1
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Sackstein P, Williams A, Zemel R, Marks JA, Renteria AS, Rivero G. Transplant Eligible and Ineligible Elderly Patients with AML-A Genomic Approach and Next Generation Questions. Biomedicines 2024; 12:975. [PMID: 38790937 PMCID: PMC11117792 DOI: 10.3390/biomedicines12050975] [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: 03/17/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/26/2024] Open
Abstract
The management of elderly patients diagnosed with acute myelogenous leukemia (AML) is complicated by high relapse risk and comorbidities that often preclude access to allogeneic hematopoietic cellular transplantation (allo-HCT). In recent years, fast-paced FDA drug approval has reshaped the therapeutic landscape, with modest, albeit promising improvement in survival. Still, AML outcomes in elderly patients remain unacceptably unfavorable highlighting the need for better understanding of disease biology and tailored strategies. In this review, we discuss recent modifications suggested by European Leukemia Network 2022 (ELN-2022) risk stratification and review recent aging cell biology advances with the discussion of four AML cases. While an older age, >60 years, does not constitute an absolute contraindication for allo-HCT, the careful patient selection based on a detailed and multidisciplinary risk stratification cannot be overemphasized.
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Affiliation(s)
- Paul Sackstein
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Alexis Williams
- Department of Medicine, New York University, New York, NY 10016, USA;
| | - Rachel Zemel
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Jennifer A. Marks
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Anne S. Renteria
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Gustavo Rivero
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
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2
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Miyazaki T, Tachibana T, Suzuki T, Izumi A, Fujimaki K, Sato S, Tamai Y, Michishita Y, Suzuki T, Ishii R, Hirasawa A, Hashimoto C, Kabasawa N, Inoue Y, Ishiyama T, Yamamoto K, Kanamori H, Tanaka M, Nakajima H. Pretransplantation Inflammatory and Nutritional Status in Elderly Allogeneic Hematopoietic Stem Cell Transplantation: Prognostic Value of C-Reactive Protein-to-Albumin Ratio. Transplant Cell Ther 2024; 30:400.e1-400.e9. [PMID: 38253183 DOI: 10.1016/j.jtct.2024.01.068] [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: 11/12/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024]
Abstract
There are no clear criteria for selecting elderly patients with hematologic malignancies eligible for allogeneic hematopoietic stem cell transplantation (HSCT). This study aimed to evaluate inflammatory and nutritional status biomarkers as prognostic indicators of allogeneic HSCT in elderly patients. We compared the prognostic effects of 4 representative pretransplantation biomarkers: C-reactive protein-to-albumin ratio (CAR), Glasgow Prognostic Score (GPS), prognostic nutritional index (PNI), and albumin-to-globulin ratio (AGR). A total of 143 patients age ≥60 years who underwent their first allogeneic HSCT for a hematologic malignancy were enrolled between 2010 and 2020 in our single-center cohort. The median patient age was 65 years (range, 60 to 72 years). Pretransplantation high CAR, high GPS, and low PNI scores were associated with poor overall survival (OS), but the AGR was not associated with OS. Among the 4 biomarkers, CAR stratified OS most significantly (P < .001). Multivariate analyses identified only high CAR as an independent prognostic factor associated with OS (hazard ratio [HR], 1.98; P = .031) and showed that a Hematopoietic Cell Transplantation-Specific Comorbidity Index (HCT-CI) score ≥3 also was associated with OS (HR, 2.04; P = .012). High CAR was correlated with poor performance status, male sex, and high Disease Risk Index, but not with high HCT-CI score. When the patients were stratified into 3 groups according to a composite risk assessment using CAR and HCT-CI, the 3-year OS decreased significantly with increasing scores (82.8%, 50.3%, and 27.0%, respectively; P < .0001). In conclusion, CAR is the most useful prognostic indicator among the inflammatory and nutritional status biomarkers for allogeneic HSCT in elderly patients. Inflammatory and nutritional status in the elderly may be important prognostic factors for allogeneic HSCT independent of HCT-CI score.
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Affiliation(s)
- Takuya Miyazaki
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan.
| | | | - Taisei Suzuki
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan; Department of Hematology, Fujisawa City Hospital, Fujisawa, Japan
| | - Akihiko Izumi
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | | | - Shuku Sato
- Department of Hematology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yotaro Tamai
- Department of Hematology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Yusuke Michishita
- Department of Hematology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takahiro Suzuki
- Department of Hematology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ryuji Ishii
- Division of Hematology, Japan Community Health Care Organization Sagamino Hospital, Sagamihara, Japan
| | - Akira Hirasawa
- Department of Hematology, Yokohama Rosai Hospital, Yokohama, Japan
| | - Chizuko Hashimoto
- Department of Hematology/Oncology, Yamato Municipal Hospital, Yamato, Japan
| | - Nobuyuki Kabasawa
- Division of Hematology, Department of Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Yasuyuki Inoue
- Department of Hematology, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Taijiro Ishiyama
- Department of Hematology, Yokohama Tsurugamine Hospital, Yokohama, Japan
| | - Koh Yamamoto
- Department of Hematology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
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3
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Othman T, Quan MA, Zhang S, Gaut D, Young PA, Mahmood O, Abdulhaq H, Shieh K, Reid J, Brem EA, Hariharan N, Heyman B, Tuscano J. Impact of Thiotepa-Based Autologous Hematopoietic Cell Transplantation in Primary Central Nervous System Lymphoma in First Complete Remission: A University of California Hematologic Malignancies Consortium Retrospective Analysis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:749-756. [PMID: 37336714 DOI: 10.1016/j.clml.2023.06.003] [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: 04/18/2023] [Revised: 05/27/2023] [Accepted: 06/03/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND The choice between nonmyeloablative chemotherapy (NMA-C) or autologous hematopoietic cell transplantation (autoHCT) as consolidation in primary central nervous system lymphoma (PCNSL), and timing of autoHCT differs among centers. We aimed to clarify these points. METHODS We retrospectively analyzed PCNSL adult patients who received consolidation in CR1 or underwent autoHCT during their treatment course. Cohort A included those who underwent autoHCT in CR1, cohort B included those who underwent NMA-C in CR1, and cohort C included patients who underwent autoHCT in CR2+. We compared cohorts A and B, and cohorts A and C. The primary endpoint was overall survival (OS), and secondary endpoints were progression-free survival (PFS), treatment-related mortality (TRM) and cumulative incidence of relapse (CIR). RESULTS 36 patients were included in cohort A, 30 in cohort B, and 14 in cohort C. The 5-year OS for cohorts A vs B and vs C were 90.7% vs 62.8% (P = .045) and vs 77.9% (P = .32), respectively. The 5-year PFS from diagnosis for cohorts A vs B was 87.8% vs 37.3% (P < .001). The 5-year PFS from autoHCT for cohorts A vs C was 87.6% vs 58.4% (P = .023). The 5-year TRM and CIR in cohorts A vs B was 9.4% vs 9.5% (P = .674), and 2.9% vs 53.2% (P < .001), respectively. The 5-year TRM and CIR in cohorts A vs C from the time of autoHCT was 9.5% vs 22.1% (P = .188), and 2.9% vs 19.5% (P = .104), respectively. CONCLUSION Despite the limitations, thiotepa-based autoHCT in CR1 appears to improve outcomes in eligible patients with PCNSL.
