in newly diagnosed secondary AML, considerations around allogeneic stem-cell transplantation, and the role of maintenance therapy. Finally, we highlight important areas of future investigation and novel agents that may hold promise in combination with standard therapies.
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Affiliation(s)
| | - Navika Shukla
- Department of Medicine, University of Chicago, Chicago, IL
| | - Mariam T. Nawas
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, Chicago, IL
| | - Anand Ashwin Patel
- Section of Hematology-Oncology, Department of Medicine, University of Chicago, Chicago, IL
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8
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del Pozo-Rubio R, Ortega-Ortega M. Sociodemographic and health factors associated with the risk of financial catastrophe when informal care for patients with haematological neoplasms is replaced by formal care. HEALTH ECONOMICS REVIEW 2022; 12:20. [PMID: 35266072 PMCID: PMC8908606 DOI: 10.1186/s13561-022-00364-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/24/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Cancer is one of the diseases with the highest incidence and mortality in the world, and one that requires greater care (formal and informal). At present, the traditional informal caregiver is disappearing. The objective is to analyse the sociodemographic and health factors associated with the possible catastrophic financial effect on households of replacing informal care by formal care for patients with blood cancer, during the different stages of treatment in Spain. METHODS A total of 139 patients with haematological neoplasm who underwent stem cell transplantation completed a longitudinal questionnaire during each of three treatment phases. Of this population, 88.49% received informal care. The households were classified into those where the replacement of informal care with formal care would impose a financial burden exceeding 40% of equivalent household income, versus those who would not suffer this consequence. Three logistic regression models (one for each treatment phase) were estimated and the corresponding marginal effects determined. RESULTS The factors associated with a higher probability of financial catastrophe were married marital status, low education level, fair to very poor self-perceived health status, the diagnosis of leukaemia in the pre-transplant and first-year post-transplant phases and of multiple myeloma disease in the final post-transplant phase. CONCLUSIONS These findings reveal the need to design social policies to meet the care needs of patients with blood cancer which at present are covered by informal care. Given the foreseeable elimination of this option, these families must be protected from the financial burden incurred from the use of privately-contracted assistance.
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Affiliation(s)
- Raúl del Pozo-Rubio
- Department of Economics and Finance, Faculty of Social Sciences, University of Castilla-La Mancha, Avenida de los Alfares, 44. C.P.: 16.071, Cuenca, Spain
| | - Marta Ortega-Ortega
- Department of Applied and Public Economics, and Political Economy, Complutense University of Madrid, Campus de Somosaguas s/n. 28.023, Madrid, Pozuelo de Alarcón, Spain
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9
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Huang LW, Sheng Y, Andreadis C, Logan AC, Mannis GN, Smith CC, Gaensler KML, Martin TG, Damon LE, Huang CY, Olin RL. Patterns and predictors of functional decline after alloHCT in older adults. Transplant Cell Ther 2022; 28:309.e1-309.e9. [PMID: 35247612 DOI: 10.1016/j.jtct.2022.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/17/2022] [Accepted: 02/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND As allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, geriatric assessments (GA) have been identified as a useful tool for predicting outcomes, particularly functional status. However, very few studies have examined the longitudinal change in GA measures in the post-alloHCT period. OBJECTIVES The objectives of this study are to 1) describe the longitudinal change in GA and QOL measures after alloHCT and to 2) identify predictors of greater functional decline post-transplant. STUDY DESIGN In this single-center prospective cohort study, patients aged 50 years or older planning to undergo alloHCT completed a cancer-specific GA and the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) survey at baseline prior to alloHCT and then at 3, 6, and 12 months after transplant. Changes in GA and QOL measures at each post-transplant time point (3, 6, or 12 months) compared to baseline were analyzed using paired t-tests. Exploration of potential predictors of greater post-transplant functional decline, as measured by instrumental activities of daily living (IADL) and Medical Outcomes Study Physical Health scale (MOS-PH), were examined using linear regressions and chi-squared two-sample test of proportions. RESULTS Mean functional status generally exhibited a pattern of decline at 3 to 6 months post-alloHCT, with recovery to near baseline by 12 months. Mean mental health and emotional QOL were lowest at baseline and improved at all time points post-transplant. Differences in baseline clinical characteristics were not associated with any differences in functional trajectories. Differences in baseline GA measures (patient-rated KPS, IADL, MOS-PH, Timed-Up-and-Go, Blessed Orientation-Memory-Concentration test, Mental Health Inventory 5) also did not predict greater functional decline at 3 months. Patients whose IADL was improved or maintained at 3 months generally maintained their functional status at 6 and 12 months. Similarly, most patients who had IADL decline at 3 months still had functional decline at 6 months, though a portion did have functional recovery by 12 months. Compared to those with improved/maintained IADL at 3 months, those with declined IADL at 3 months were significantly more likely to have persistent functional decline at 6 months (p<0.0001) and 12 months (p=0.02). CONCLUSIONS In older alloHCT patients, mean functional status declines short-term after alloHCT with possibility of recovery by 6 to 12 months, while mean mental and emotional health improve post-alloHCT. Functional decline at 3 months post-alloHCT is associated with persistent functional decline at 12 months.