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Affiliation(s)
- Tamer Othman
- Department of Internal Medicine, Division of Cellular Therapy, Bone Marrow Transplantation and Malignant Hematology, University of California Davis School of Medicine, Sacramento, CA
| | - Michelle A Quan
- Department of Internal Medicine, Division of Cellular Therapy, Bone Marrow Transplantation and Malignant Hematology, University of California Davis School of Medicine, Sacramento, CA
| | - Shiliang Zhang
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Daria Gaut
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Patricia A Young
- Division of Hematology Oncology, David Geffen School of Medicine and University of California, Los Angeles, CA
| | - Omar Mahmood
- Department of Medicine, University of California San Francisco, Fresno campus, Fresno, CA
| | - Haifaa Abdulhaq
- Department of Medicine, University of California San Francisco, Fresno campus, Fresno, CA
| | - Kevin Shieh
- Division of Blood & Marrow Transplant, Department of Medicine, University of California, San Diego Health, La Jolla, CA
| | - Jack Reid
- Division of Blood & Marrow Transplant, Department of Medicine, University of California, San Diego Health, La Jolla, CA
| | - Elizabeth A Brem
- Division of Blood & Marrow Transplant, Department of Medicine, University of California, San Diego Health, La Jolla, CA
| | - Nisha Hariharan
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Benjamin Heyman
- Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Joseph Tuscano
- Department of Internal Medicine, Division of Cellular Therapy, Bone Marrow Transplantation and Malignant Hematology, University of California Davis School of Medicine, Sacramento, CA.
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Schoenborn NL, Boyd CM, Pollack CE. Different Types of Patient Health Information Associated With Physician Decision-making Regarding Cancer Screening Cessation for Older Adults. JAMA Netw Open 2023; 6:e2313367. [PMID: 37184836 DOI: 10.1001/jamanetworkopen.2023.13367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Importance Although guidelines use limited life expectancy to guide physician decision-making regarding cessation of cancer screening, many physicians recommend screening for older adults with limited life expectancies. Different ways of presenting information may influence older adults' screening decision-making; whether the same is true for physicians is unknown. Objective To examine how different ways of presenting patient health information are associated with physician decision-making about cancer screening cessation for older adults. Design, Setting, and Participants A national survey was mailed from April 29 to November 8, 2021, to a random sample of 1800 primary care physicians and 600 gynecologists from the American Medical Association Physician Masterfile. Primary care physicians were surveyed about breast, colorectal, or prostate cancer screenings. Gynecologists were surveyed about breast cancer screening. Main Outcomes and Measures Using vignettes of 2 older patients with limited life expectancies, 4 pieces of information about each patient were presented: (1) description of health conditions and functional status, (2) life expectancy, (3) equivalent physiological age, and (4) risk of dying from the specific cancer in the patient's remaining lifetime. The primary outcome was which information was perceived to be the most influential in screening cessation. Results The final sample included 776 participants (adjusted response rate, 52.8%; mean age, 51.4 years [range, 27-91 years]; 402 of 775 participants were men [51.9%]; 508 of 746 participants were White [68.1%]). The 2 types of information that were most often chosen as the factors most influential in cancer screening cessation were description of the patient's health or functional status (36.7% of vignettes [569 of 1552]) and risk of death from cancer in the patient's remaining lifetime (34.9% of vignettes [542 of 1552]). Life expectancy was chosen as the most influential factor in 23.1% of vignettes (358 of 1552). Physiological age was the least often chosen (5.3% of vignettes [83 of 1552]) as the most influential factor. Description of patient's health or functional status was the most influential factor among primary care physicians (estimated probability, 40.2%; 95% CI, 36.2%-44.2%), whereas risk of death from cancer was the most influential factor among gynecologists (estimated probability, 43.1%; 95% CI, 34.0%-52.1%). Life expectancy was perceived as a more influential factor in the vignette with more limited life expectancy (estimated probability, 27.9%; 95% CI, 24.5%-31.3%) and for colorectal cancer (estimated probability, 33.9%; 95% CI, 27.3%-40.5%) or prostate cancer (28.0%; 95% CI, 21.7%-34.2%) screening than for breast cancer screening (estimated probability, 14.5%; 95% CI, 10.9%-18.0%). Conclusions and Relevance Findings from this national survey study of physicians suggest that, in addition to the patient's health and functional status, the cancer risk in the patient's remaining lifetime and life expectancy were the factors most associated with physician decision-making regarding cancer screening cessation; information on cancer risk in the patient's remaining lifetime and life expectancy is not readily available during clinical encounters. Decision support tools that present a patient's cancer risk and/or limited life expectancy may help reduce overscreening among older adults.
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Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Craig E Pollack
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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5
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Rudym D, Natalini JG, Trindade AJ. Listing Dilemmas: Age, Frailty, Weight, Preexisting Cancers, and Systemic Diseases. Clin Chest Med 2023; 44:35-46. [PMID: 36774166 DOI: 10.1016/j.ccm.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Selection of lung transplant candidates is an evolving field that pushes the boundaries of what is considered the norm. Given the continually changing demographics of the typical lung transplant recipient as well as the growing list of risk factors that predispose patients to poor posttransplant outcomes, we explore the dilemmas in lung transplant candidate selections pertaining to older age, frailty, low and high body mass index, preexisting cancers, and systemic autoimmune rheumatic diseases.
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Affiliation(s)
- Darya Rudym
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA.
| | - Jake G Natalini
- Division of Pulmonary and Critical Care Medicine, New York University, Langone Health, 530 First Avenue, HCC-4A, New York, NY 10016, USA
| | - Anil J Trindade
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Oxford House, Room 539, 1313 21st Avenue South, Nashville, TN 37232, USA
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6
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Keir M, Borman M, Clegg R, Colbert J, Guron N, Harper L, Helmerson D, Patzer J, Reynolds S, Alvarez N. Caring for the Aging Patient With Adult Congenital Heart Disease: A Review of Cardiac and Noncardiac Comorbidities. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:274-281. [PMID: 37969485 PMCID: PMC10642149 DOI: 10.1016/j.cjcpc.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/12/2022] [Indexed: 11/17/2023]
Abstract
As the demographics of congenital heart disease (CHD) have shifted, there are now more adults living with CHD than children in North America. This presents unprecedented challenges as patients with CHD acquire noncardiac comorbidities and seek care for a variety of reasons, including noncardiac surgery and emergency department (ED) visits. CHD shifts from a one organ problem to a multisystem disease and requires a team of specialists to maintain high-quality longitudinal care. In this review, we summarize the challenges patients with CHD and their providers face as they age. We review the demographics of CHD and health care utilization. We examine the rates of noncardiac comorbidities and the current quality of care received by adult patients with CHD.