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Affiliation(s)
- Li-Wen Huang
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California; Division of Hematology/Oncology, Department of Medicine, San Francisco VA Medical Center, San Francisco, California
| | - Ying Sheng
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Charalambos Andreadis
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Aaron C Logan
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Gabriel N Mannis
- Division of Hematology, Department of Medicine, Stanford University, Stanford, California
| | - Catherine C Smith
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Karin M L Gaensler
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Thomas G Martin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Lloyd E Damon
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Rebecca L Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California.
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10
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Goede V, Neuendorff NR, Schulz RJ, Hormigo AI, Martinez-Peromingo FJ, Cordoba R. Frailty assessment in the care of older people with haematological malignancies. THE LANCET HEALTHY LONGEVITY 2021; 2:e736-e745. [DOI: 10.1016/s2666-7568(21)00184-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/01/2021] [Accepted: 07/21/2021] [Indexed: 02/03/2023]
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11
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Rosko AE, Cordoba R, Abel G, Artz A, Loh KP, Klepin HD. Advances in Management for Older Adults With Hematologic Malignancies. J Clin Oncol 2021; 39:2102-2114. [PMID: 34043442 PMCID: PMC8260925 DOI: 10.1200/jco.21.00242] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ashley E. Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Gregory Abel
- Leukemia Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Heidi D. Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC
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12
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Wildes TM, Artz AS. Characterize, Optimize, and Harmonize: Caring for Older Adults With Hematologic Malignancies. Am Soc Clin Oncol Educ Book 2021; 41:1-9. [PMID: 33979197 DOI: 10.1200/edbk_320141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
With the aging of the population, the number of older adults with hematologic malignancies is growing, and treatment paradigms for these patients are rapidly evolving. Use of allogeneic stem cell transplant has been expanding to include septuagenarians but remains a potentially morbid procedure, creating an opportunity for a geriatric-focused evaluation to improve assessment of the individual's risk in undergoing the procedure. Although age alone should not be the sole determinant for transplant eligibility, geriatric assessment often identifies vulnerabilities that are not captured in assessing performance status and comorbidities alone. Those vulnerabilities may be optimized in an approach employing three sequential steps: characterize resiliency, bolster resilience, and harmonize with patient goals. Data are emerging that show that this approach is associated with lower nonrelapse mortality, shorter length of stay, and better survival after transplant. In older adults with myeloma, treatment recommendations also aim to balance the expected efficacy and toxicity profile and incorporate the patient's goals and preferences. Assessment of frailty allows for more personalized estimates of risk of toxicity. Currently, the European Myeloma Network currently recommends using the International Myeloma Working Group frailty scale as a standard approach to defining frail or at-risk populations with myeloma. In addition to treatment selection, the care of older adults with myeloma must include consideration of other issues, including reducing early mortality with antibiotic prophylaxis, polypharmacy, depression, cognition, and falls. Overall, appreciation of the aging-associated vulnerabilities will allow for the ultimate personalized care and treatment of older adults with hematologic malignancies.
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Affiliation(s)
| | - Andrew S Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
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13
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Lin RJ, Elias HK, van den Brink MRM. Immune Reconstitution in the Aging Host: Opportunities for Mechanism-Based Therapy in Allogeneic Hematopoietic Cell Transplantation. Front Immunol 2021; 12:674093. [PMID: 33953731 PMCID: PMC8089387 DOI: 10.3389/fimmu.2021.674093] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 03/30/2021] [Indexed: 12/13/2022] Open
Abstract
Older patients with hematologic malignancies are increasingly considered for allogeneic hematopoietic cell transplantation with encouraging outcomes. While aging-related thymic dysfunction remains a major obstacle to optimal and timely immune reconstitution post- transplantation, recent accumulating evidence has suggested that various aging hallmarks such as cellular senescence, inflamm-aging, and hematopoietic stem cell exhaustion, could also impact immune reconstitution post-transplantation in both thymic-dependent and independent manner. Here we review molecular and cellular aspects of immune senescence and immune rejuvenation related to allogeneic hematopoietic cell transplantation among older patients and discuss potential strategies for mechanism-based therapeutic intervention.
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Affiliation(s)
- Richard J Lin
- Adult Bone Marrow Transplantation (BMT) Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | - Harold K Elias
- Adult Bone Marrow Transplantation (BMT) Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Department of Medicine, Weill Cornell Medical College, New York, NY, United States
| | - Marcel R M van den Brink
- Adult Bone Marrow Transplantation (BMT) Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States.,Department of Medicine, Weill Cornell Medical College, New York, NY, United States
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14
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Fitch MI, Strohschein FJ, Nyrop K. Measuring quality of life in older people with cancer. Curr Opin Support Palliat Care 2021; 15:39-47. [PMID: 33507038 DOI: 10.1097/spc.0000000000000535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The number of individuals aged 65+ with cancer will double in the next decade. Attention to quality of life (QOL) is imperative to identify relevant endpoints/outcomes in research and provide care that matches individual needs. This review summarizes recent publications regarding QOL measurement in older adults with cancer, considering implications for research and practice. RECENT FINDINGS QOL is a complex concept and its measurement can be challenging. A variety of measurement tools exist, but only one specific to older adults with cancer. QOL is frequently measured as functional health, adverse symptoms, and global QOL, thus only capturing a portion of this concept. Yet successful QOL intervention for older adults requires drawing from behavioral and social dimensions.Growing interest in comprehensive geriatric assessment (CGA) and patient-reported outcomes (PROs) provides important opportunities for measuring QOL. Recommendations for use of CGAs and PROs in clinical practice have been made but widespread uptake has not occurred. SUMMARY QOL is important to older adults and must be central in planning and discussing their care. It is modifiable but presents measurement challenges in this population. Various domains are associated with decline, survival, satisfaction with life, coping, and different interventions. Measurement approaches must fit with intention and capacity to act within given contexts.
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Affiliation(s)
- Margaret I Fitch
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Fay J Strohschein
- Oncology and Aging Program, Jewish General Hospital, Montreal, Canada, Nursing Research Consultant, Wainwright, Alberta
| | - Kirsten Nyrop
- Division of Oncology, School of Medicine, Lineberger Comprehensive Cancer Center, Deputy Director/Research - Geriatric Oncology Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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15
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Isobe M, Konuma T, Masuko M, Uchida N, Miyakoshi S, Sugio Y, Yoshida S, Tanaka M, Matsuhashi Y, Hattori N, Onizuka M, Aotsuka N, Kouzai Y, Wake A, Kimura T, Ichinohe T, Atsuta Y, Yanada M. Single cord blood transplantation for acute myeloid leukemia patients aged 60 years or older: a retrospective study in Japan. Ann Hematol 2021; 100:1849-1861. [PMID: 33624134 DOI: 10.1007/s00277-021-04464-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022]
Abstract