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Affiliation(s)
- Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Meredith Borman
- Section of Gastroenterology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Robin Clegg
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Colbert
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nita Guron
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lea Harper
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Doug Helmerson
- Section of Respirology, Division of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Patzer
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Stephen Reynolds
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Nanette Alvarez
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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7
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Lew MV, Ren Y, Lowder YP, Siamakpour-Reihani S, Ramalingam S, Romero KM, Thompson JC, Bohannon LM, McIntyre J, Tang H, Van Opstal J, Johnson E, Cohen HJ, Bartlett DB, Pastva AM, Morey M, Hall KS, Smith P, Peters KB, Somers TJ, Kelleher S, Smith SK, Wischmeyer PE, Lin PH, Wood WA, Thorpe G, Minor K, Wiggins K, Hennig T, Helms T, Welch R, Matthews B, Liu J, Burleson J, Aberant T, Engemann AK, Henshall B, Darby M, Proch C, Dellascio M, Pittman A, Suminguit J, Choi T, Gasparetto C, Long GD, Lopez RD, Sarantopoulos S, Horwitz ME, Chao NJ, Sung AD. Geriatric Assessment Reveals Actionable Impairments in Hematopoietic Stem Cell Transplantation Candidates Age 18 to 80 Years. Transplant Cell Ther 2022; 28:498.e1-498.e9. [PMID: 35595226 PMCID: PMC10042624 DOI: 10.1016/j.jtct.2022.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 10/18/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for both malignant and nonmalignant hematologic diseases; however, reported rates of treatment-related mortality approach 30%. Outcomes are worse in patients who begin HCT with functional impairments. To detect such impairments, a geriatric assessment (GA) is recommended in adults age ≥65 years. Younger HCT candidates also may be impaired because of chemotherapy regimens pre-HCT. Therefore, we hypothesized that GA can be beneficial for adult patients of all ages and subsequently created a clinical pretransplantation optimization program to assess all HCT candidates using a modified GA. One-hundred fifty-seven patients were evaluated in 4 functional domains- physical, cognitive, nutritional, and psychological-at 2 time points prior to HCT-new patient evaluation (NPE) and sign-off (SO)-between October 2017 and January 2020. At NPE, 80.9% of the patients had at least 1 domain with a functional impairment, and physical (P = .006), cognitive (P = .04), and psychological (P = .04) impairments were associated with an increased likelihood of not proceeding to HCT. In addition, patients age 18 to 39 years were more likely than older patients to have a physical function impairment (P = .001). Between NPE and SO, 51.9% of the patients had resolution of 1 or more impairments, and nutritional impairment at SO was predictive of worse overall survival (P = .01). Our study shows that GA can identify functional impairments in patients of all ages. Early identification of impairments could facilitate referrals to supportive care and resolution of impairments prior to HCT, suggesting that GA could be recommended for HCT candidates of all ages.
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Affiliation(s)
- Meagan V Lew
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Yi Ren
- Duke Cancer Institute Biostatistics Shared Resources, Durham, North Carolina
| | - Yen P Lowder
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Sharareh Siamakpour-Reihani
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Sendhilnathan Ramalingam
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | | | - Jillian C Thompson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Lauren M Bohannon
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Jackie McIntyre
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Helen Tang
- Duke University School of Medicine, Durham, North Carolina
| | - Jolien Van Opstal
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina; Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Ernaya Johnson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Harvey Jay Cohen
- Claude D. Pepper Older Americans Independence Center, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina
| | - David B Bartlett
- Claude D. Pepper Older Americans Independence Center, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina; School of Biosciences and Medicine, University of Surrey, Surrey, United Kingdom
| | - Amy M Pastva
- Claude D. Pepper Older Americans Independence Center, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina; Department of Orthopedic Surgery, Division of Physical Therapy, Duke University Medical Center, Durham, North Carolina
| | - Miriam Morey
- Claude D. Pepper Older Americans Independence Center, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina; Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina
| | - Katherine S Hall
- Claude D. Pepper Older Americans Independence Center, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina; Geriatric Research, Education and Clinical Center, Durham VA Healthcare System, Durham, North Carolina
| | - Patrick Smith
- Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Katherine B Peters
- Departments of Neurology and Neurosurgery, The Preston Robert Tisch Brain Tumor Center, Duke University Medical Center, Durham, North Carolina
| | - Tamara J Somers
- Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Sarah Kelleher
- Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Sophia K Smith
- School of Nursing, Duke University Medical Center, Durham, North Carolina
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Pao-Hwa Lin
- Duke Molecular Physiology Institute, Duke University School of Medicine, Durham, North Carolina
| | - William A Wood
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Glynnis Thorpe
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Kerry Minor
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Kristi Wiggins
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Therese Hennig
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Tanya Helms
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Renee Welch
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Brittany Matthews
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - JoAnn Liu
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Jill Burleson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Thomas Aberant
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Ashley K Engemann
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Bethany Henshall
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Maurisa Darby
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Christina Proch
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Michelle Dellascio
- Duke Health Department of Physical Therapy and Occupational Therapy, Durham, North Carolina
| | - Alyssa Pittman
- Duke Health Department of Physical Therapy and Occupational Therapy, Durham, North Carolina
| | - Jacob Suminguit
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Taewoong Choi
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Cristina Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gwynn D Long
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richard D Lopez
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Stefanie Sarantopoulos
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina; Claude D. Pepper Older Americans Independence Center, Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina.
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8
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Hills JM, Weisenthal BM, Wanner JP, Gupta R, Steinle A, Pennings JS, Stephens BF. A Patient-specific Approach to Alignment and Proximal Junctional Kyphosis Risk Assessment in Adult Spinal Deformity Surgery: Development and Validation of a Predictive Tool. Clin Spine Surg 2022; 35:256-263. [PMID: 35034047 DOI: 10.1097/bsd.0000000000001296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a single-institution, retrospective cohort study. OBJECTIVE We aimed to develop a predictive model for proximal junctional kyphosis (PJK) severity that considers multiple preoperative variables and modifiable surgical alignment. SUMMARY OF BACKGROUND DATA PJK is a common complication following adult deformity surgery. Current alignment targets account for age and pelvic incidence but not other risk factors. MATERIALS AND METHODS This is a single-institution, retrospective cohort study of adult deformity patients with a minimum 2-year follow-up undergoing instrumented fusion between 2009 and 2018. A proportional odds regression model was fit to estimate PJK probability and Hart-International Spine Study Group (ISSG) PJK severity score. Predictors included preoperative Charlson Comorbidity Index, vertebral Hounsfield Units near the upper instrumented vertebrae, pelvic incidence, T1-pelvic angle, and postoperative L1-L4 and L4-S1 lordosis. Predictor effects were assessed using adjusted odds ratios and a nomogram constructed for estimating PJK probability. Bootstrap resampling was used for internal validation. RESULTS Of 145 patients, 47 (32%) developed PJK. The median PJK severity score was 6 (interquartile range, 4-7.5). After adjusting for predictors, Charlson Comorbidity Index, Hounsfield Units, preoperative T1-pelvic angle, and postoperative L1-L4 and L4-S1 lordosis were significantly associated with PJK severity ( P <0.05). After adjusting for potential overfitting, the model showed acceptable discrimination [ C -statistic (area under the curve)=0.75] and accuracy (Brier score=0.10). CONCLUSIONS We developed a model to predict PJK probability, adjusted for preoperative alignment, comorbidity burden, vertebral bone density, and modifiable postoperative L1-L4 and L4-S1 lordosis. This approach may help surgeons assess the patient-specific risk of developing PJK and provide a framework for future predictive models assessing PJK risk after adult deformity surgery. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jeffrey M Hills
- Department of Orthopedics, Washington University School of Medicine
| | | | | | - Rishabh Gupta
- Department of Orthopaedic Surgery
- Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
- University of Minnesota School of Medicine, Minneapolis, MN
| | - Anthony Steinle
- Department of Orthopaedic Surgery
- St. Louis University School of Medicine, St. Louis, MO
| | - Jacquelyn S Pennings
- Department of Orthopaedic Surgery
- Vanderbilt Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN
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9
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Outcomes of Autologous Hematopoietic Cell Transplantation in Older Patients with Diffuse Large B Cell Lymphoma. Transplant Cell Ther 2022; 28:487.e1-487.e7. [PMID: 35609865 PMCID: PMC9375438 DOI: 10.1016/j.jtct.2022.05.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/13/2022] [Accepted: 05/15/2022] [Indexed: 11/17/2022]
Abstract
Data for outcomes after autologous hematopoietic cell transplantation (auto-HCT) in diffuse large B-cell lymphoma (DLBCL) patients ≥70 years are limited. Auto-HCT is feasible in older DLBCL patients. Using the Center for International Blood and Marrow Transplant Research database, we compared outcomes of auto-HCT in DLBCL patients aged 60 to 69 years (n = 363) versus ≥70 years (n = 103) between 2008 and 2019. Non-relapse mortality (NRM), relapse/progression (REL), progression-free survival (PFS), and overall survival (OS) were modeled using Cox proportional hazards models. All patients received BEAM conditioning (carmustine, etoposide, cytosine arabinoside and melphalan). On univariate analysis, in the 60 to 69 years versus ≥70 years cohorts, 100-day NRM was 3% versus 4%, 5-year REL was 47% versus 45%, 5-year PFS 40% versus 38% and 5-year OS 55% versus 41%, respectively. On multivariate analysis, patients ≥70 had no significant difference in NRM (hazard ratio [HR] 1.43, 95% confidence interval [CI] 0.85-2.39), REL (HR 1.11, 95% CI 0.79-1.56), PFS (HR 1.23, 95% CI 0.92-1.63) compared to patients 60 to 69 years. Patients ≥70 years had a higher mortality (HR 1.39, 95% CI 1.05-1.85, p=0.02), likely because of inferior post-relapse OS in this cohort (HR 1.82, 95% CI 1.27-2.61, P = .001). DLBCL was the major cause of death in both cohorts (62% versus 59%). Older patients should not be denied auto-HCT solely on the basis of chronological age.