The availability of alternative donor sources could allow elderly patients to receive allogeneic hematopoietic cell transplantation (HCT). We retrospectively evaluated the outcomes of single-unit cord blood transplantation (CBT) in 1577 patients aged ≥60 years with acute myeloid leukemia (AML) in Japan between 2002 and 2017. In total, 990 (63%) patients were not in complete remission (CR) at the time of CBT. A myeloablative conditioning regimen (52%) and calcineurin inhibitor (CI) + mycophenolate mofetil (MMF)-based graft-versus-host disease (GVHD) prophylaxis (45%) were more commonly used. With a median follow-up for survivors of 31 months, the probability of overall survival and the cumulative incidence of leukemia-related mortality at 3 years was 31% and 29%, respectively. The cumulative incidence of non-relapse mortality (NRM) at 100 days and 3 years were 24% and 41%, respectively. The cumulative incidences of grade II-IV and grade III-IV acute GVHD at 100 days and extensive chronic GVHD at 2 years were 44%, 16%, and 14%, respectively. The cumulative incidence of neutrophil engraftment was 80% at 42 days. Results of multivariate analysis indicated that the following factors were significantly associated with higher overall mortality: performance status ≥1, hematopoietic cell transplantation-specific comorbidity index ≥3, adverse cytogenetics, extramedullary disease at diagnosis, and non-CR status at CBT. By contrast, female sex, HLA disparities ≥2, mycophenolate mofetil-based GVHD prophylaxis, and recent CBT were significantly associated with lower overall mortality. In conclusion, single CBT offers a curative option for AML patients aged ≥60 years with careful patient selection.
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Affiliation(s)
- Masamichi Isobe
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan
| | - Takaaki Konuma
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, 4-6-1, Shirokanedai, Minato-ku, Tokyo, 108-8639, Japan.
| | - Masayoshi Masuko
- Department of Hematopoietic Cell Transplantation, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Naoyuki Uchida
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | | | - Yasuhiro Sugio
- Department of Internal Medicine, Kitakyushu City Hospital Organization, Kitakyushu Municipal Medical Center, Kitakyushu, Japan
| | - Shuro Yoshida
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshiko Matsuhashi
- Department of Hematology, Kawasaki Medical School Hospital, Kurashiki, Japan
| | - Norimichi Hattori
- Division of Hematology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Nobuyuki Aotsuka
- Division of Hematology-Oncology, Japanese Red Cross Society Narita Hospital, Narita, Japan
| | - Yasushi Kouzai
- Department of Transfusion Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Atsushi Wake
- Department of Hematology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Takafumi Kimura
- Preparation Department, Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamitsu Yanada
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
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16
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Devarakonda S, Efebera Y, Sharma N. Role of Stem Cell Transplantation in Multiple Myeloma. Cancers (Basel) 2021; 13:863. [PMID: 33670709 PMCID: PMC7922596 DOI: 10.3390/cancers13040863] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 12/11/2022] Open
Abstract
Autologous stem cell transplantation (auto-SCT) has been the standard of care in eligible newly diagnosed multiple myeloma (MM) patients. Outcomes of patients with MM have improved significantly due to the advent of several novel drugs. Upfront use of these drugs in induction therapy has significantly increased the rate and depth of responses that have translated into longer remission and survival. This has now raised a debate regarding the role and relevance of auto-SCT in the management of myeloma. However, clinical trials have confirmed the utility of auto-SCT even in the era of novel drugs. Tandem auto-SCT followed by maintenance has shown a progression-free survival (PFS) benefit in high-risk MM, and hence can be considered in young and fit patients with high-risk disease. Auto-SCT has the advantages of resetting the bone marrow microenvironment, short-lived toxicity compared to the long-term physical and financial toxicities of continued chemotherapy in the absence of SCT, very low transplant-related mortality (TRM) in high volume centers, and providing longer disease-free survival when followed by maintenance therapy. Allogeneic SCT is one potentially curative option for MM, albeit with an increased risk of death due to high TRM. Strategies to modulate the graft-versus-host disease (GVHD) while maintaining or improving the graft-versus-myeloma (GVM) effect could place allogeneic SCT back in the treatment armamentarium of MM.
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Affiliation(s)
| | - Yvonne Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center Columbus, Columbus, OH 43210, USA; (S.D.); (N.S.)