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10
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Deeg HJ. Not all patients with AML over 60 years of age should be offered early allogeneic stem cell transplantation. Blood Adv 2022; 6:1623-1627. [PMID: 34607346 PMCID: PMC8905709 DOI: 10.1182/bloodadvances.2021004799] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- H. Joachim Deeg
- Fred Hutchinson Cancer Research Center and the University of Washington School of Medicine, Seattle, WA
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11
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Gu YF, Lin FP, Epstein RJ. How aging of the global population is changing oncology. Ecancermedicalscience 2022; 15:ed119. [PMID: 35211208 PMCID: PMC8816510 DOI: 10.3332/ecancer.2021.ed119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
Population aging is causing a demographic redistribution with implications for the future of healthcare. How will this affect oncology? First, there will be an overall rise in cancer affecting older adults, even though age-specific cancer incidences continue to fall due to better prevention. Second, there will be a wider spectrum of health functionality in this expanding cohort of older adults, with differences between “physiologically older” and “physiologically younger” patients becoming more important for optimal treatment selection. Third, greater teamwork with supportive care, geriatric, mental health and rehabilitation experts will come to enrich oncologic decision-making by making it less formulaic than it is at present. Success in this transition to a more nuanced professional mindset will depend in part on the development of user-friendly computational tools that can integrate a complex mix of quantitative and qualitative inputs from evidence-based medicine, functional and cognitive assessments, and the personal priorities of older adults.
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Affiliation(s)
- Yan Fei Gu
- New Hope Cancer Center, United Family Hospitals, 9 Jiangtai W Rd, Chaoyang, Beijing 100015, China
| | - Frank P Lin
- Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney 2010, Australia.,NH&MRC Clinical Trials Centre, 92 Parramatta Rd, Camperdown, Sydney 2050, Australia
| | - Richard J Epstein
- New Hope Cancer Center, United Family Hospitals, 9 Jiangtai W Rd, Chaoyang, Beijing 100015, China.,Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney 2010, Australia.,UNSW Clinical School, St Vincent's Hospital, 390 Victoria St, Darlinghurst, Sydney 2010, Australia.,https://orcid.org/0000-0002-4640-0195
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12
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Pitfalls and Successes in Trials in Older Transplant Patients with Hematologic Malignancies. Curr Oncol Rep 2022; 24:125-133. [DOI: 10.1007/s11912-022-01194-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/03/2022]
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13
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Lin RJ, Artz AS. Allogeneic hematopoietic cell transplantation for older patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:254-263. [PMID: 34889392 PMCID: PMC8791130 DOI: 10.1182/hematology.2021000257] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Hematologic malignances are more common and often higher risk in older patients. Allogeneic hematopoietic cell transplantation (alloHCT) best enables long-term disease control for patients with poor risk or relapsed/refractory hematologic malignancies such as acute myeloid leukemia, myelodysplastic syndromes, or myelofibrosis. Rates of alloHCT among older patients, while still relatively low compared with younger patients, have risen sharply over the past decade. Accumulating evidence supports alloHCT for patients ≥60 years of age relative to non-HCT therapies based on improved overall and disease-free survival. However, a significant proportion of older adults have limitations characterized by geriatric assessment. A systematic process to evaluate and optimize older patients may improve decision making, transplant outcomes, and alloHCT access. We present case-based studies to illustrate a stepwise and rational approach to proper older patient evaluation, pretransplant optimization, and posttransplant care with attention to important geriatric issues and quality of life.
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Affiliation(s)
- Richard J Lin
- Memorial Sloan Kettering Cancer Center, New York, NY
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14
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Evolving Therapeutic Approaches for Older Patients with Acute Myeloid Leukemia in 2021. Cancers (Basel) 2021; 13:cancers13205075. [PMID: 34680226 PMCID: PMC8534216 DOI: 10.3390/cancers13205075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary The better understanding of disease biology, the availability of new effective drugs and the increased awareness of patients’ heterogeneity in terms of fitness and personal expectations has made the current treatment paradigm of AML in the elderly very challenging. Here, we discuss the evolving criteria used to define eligibility for induction chemotherapy and transplantation, the introduction of new agents in the treatment of patients with very different clinical conditions, the implications of precision medicine and the importance of quality of life and supportive care, proposing a simplified algorithm that we follow in 2021. Abstract Acute myeloid leukemia (AML) in older patients is characterized by unfavorable prognosis due to adverse disease features and a high rate of treatment-related complications. Classical therapeutic options range from intensive chemotherapy in fit patients, potentially followed by allogeneic hematopoietic cell transplantation (allo-HCT), to hypomethylating agents or palliative care alone for unfit/frail ones. In the era of precision medicine, the treatment paradigm of AML is rapidly changing. On the one hand, a plethora of new targeted drugs with good tolerability profiles are becoming available, offering the possibility to achieve a prolonged remission to many patients not otherwise eligible for more intensive therapies. On the other hand, better tools to assess patients’ fitness and improvements in the selection and management of those undergoing allo-HCT will hopefully reduce treatment-related mortality and complications. Importantly, a detailed genetic characterization of AML has become of paramount importance to choose the best therapeutic option in both intensively treated and unfit patients. Finally, improving supportive care and quality of life is of major importance in this age group, especially for the minority of patients that are still candidates for palliative care because of very poor clinical conditions or unwillingness to receive active treatments. In the present review, we discuss the evolving approaches in the treatment of older AML patients, which is becoming increasingly challenging following the advent of new effective drugs for a very heterogeneous and complex population.