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17
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Nawas MT, Sheng Y, Huang CY, Andreadis C, Martin TG, Wolf JL, Ai WZ, Kaplan LD, Mannis GN, Logan AC, Damon LE, Olin RL. Serial comprehensive geriatric and quality of life assessments in adults age ≥ 50 years undergoing autologous hematopoietic cell transplantation. J Geriatr Oncol 2020; 12:531-539. [PMID: 33059999 DOI: 10.1016/j.jgo.2020.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/17/2020] [Accepted: 09/29/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We sought to examine the natural history of geriatric assessment (GA) and quality of life (QOL) domains among adults age ≥ 50 years undergoing autologous hematopoietic cell transplantation (autoHCT). MATERIALS AND METHODS A QOL tool and cancer-specific GA were completed before autoHCT in patients ≥50 years, and at 100 days, six months, and one year post-transplant. RESULTS One hundred eighty-four patients completed the pre-transplant QOL/GA assessment, 169 (92%) completed the 100-day assessment, 162 (88%) completed the six-month assessment, and 145 (79%) completed the twelve-month assessment. Functional status, as measured by instrumental activities of daily living (IADL), decreased from baseline to day 101 (mean change -0.42 points, 95% CI, -0.75 to -0.09, p = 0.01) but returned to baseline by one year. Physical function as measured by Medical Outcomes Study-Physical Health (MOS-PH) increased by mean of 3.27 points (95% CI, -0.02 to 6.56, p = 0.05) by one year. Physician-rated KPS improved by one year, but patient-rated KPS did not. No QOL metric deteriorated from baseline. Baseline factors predictive of IADL and MOS-PH as measured over time included comorbidities and disease status at transplant. IADL and MOS-PH as measured over time were not significantly associated with age. CONCLUSIONS AutoHCT for adults age ≥ 50 years resulted in an initial decrease in functional status, with subsequent improvement back to baseline by one year. Physical health and QOL measures were improved or unchanged over time. AutoHCT is well tolerated in well selected older patients, using patient reported geriatric metrics as outcomes.
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Affiliation(s)
- Mariam T Nawas
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA.
| | - Ying Sheng
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA.
| | - Chiung-Yu Huang
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, 550 16th Street, San Francisco, CA 94158, USA.
| | - Charalambos Andreadis
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Thomas G Martin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Jeffrey L Wolf
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Weiyun Z Ai
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Lawrence D Kaplan
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Gabriel N Mannis
- Stanford Cancer Institute, Stanford University Medical Center, 875 Blake Wilbur Dr, Stanford, CA 94305, USA.
| | - Aaron C Logan
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Lloyd E Damon
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
| | - Rebecca L Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, 400 Parnassus Avenue, San Francisco, CA 94131, USA.
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18
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Flannelly C, Tan BEX, Tan JL, McHugh CM, Sanapala C, Lagu T, Liesveld JL, Aljitawi O, Becker MW, Mendler JH, Klepin HD, Stock W, Wildes TM, Artz A, Majhail NS, Loh KP. Barriers to Hematopoietic Cell Transplantation for Adults in the United States: A Systematic Review with a Focus on Age. Biol Blood Marrow Transplant 2020; 26:2335-2345. [PMID: 32961375 DOI: 10.1016/j.bbmt.2020.09.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 12/17/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an effective treatment for many hematologic malignancies, and its utilization continues to rise. However, due to the difficult logistics and high cost of HCT, there are significant barriers to accessing the procedure; these barriers are likely greater for older patients. Although numerous factors may influence HCT access, no formal analysis has detailed the cumulative barriers that have been studied thus far. We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to better categorize the barriers to access and referral to HCT, with a focus on the subgroup of older patients. We searched for articles published in English from PubMed, Embase, Cumulative Index for Nursing and Allied Health, and Cochrane Central Register of Controlled Trials between the database inception and January 31, 2020. We selected articles that met the following inclusion criteria: (1) study design: qualitative, cross-sectional, observational cohort, or mixed-method study designs; (2) outcomes: barriers related to patient and physician access to HCT; and (3) population: adults aged ≥18 years with hematologic malignancies within the United States. Abstracts without full text were excluded. QUALSYST methodology was used to determine article quality. Data on the barriers to access and referral for HCT were extracted, along with other study characteristics. We summarized the findings using descriptive statistics. We included 26 of 3859 studies screened for inclusion criteria. Twenty studies were retrospective cohorts and 4 were cross-sectional. There was 1 prospective cohort study and 1 mixed-method study. Only 1 study was rated as high quality, and 16 were rated as fair. Seventeen studies analyzed age as a potential barrier to HCT referral and access, with 16 finding older age to be a barrier. Other consistent barriers to HCT referral and access included nonwhite race (n = 16/20 studies), insurance status (n = 13/14 studies), comorbidities (n = 10/11 studies), and lower socioeconomic status (n = 7/8 studies). High-quality studies are lacking related to HCT barriers. Older age and nonwhite race were consistently linked to reduced access to HCT. To produce a more just health care system, strategies to overcome these barriers for vulnerable populations should be prioritized. Examples include patient and physician education, as well as geriatric assessment guided care models that can be readily incorporated into clinical practice.