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15
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Results from a multidisciplinary clinic guided by geriatric assessment before stem cell transplantation in older adults. Blood Adv 2020; 3:3488-3498. [PMID: 31725894 DOI: 10.1182/bloodadvances.2019000790] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/03/2019] [Indexed: 12/11/2022] Open
Abstract
Limitations found on geriatric assessment (GA) track with worse outcomes after hematopoietic cell transplantation (HCT). We report on a multidisciplinary team clinic (MDC), consisting of a cancer-specific GA and a multidisciplinary team of providers, to assess candidacy and create an individualized optimization plan for allogeneic HCT candidates aged ≥60 years and autologous HCT and adoptive T-cell therapy candidates aged ≥70 years. Among the 247 patients evaluated in the MDC, allogeneic HCT candidates comprised the majority (60%), followed by autologous HCT (37%) with occasional older cellular therapy candidates (3%). Almost all patients meeting program-required minimum ages for MDC optimization at our institution were assessed (98%). Relative to historical control subjects undergoing GA alone, allogeneic HCT patients aged ≥60 years who underwent MDC appraisal had similar frequencies of high-risk disease, reduced intensity regimens, and high comorbidity but fewer GA-graded functional impairments. The MDC cohort experienced fewer inpatient deaths, shorter length of stay, and fewer discharges to nursing facilities compared with control subjects. Improvements in early mortality were observed over time; 1-year overall survival improved from 43% in the pre-MDC era to 70% in the recent MDC era, and 1-year nonrelapse mortality decreased from 43% to 18%. The 31 autologous HCT recipients aged ≥70 years optimized by the MDC achieved 0% nonrelapse mortality and 97% overall survival at 1 year. A GA-guided MDC for older HCT candidates is feasible and seems to reduce transplant-associated morbidity and mortality. An MDC should encourage broader and safer utilization of transplantation in older patients.
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16
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Lin RJ, Michaud L, Lobaugh SM, Nakajima R, Mauguen A, Elko TA, Ruiz JD, Maloy MA, Sauter CS, Dahi PB, Perales MA, Shah GL, Flores NC, Sanchez-Escamilla M, Tomas AA, Segundo LYS, Cho C, Politikos I, Kim SJ, Korc-Grodzicki B, Devlin SM, Scordo M, Schöder H, Giralt SA, Hamlin PA. The geriatric syndrome of sarcopenia impacts allogeneic hematopoietic cell transplantation outcomes in older lymphoma patients. Leuk Lymphoma 2020; 61:1833-1841. [PMID: 32228298 PMCID: PMC7429343 DOI: 10.1080/10428194.2020.1742909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/04/2020] [Accepted: 03/08/2020] [Indexed: 01/06/2023]
Abstract
Older patients with advanced hematologic malignancies are increasingly considered for allogeneic hematopoietic cell transplantation (allo-HCT) yet their survival outcomes remain suboptimal. We and others have previously shown that pre-HCT multi-morbidity and functional limitation and post-HCT geriatric syndromes significantly impact outcomes. Sarcopenia, an accelerated loss of muscle mass and function, has been increasingly recognized in older cancer patients. We identified 146 lymphoma patients 50 years or older who were allografted from 2008 to 2018 at our institution and found that before allo-HCT, 80 (55%) patients were sarcopenic. Pre-HCT sarcopenia was significantly associated with overall survival, progression-free survival, and nonrelapse mortality independent of multi-morbidity and functional limitation. In 6-month landmark analysis, post-HCT sarcopenia remained significantly associated with survival. Our findings illustrate the high prevalence and profound impact of sarcopenia on survival. While requiring prospective confirmation, preemptive, longitudinal, and multidisciplinary interventions for sarcopenia are warranted to improve HCT outcomes for older patients.
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Affiliation(s)
- Richard J. Lin
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Laure Michaud
- Nuclear Medicine Service, Memorial Sloan Kettering Cancer Center
| | - Stephanie M. Lobaugh
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Reiko Nakajima
- Nuclear Medicine Service, Memorial Sloan Kettering Cancer Center
| | - Audrey Mauguen
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center
| | | | - Josel D. Ruiz
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
| | - Molly A. Maloy
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
| | - Craig S. Sauter
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Parastoo B. Dahi
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Miguel-Angel Perales
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Gunjan L. Shah
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | | | | | | | | | - Christina Cho
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Ioannis Politikos
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Soo Jung Kim
- Lymphoma Service, Memorial Sloan Kettering Cancer Center
| | | | - Sean M. Devlin
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Michael Scordo
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Heiko Schöder
- Weill Cornell Medical College
- Nuclear Medicine Service, Memorial Sloan Kettering Cancer Center
| | - Sergio A. Giralt
- Adult BMT Service, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Paul A. Hamlin
- Weill Cornell Medical College
- Lymphoma Service, Memorial Sloan Kettering Cancer Center
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17
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Polverelli N, Tura P, Battipaglia G, Malagola M, Bernardi S, Gandolfi L, Zollner T, Zanaglio C, Farina M, Morello E, Turra A, Mohty M, Russo D. Multidimensional geriatric assessment for elderly hematological patients (≥60 years) submitted to allogeneic stem cell transplantation. A French–Italian 10-year experience on 228 patients. Bone Marrow Transplant 2020; 55:2224-2233. [DOI: 10.1038/s41409-020-0934-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023]
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18
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Burden and impact of multifactorial geriatric syndromes in allogeneic hematopoietic cell transplantation for older adults. Blood Adv 2020; 3:12-20. [PMID: 30606722 DOI: 10.1182/bloodadvances.2018028241] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/02/2018] [Indexed: 11/20/2022] Open
Abstract
Multifactorial geriatric syndromes are highly prevalent in older patients with cancer. Because an increasing number of older patients undergo allogeneic hematopoietic stem cell transplantation (allo-HCT), we examined the incidence and impact of transplant-related geriatric syndromes using our institutional database and electronic medical records. We identified 527 patients age 60 years or older who had undergone first allo-HCT from 2001 to 2016 for hematologic malignancies. From the initiation of conditioning to 100 days posttransplant, new geriatric syndromes were predominantly delirium with a cumulative incidence of 21% (95% confidence interval [CI], 18%-25%) at day 100 followed by fall at 7% (95% CI, 5%-9%). In multivariable analyses of available pretransplant variables, fall within the last year, potentially inappropriate use of medication, thrombocytopenia, and reduced creatinine clearance were significantly associated with delirium; age older than 70 years and impaired activities of daily living were significantly associated with fall. In the 100-day landmark analysis, both delirium (hazard ratio [HR], 1.66; 95% CI, 1.09-2.52; P = .023) and fall (HR, 2.14; 95% CI, 1.16-3.95; P = .026) were significantly associated with increased nonrelapse mortality; moreover, fall (HR, 1.93; 95% CI, 1.18-3.14; P = .016), but not delirium, was significantly associated with reduced overall survival. Here, we establish baseline incidences and risk factors of common transplant-related geriatric syndromes. Importantly, we demonstrate significant associations of delirium and fall with inferior transplant outcomes. The burden and impact of transplant-related geriatric syndromes warrant the institution of patient-centered, preemptive, longitudinal, and multidisciplinary interventions to improve outcomes for older allo-HCT patients.