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Affiliation(s)
- Colin Flannelly
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Bryan E-Xin Tan
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | | | - Colin M McHugh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Chandrika Sanapala
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Tara Lagu
- Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts; Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Jane L Liesveld
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Omar Aljitawi
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Michael W Becker
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Jason H Mendler
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Heidi D Klepin
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina
| | - Wendy Stock
- University of Chicago Medicine Comprehensive Cancer Center, Chicago, Illinois
| | - Tanya M Wildes
- Division of Medical Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Andrew Artz
- City of Hope National Medical Center, Duarte, California
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, Ohio
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, New York.
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19
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Patient General Condition at Diagnosis: A Systematic Evaluation for Adults Diagnosed with Hematologic Malignancies. J Pers Med 2020; 10:jpm10030106. [PMID: 32867114 PMCID: PMC7564839 DOI: 10.3390/jpm10030106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/17/2022] Open
Abstract
Several societies have published recommendations for evaluating older adults with cancer in standard conditions. It is vital to assure a proper systematic patient condition evaluation, not only in the oldest (geriatric assessment) but in all adult patients. We have investigated the feasibility of a systematic evaluation of the general condition of all patients diagnosed with hematologic malignancies, and the degree of acceptance by the clinical team, in a prospective cohort of 182 consecutive adults, by using the ECOG performance status scale (ECOG, age 18 and over, 18+), Lee Index for Older Adults (LEE, 50+), Geriatric Assessment in Hematology (GAH, 65+), and the Comprehensive Geriatric Assessment (CGA, 75+). Clinical team acceptance was analyzed with a visual analogue scale, and the objective feasibility was calculated as the proportion of patients that could be finally evaluated with each tool. Acceptance was high, but the objective feasibility was progressively lower as the complexity of the different tools increased (ECOG 100%, LEE 99.4%, GAH 93.2%, and CGA 67.9%). LEE and GAH categories showed a weak concordance (Cohen’s Kappa 0.24) that was slight between LEE and CGA (Kappa 0.18). Unexpectedly, we found no significant association between the GAH and CGA categories (p = 0.16). We confirm that a systematic evaluation of all adult patients diagnosed with hematologic malignancies is feasible in daily practice by using an age-adapted approach. Direct comparisons among the different predictive tools in regard to patients’ tolerance to treatments of different intensities must be a priority research subject in the coming years.
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Arslan S, Nakamura R. Decision Analysis of Transplantation for Patients with Myelodysplasia: "Who Should We Transplant Today?". Curr Hematol Malig Rep 2020; 15:305-315. [PMID: 32222884 PMCID: PMC8080957 DOI: 10.1007/s11899-020-00573-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Myelodysplastic syndrome (MDS) is a heterogeneous hematological disorder characterized by a spectrum of clinical presentation, cytogenetic, and somatic gene mutations and the risk of transformation to acute leukemia. Management options include observation, supportive care, blood transfusion, administration of growth factors and/or hypomethylating agents, and hematopoietic cell transplant (HCT) either upfront or after disease progression. RECENT FINDINGS Currently, HCT is the only curative therapy available for patients with MDS, with multiple factors such as donor availability, patient, and disease characteristics being involved in making the decision to proceed with transplant. In this article, we summarize (1) overall prognosis and natural history of MDS, (2) currently available non-HCT therapy with a focus on hypomethylating agents (HMA), (3) outcomes after HCT in patients with MDS, (4) factors to be considered to proceed to HCT for treatment of MDS, and (5) more recent/ongoing studies relevant to HCT decision-making processes.
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Affiliation(s)
- Shukaib Arslan
- Department of Hematology & Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA, 91010, USA
| | - Ryotaro Nakamura
- Department of Hematology & Hematopoietic Cell Transplant, City of Hope National Medical Center, Duarte, CA, 91010, USA.
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Wu HH, Woywodt A, Nixon AC. Frailty and the Potential Kidney Transplant Recipient: Time for a More Holistic Assessment? KIDNEY360 2020; 1:685-690. [PMID: 35372945 PMCID: PMC8815542 DOI: 10.34067/kid.0001822020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/22/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Henry H.L. Wu
- Department of Renal Medicine, Lancashire Teaching Hospitals National Health Service Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Alexander Woywodt
- Department of Renal Medicine, Lancashire Teaching Hospitals National Health Service Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Andrew C. Nixon
- Department of Renal Medicine, Lancashire Teaching Hospitals National Health Service Foundation Trust, Royal Preston Hospital, Preston, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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Salas MQ, Atenafu EG, Bascom O, Wilson L, Lam W, Law AD, Pasic I, Kim DDH, Michelis FV, Al-Shaibani Z, Gerbitz A, Viswabandya A, Lipton JH, Mattsson J, Alibhai SMH, Kumar R. Pilot prospective study of Frailty and Functionality in routine clinical assessment in allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2020; 56:60-69. [PMID: 32606454 DOI: 10.1038/s41409-020-0979-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/01/2020] [Accepted: 06/11/2020] [Indexed: 12/14/2022]
Abstract
A Frailty and Functionality evaluation for alloHCT was implemented using existing resources. We describe the implementation of this evaluation across all ages and at first consultation, and correlate results with posttransplant outcomes in 168 patients. The evaluation consists of: Clinical Frailty Scale (CFS), Instrumental Activities of Daily Living (IADL), grip strength (GS), timed up and go test (TUGT), self-rated health question (SRH), Single question of Falls, albumin and C-Reactive Protein (CRP) levels. Median time to perform the evaluation was 5-6 min. Median age was 58 years (range: 19-77) and median follow-up was 5.3 months. TUGT > 10 s (HR 2.92; p = 0.003), raised CRP (HR 4.40; p < 0.001), and hypoalbuminemia (HR 2.10; p = 0.043) were significant risk factors for worse overal survival (OS). CFS ≥ 3 (HR 3.11; p = 0.009), TUGT > 10 s (HR 3.47; p = 0.003), GS (HR 2.56; p = 0.029), SRH (<excellent) (HR 3.8 × 106; p < 0.001), elevated CRP (HR 11.8; p < 0.001), and hypoalbuminemia (HR 4.6; p < 0.001), were significant predictors for worse non relapse mortality (NRM). On multivariable analysis, TUGT > 10 s and raised CRP were significant predictors for worse OS and NRM. SRH (<excellent) was a significant predictor for higher NRM. Frailty and Functionality can be assessed in routine clinical practice in alloHCT and may be predictive of short-term outcomes.
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Affiliation(s)
- Maria Queralt Salas
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Hematology Department, Institut Català d'Oncologia-Hospitalet, IDIBELL, Barcelona, Spain
| | - Eshetu G Atenafu
- Department of Biostatistics, Princes Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ora Bascom
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Leeann Wilson
- Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Wilson Lam
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Arjun Datt Law
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ivan Pasic
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Dennis Dong Hwan Kim
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Fotios V Michelis
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Zeyad Al-Shaibani
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Armin Gerbitz
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Auro Viswabandya
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jeffrey Howard Lipton
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Jonas Mattsson
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada.,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Rajat Kumar
- Department of Medicine, Section of Medical Oncology and Hematology, University of Toronto, Toronto, ON, Canada. .,Hans Messner Allogeneic Blood and Marrow Transplantation Program, Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
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