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19
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Unmanipulated haploidentical hematopoietic stem cell transplantation using very low-dose antithymocyte globulin and methylprednisolone in adults with relapsed/refractory acute leukemia. Ann Hematol 2019; 99:147-155. [PMID: 31786646 DOI: 10.1007/s00277-019-03865-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) could be the only curative therapy for patients with relapsed/refractory acute leukemia (RRAL). Many reports have described unmanipulated haploidentical HSCT (HID-HSCT) using high-dose antithymocyte globulin (ATG). However, the transplant outcomes of HID-HSCT using very low-dose ATG (thymoglobulin, 2-2.5 mg/kg) and methylprednisolone (mPSL, 1 mg/kg) for patients with RRAL have not been reported. We compared the outcomes of 46 patients with RRAL who underwent HID-HSCT using very low-dose ATG (thymoglobulin) and mPSL with the outcomes of 72 patients who underwent non-HID-HSCT. Patient characteristics differed regarding conditioning intensity (myeloablative; 19.6% in HID-HSCT vs. 61.1% in non-HID-HSCT, P < 0.001) and having undergone multiple HSCT (26.1% vs. 11.1%, P = 0.045). However, we found no significant differences in the 1-year overall survival (OS, 31.7% vs. 29.1%; P = 0.25), disease-free survival (DFS, 20.5% vs. 23.7%; P = 0.23), cumulative incidence of relapse (CIR, 40.0% vs. 42.8%; P = 0.92), non-relapse mortality (NRM, 39.5% vs. 33.5%; P = 0.22), or 100-day grade II-IV acute graft-versus-host disease (32.6% vs. 34.7%; P = 0.64) following HID-HSCT vs. non-HID-HSCT, respectively. Subgroup analysis stratified by disease and intensity of conditioning regimen demonstrated the same results between HID-HSCT and non-HID-HSCT. Furthermore, multivariate analysis showed that HID-HSCT was not an independent prognostic factor for OS (hazard ratio (HR) = 0.95 [95% confidence interval (CI), 0.58-1.58]), DFS (HR = 1.05 [95%CI, 0.67-1.68]), CIR (HR = 0.84 [95%CI, 0.48-1.47]), or NRM (HR = 1.28 [95%CI, 0.66-2.46]). In summary, transplant outcomes for RRAL were comparable in the HID-HSCT and non-HID-HSCT groups. HID-HSCT using very low-dose ATG and mPSL for RRAL may be a viable alternative to non-HID-HSCT.
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20
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Impact of geriatric vulnerabilities on allogeneic hematopoietic cell transplantation outcomes in older patients with hematologic malignancies. Bone Marrow Transplant 2019; 55:157-164. [PMID: 31471572 DOI: 10.1038/s41409-019-0654-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 02/04/2023]
Abstract
Older patients are at increased risk for complications and death following allogeneic hematopoietic cell transplantation (allo-HCT). Traditional transplant-specific prognostic indices such as hematopoietic cell transplant comorbidity index (HCT-CI) may not capture all underlying geriatric vulnerabilities, and in-depth evaluation by a geriatrician prior to transplant may not always be available. We hypothesize that routine pretransplant interdisciplinary clinical assessment may uncover prognostically important geriatric deficits. Using an institutional database of 457 adults aged 60 years and older who underwent first allo-HCT for hematological malignancies from 2010 to 2017, we examined the prognostic impact of pretransplant deficits in geriatric domains of function, mobility, mood, medication, nutrition, and relevant biochemical markers. We found that impairment in instrumental activities of daily living (IADL) was associated with reduced survival through increased nonrelapse mortality (NRM, HR = 1.82; 95% CI, 1.04-3.19). The combination of IADL impairment with either HCT-CI/age index or disease risk index readily stratified NRM and overall survival, respectively. In addition, we found that even mild renal dysfunction adversely impacted survival in older transplant patients. Our findings establish important geriatric vulnerabilities in older patients prior to allo-HCT and may provide an entry point for prospective, interventional trials to improve their outcomes.
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21
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Lin RJ, Dahi PB, Shahrokni A, Sarraf S, Korc-Grodzicki B, Devlin SM, Maloy MA, Shah GL, Jakubowski AA, Giralt SA. Feasibility of a patient-reported, electronic geriatric assessment tool in hematopoietic cell transplantation - a single institution pilot study. Leuk Lymphoma 2019; 60:3308-3311. [PMID: 31226901 DOI: 10.1080/10428194.2019.1630621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Richard J Lin
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA
| | - Parastoo B Dahi
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Armin Shahrokni
- Geriatrics Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Saman Sarraf
- Geriatrics Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA
| | - Beatriz Korc-Grodzicki
- Geriatrics Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Sean M Devlin
- Department of Biostatistics and Epidemiology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Molly A Maloy
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Ann A Jakubowski
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, Medicine, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College, New York, NY, USA
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22
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Nawas MT, Andreadis C, Martin TG, Wolf JL, Ai WZ, Kaplan LD, Mannis GN, Logan AC, Damon LE, Huang CY, Olin RL. Limitation in Patient-Reported Function Is Associated with Inferior Survival in Older Adults Undergoing Autologous Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1218-1224. [DOI: 10.1016/j.bbmt.2019.01.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 01/15/2019] [Indexed: 11/29/2022]
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23
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Rice C, Eikema DJ, Marsh JCW, Knol C, Hebert K, Putter H, Peterson E, Deeg HJ, Halkes S, Pidala J, Anderlini P, Tischer J, Kroger N, McDonald A, Antin JH, Schaap NP, Hallek M, Einsele H, Mathews V, Kapoor N, Boelens JJ, Mufti GJ, Potter V, Pefault de la Tour R, Eapen M, Dufour C. Allogeneic Hematopoietic Cell Transplantation in Patients Aged 50Years or Older with Severe Aplastic Anemia. Biol Blood Marrow Transplant 2019; 25:488-495. [PMID: 30194027 PMCID: PMC6401340 DOI: 10.1016/j.bbmt.2018.08.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 08/26/2018] [Indexed: 01/30/2023]
Abstract
We report on 499 patients with severe aplastic anemia aged ≥ 50years who underwent hematopoietic cell transplantation (HCT) from HLA-matched sibling (n = 275, 55%) or HLA-matched (8/8) unrelated donors (n = 187, 37%) between 2005 and 2016. The median age at HCT was 57.8 years; 16% of patients were 65 to 77years old. Multivariable analysis confirmed higher mortality risks for patients with performance score less than 90% (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.03 to 1.92; P = .03) and after unrelated donor transplantation (HR, 1.47; 95% CI, 1 to 2.16; P = .05). The 3-year probabilities of survival for patients with performance scores of 90 to 100 and less than 90 after HLA-matched sibling transplant were 66% (range, 57% to 75%) and 57% (range, 47% to 76%), respectively. The corresponding probabilities after HLA-matched unrelated donor transplantation were 57% (range, 48% to 67%) and 48% (range, 36% to 59%). Age at transplantation was not associated with survival, but grades II to IV acute graft-versus-host disease (GVHD) risks were higher for patients aged 65years or older (subdistribution HR [sHR], 1.7; 95% confidence interval, 1.07 to 2.72; P = .026). Chronic GVHD was lower with the GVHD prophylaxis regimens calcineurin inhibitor (CNI) + methotrexate (sHR, .52; 95% CI, .33 to .81; P = .004) and CNI alone or with other agents (sHR, .27; 95% CI, .14 to .53; P < .001) compared with CNI + mycophenolate. Although donor availability is modifiable only to a limited extent, choice of GVHD prophylaxis and selection of patients with good performance scores are key for improved outcomes.
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Affiliation(s)
- Carmel Rice
- Department of Haematology, King's College Hospital, London, United Kingdom
| | | | - Judith C W Marsh
- Department of Haematology, King's College Hospital, London, United Kingdom; Department of Haematology, King's College London, London, United Kingdom.
| | - Cora Knol
- EBMT Data Office, Leiden, Netherlands
| | - Kyle Hebert
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Stijn Halkes
- Leiden University Medical Centre, Leiden, Netherlands
| | | | | | | | | | - Andrew McDonald
- Albert Stem Cell Transplantation Centre, Pretoria Gauteng, South Africa
| | | | | | | | | | | | - Neena Kapoor
- Children's Hospital of Los Angeles, Los Angeles, California
| | | | - Ghulam J Mufti
- Department of Haematology, King's College Hospital, London, United Kingdom; Department of Haematology, King's College London, London, United Kingdom
| | - Victoria Potter
- Department of Haematology, King's College Hospital, London, United Kingdom
| | | | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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24
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Kennedy VE, Muffly LS. Assessment of older adult candidates for allogeneic hematopoietic cell transplantation: updates and remaining questions. Expert Rev Hematol 2019; 12:99-106. [DOI: 10.1080/17474086.2019.1568236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Vanessa E. Kennedy
- Department of Internal Medicine, Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Lori S. Muffly
- Department of Internal Medicine, Division of Blood and Marrow Transplantation, Stanford University School of Medicine, Stanford, CA, USA
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25
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Bhalla S, Dubey GK, Basu S, Kanangat S, Dobrescu C, Nath DS. Description and analysis of patients and outcomes following third-time heart transplantation: An analysis of the United Network for Organ Sharing database from 1985 to 2017. Clin Transplant 2019; 33:e13482. [PMID: 30659652 DOI: 10.1111/ctr.13482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/26/2018] [Accepted: 01/13/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Following second heart transplantation (HTx), some patients experience graft failure and require third-time heart transplantation. Little data exist to guide decision-making with regard to repeat retransplantation in older patients. METHODS We performed a retrospective cohort analysis of patients receiving a third HTx, as identified in the United Network for Organ Sharing (UNOS) database from 1985 to 2017. RESULTS The study cohort consisted of N = 60 patients, with an average age of 29 with a standard deviation of ±18 years. Overall survival for the cohort at 1, 5, and 10 years is 83%, 64%, and 44%, respectively. The rate of third-time HTxs has steadily increased in all age groups. Patients older than 50 years now account for 18.3% of all third-time HTxs. Although this group demonstrated longer average previous graft survival, after third HTx they demonstrate significantly poorer survival outcomes compared to third-time HTx recipients younger than 21 (P = 0.05). Age over 50, BMI over 30, and diabetes were all found to be independent risk factors for decreased survival following third HTx. CONCLUSIONS We describe trends in patients undergoing third HTx. We highlight subsets of such recipients who exhibit decreased survival.
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Affiliation(s)
| | - Gaurav K Dubey
- Department of Cardiovascular and Thoracic Surgery, Rush Medical Center, Chicago, Illinois
| | - Sanjib Basu
- Department of Preventative Medicine, Rush University, Chicago, Illinois
| | | | - Cosmin Dobrescu
- Department of Cardiovascular and Thoracic Surgery, Rush Medical Center, Chicago, Illinois
| | - Dilip S Nath
- Department of Cardiovascular and Thoracic Surgery, Rush Medical Center, Chicago, Illinois
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26
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Lipof JJ, Loh KP, O'Dwyer K, Liesveld JL. Allogeneic Hematopoietic Cell Transplantation for Older Adults with Acute Myeloid Leukemia. Cancers (Basel) 2018; 10:cancers10060179. [PMID: 29866998 PMCID: PMC6025016 DOI: 10.3390/cancers10060179] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 05/30/2018] [Accepted: 06/01/2018] [Indexed: 12/17/2022] Open
Abstract
Acute myeloid leukemia (AML) is a disease that affects adults aged 65 years and above, and survival in this population is poor. Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative therapy for these patients but is underutilized due to frequent comorbidities and perceived higher risk of treatment-related mortality and non-relapse mortality. Increasing data supports the utility of allo-HCT in fit older patients after intensive chemotherapy resulting in improvement of outcomes. With the development of reduced intensity and non-myeloablative conditioning regimens that are associated with lower rates of treatment-related toxicity and mortality, this has allowed more older patients with AML to receive allo-HCT. In this review, we provide some guidance on appropriate selection of older patients as transplant candidates, benefits and risks associated with allo-HCT, conditioning regimen choice, and stem cell transplant sources as they relate to the conduct of stem cell transplantation in older patients.
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Affiliation(s)
- Jodi J Lipof
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, 601 Elmwood Avenue, P.O. Box 704, Rochester, NY 14642, USA.
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, 601 Elmwood Avenue, P.O. Box 704, Rochester, NY 14642, USA.
| | - Kristen O'Dwyer
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, 601 Elmwood Avenue, P.O. Box 704, Rochester, NY 14642, USA.
| | - Jane L Liesveld
- James P. Wilmot Cancer Institute, University of Rochester Medical Center, 601 Elmwood Avenue, P.O. Box 704, Rochester, NY 14642, USA.
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27
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Liu H, Zhang CL, Feng R, Li JT, Tian Y, Wang T. Validation and Refinement of the Age, Comorbidities, and Albumin Index in Elderly Patients with Diffuse Large B-Cell Lymphoma: An Effective Tool for Comprehensive Geriatric Assessment. Oncologist 2018; 23:722-729. [PMID: 29317552 PMCID: PMC6067934 DOI: 10.1634/theoncologist.2017-0361] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 11/07/2017] [Indexed: 01/22/2023] Open
Abstract
Diffuse large B‐cell lymphoma (DLBCL) is one of the most frequent types of malignant lymphoma in elderly people; thus, the management of elderly DLBCL patients is important. This study aimed to validate the ACA index in Chinese elderly DLBCL patients and to refine the ACA index to propose a more effective comprehensive geriatric assessment method that could serve as a guide for optimal personalized therapy for elderly DLBCL patients treated with R‐CHOP. Background. We aimed to validate and refine the Age, Comorbidities, and Albumin (ACA) index in elderly Chinese patients with diffuse large B‐cell lymphoma (DLBCL) and propose a more effective method for comprehensive geriatric assessment (CGA). Materials and Methods. Patients ≥65 years of age who had been diagnosed with de novo DLBCL in the Institute of Hematology, Beijing Hospital, were screened for eligibility (n = 99). Results. Based on the ACA index, 39, 31, 26, and 3 patients were categorized into the “excellent,” “good,” “moderate,” and “poor” groups, respectively. The 2‐year treatment‐related mortality rate was significantly higher and the survival rates poorer in the ACA “moderate to poor” group compared with those of the ACA “good” and “excellent” groups. Multivariable model analysis identified two independent predictors of overall survival: the instrumental activities of daily living (IADL) scale and the ACA index. IADL scores of 6 to 7 and the ACA “good” group were assigned 1 point; IADL scores ≤5 and the ACA “moderate to poor” group were assigned 2 points. Based on these data, we created a three‐category system (IADL ACA index [IACA index]): low risk, score 0; intermediate risk, score 1 to 2; and high risk, score 3 to 4. The IACA index could effectively discriminate the response rates, overall survival, and progression‐free survival rates in elderly patients with DLBCL. Conclusion. We observed that the ACA index could partially predict the clinical outcomes of elderly DLBCL patients in China. Based on this index, we proposed the IACA index as an effective tool for CGA in DLBCL. Implications for Practice. Diffuse large B‐cell lymphoma (DLBCL) is one of the most frequent types of malignant lymphoma in elderly people, and identifying patients suitable for curative therapy is critical in the improvement of clinical outcomes. Recently, some authors proposed the Age, Comorbidities, and Albumin (ACA) index. Combining the use of the instrumental activities of daily living (IADL) scale and the ACA index, this article describes the IADL ACA index (IACA index), which is an effective tool for comprehensive geriatric assessment in DLBCL.
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Affiliation(s)
- Hui Liu
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Chun-Li Zhang
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Ru Feng
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Jiang-Tao Li
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Yuan Tian
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
| | - Ting Wang
- Department of Hematology, Beijing Hospital, National Center of Gerontology, Beijing, People's Republic of China
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28
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Sun L, Li S, El-Jawahri A, Armand P, Dey BR, Fisher DC, Jacobsen ED, Jacobson CA, LaCasce AS, McAfee SL, Spitzer TR, Chen YB, DeFilipp Z. Autologous Stem Cell Transplantation in Elderly Lymphoma Patients in Their 70s: Outcomes and Analysis. Oncologist 2017; 23:624-630. [PMID: 29284757 DOI: 10.1634/theoncologist.2017-0499] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 11/14/2017] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND High-dose chemotherapy and autologous stem cell transplantation (ASCT) can offer durable remission in many patients with relapsed or high-risk lymphoma. However, elderly patients are often not considered ASCT candidates based on age alone. SUBJECTS, MATERIALS, AND METHODS A retrospective analysis of patients ≥70 years of age with a diagnosis of Hodgkin or non-Hodgkin lymphoma receiving ASCT between 2000 and 2016 at two partner institutions was performed. Clinical data were extracted from institutional databases and individual medical records. Multivariate analysis was performed to examine the association of clinical variables with transplant outcomes. RESULTS One hundred seven patients were identified. Median age at transplant was 72 years (range, 70-79). The most common lymphoma subtype was diffuse large B-cell (n = 63, 59%). Median time to neutrophil and platelet engraftment were 10 and 12 days, respectively. With a median follow-up for survivors of 20 months following ASCT (range, 6 months to 13.1 years), estimates for 2-year progression-free survival and overall survival were 58% (95% confidence interval [CI], 48%-67%) and 65% (95% CI, 55%-74%), respectively. Two-year estimate for relapse was 34% (95% CI, 25%-44%) and nonrelapse mortality (NRM) was 7% (95% CI, 3%-14%). Multivariate analysis showed that more recent date of transplant was associated with lower NRM. The Hematopoietic Cell Transplantation-Comorbidity Index score was not predictive of NRM in this data set (high-risk vs. low-risk, hazard ratio 3.45, p = .065). CONCLUSION Eligibility for ASCT should be an individualized decision, and age should not be an absolute contraindication to ASCT in healthy elderly patients with lymphoma. IMPLICATIONS FOR PRACTICE Although high-dose chemotherapy and autologous stem cell transplantation (ASCT) can offer durable remission in many patients with relapsed or high-risk lymphoma, elderly patients are often not considered candidates due to concern for excess toxicity and mortality. This retrospective study showed favorable transplant outcomes, including survival and toxicity, in a large cohort of lymphoma patients over 70 years of age who underwent ASCT. Eligibility for ASCT should be an individualized decision, and age should not be an absolute contraindication to ASCT in healthy elderly patients with lymphoma.
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Affiliation(s)
- Lova Sun
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shuli Li
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Areej El-Jawahri
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Philippe Armand
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Bimalangshu R Dey
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David C Fisher
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Eric D Jacobsen
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Caron A Jacobson
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Ann S LaCasce
- Division of Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Steven L McAfee
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thomas R Spitzer
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yi-Bin Chen
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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29
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Haploidentical Hematopoietic Cell Transplant with Post-Transplant Cyclophosphamide and Peripheral Blood Stem Cell Grafts in Older Adults with Acute Myeloid Leukemia or Myelodysplastic Syndrome. Biol Blood Marrow Transplant 2017; 23:1736-1743. [PMID: 28688919 DOI: 10.1016/j.bbmt.2017.06.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 06/26/2017] [Indexed: 12/31/2022]
Abstract
Many hematologic malignancies are diseases of aging, and the use of hematopoietic cell transplant (HCT) is growing rapidly among older adults. Modern post-transplant cyclophosphamide (PTCy) protocols with haploidentical (haplo) donors have dramatically expanded the donor pool for patients requiring HCT. Initial studies were performed with bone marrow grafts, which require the donor to undergo anesthesia during harvest. However, the use of mobilized peripheral blood stem cells (PBSCs) may be desirable, especially with older donors. However, data on PBSC haplo-HCT in older adults are lacking. To characterize the impact of age on outcomes in haplo-HCT, we identified all adult patients undergoing haplo-HCT with PTCy for acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) at our institution from January 2009 to June 2016. Patients were grouped into 3 cohorts: Age 1 (≤55), Age 2 (55 to 65), and Age 3 (≥65). To characterize the impact of donor type on outcomes in older patients, we identified age- and disease risk index (DRI)-matched patient age ≥ 65 undergoing HLA-matched unrelated donor (MUD) HCT for AML or MDS during the same time frame. Patients were scored for disease risk and underlying comorbidities using the DRI and HCT-specific comorbidity index. Overall survival (OS) was analyzed using 3 different Cox proportional hazards models. We identified 112 haplo-HCT patients, 95 with AML and 17 with MDS. There were 61 patients in Age 1, 29 patients in Age 2, and 22 in Age 3. Median OS was 448, 397, and 147 days in Age 1, Age 2, and Age 3 patients (log-rank, P = .04). After adjusting for other risk factors, age ≥ 65 was associated with significantly worse OS after haplo-HCT (aHR, 2.16; 95% CI, 1.15 to 4.07). There was a trend toward increased relapse among older patients at 2 years (56%; 95% CI, 32% to 79%) versus Age 1 (41%; 95% CI, 28% to 54%) and Age 2 (31%; 95% CI, 12% to 50%) (P = .08). Among patients age ≥ 65, donor type (MUD versus haplo) did not impact OS (aHR, 1.03; 95% CI, .56 to 1.88) after adjusting for other risk factors. Prior allo-HCT (aHR, 4.95; 95% CI, 1.82 to 13.49) and myeloablative conditioning (aHR, 1.97; 95% CI, 1.04 to 3.73) were associated with inferior survival. Although age ≥ 65 was associated with inferior OS in our haplo-HCT cohort, no difference was seen in survival between MUD and haplo-HCT. Therefore, the use of haploidentical donors in older patients is a reasonable treatment option, especially if there is concern for clinical deterioration. A careful pretransplant evaluation and analysis of risks and benefits is warranted when offering this transplant modality to older adults, especially in patients with previous transplant or poor performance status. Strategies to reduce the risk of relapse and decrease nonrelapse mortality in older adults are areas of ongoing research, and prospective studies are needed.
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30
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Patterns of Care and Survival for Elderly Acute Myeloid Leukemia—Challenges and Opportunities. Curr Hematol Malig Rep 2017; 12:290-299. [DOI: 10.1007/s11899-017-0388-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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