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Lin RJ, Dahi PB, Korc-Grodzicki B, Shahrokni A, Jakubowski AA, Giralt SA. Transplantation and Cellular Therapy for Older Adults-The MSK Approach. Curr Hematol Malig Rep 2024; 19:82-91. [PMID: 38332462 PMCID: PMC11126330 DOI: 10.1007/s11899-024-00725-y] [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] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE OF REVIEW Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers. RECENT FINDINGS Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.
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Affiliation(s)
- Richard J Lin
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- David H. Koch Center for Cancer Care, Memorial Sloan Kettering Cancer Center, 530 E 74th Street, Room 21-142, New York, NY, 10022, USA.
| | - Parastoo B Dahi
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Ann A Jakubowski
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sergio A Giralt
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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2
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Jin F, Tian W, Xia L, Yang M, Chen Y, Li J, Liu L. Knowledge, attitude, and practice toward leukemia in the general population and among family members of patients with leukemia: A cross-sectional study. Heliyon 2024; 10:e26276. [PMID: 38439856 PMCID: PMC10909635 DOI: 10.1016/j.heliyon.2024.e26276] [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: 09/25/2023] [Revised: 01/17/2024] [Accepted: 02/09/2024] [Indexed: 03/06/2024] Open
Abstract
Background Patients with leukemia rely on social and family support. This study aimed to explore the knowledge, attitude, and practice (KAP) toward leukemia among family members of patients with leukemia and the general population in southeast China. Methods A cross-sectional study was conducted in September 2022 in southeast China (Anhui Province). The KAP scores and demographic data were assessed by questionnaire and analyzed by multivariable logistic regression and structural equation modeling. Results A total of 760 valid questionnaires were collected, including 117 (15.39%) answered by family members of patients with leukemia. The mean knowledge (8.30 ± 2.79 vs. 8.72 ± 2.56, P = 0.103), attitude (52.17 ± 5.52 vs. 52.27 ± 5.53, P = 0.862), and practice (8.06 ± 2.00 vs. 8.18 ± 2.05, P = 0.547) scores were comparable among family members and the general population. Higher knowledge scores [OR = 1.18 (1.10, 1.27), P < 0.001] and higher attitude scores [OR = 1.05 (1.02, 1.09), P = 0.002] were independently associated with better practice scores. Being a family member of a patient with leukemia had no significant effect on the KAP scores. Conclusion The participants demonstrated satisfactory knowledge, positive attitude, and appropriate practices toward leukemia, suggesting that access to information about leukemia to the general public might be sufficient in China. Health education might effectively improve knowledge, which could translate into improved attitude and practice.
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Affiliation(s)
- Fengbo Jin
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
| | - Wanlu Tian
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
| | - Leiming Xia
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
| | - Mingzhen Yang
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
| | - Yingying Chen
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
| | - Jianjun Li
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
| | - Lixia Liu
- Department of Hematology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China
- Department of Hematology, Anhui Public Health Clinical Center, Hefei, 230011, China
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3
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Wall SA, Olin R, Bhatt V, Chhabra S, Munshi P, Hacker E, Hashmi S, Hassel H, Howard D, Jayani R, Lin R, McCurdy S, Mishra A, Murthy H, Popat U, Wood W, Rosko AE, Artz A. The Transplantation Ecosystem: A New Concept to Improve Access and Outcomes for Older Allogeneic Hematopoietic Cell Transplantation Patients. Transplant Cell Ther 2023; 29:632.e1-632.e10. [PMID: 37137442 DOI: 10.1016/j.jtct.2023.04.020] [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: 02/16/2023] [Revised: 04/24/2023] [Accepted: 04/26/2023] [Indexed: 05/05/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is increasingly offered to older adults with hematologic malignancies, even though nonrelapse mortality remains a major concern in older patients owing to more comorbidities and greater frailty compared with their younger counterparts. The importance of patient fitness, a well-matched donor, and disease control to the success of allogeneic HCT have been well documented; however, these factors fail to account for the impact of the complex transplantation ecosystem (TE) that older adult HCT candidates must navigate. We propose a definition of the TE modeled after the social determinants of health. Furthermore, we outline a research agenda aimed at increasing understanding of the roles of individual social determinants of transplantation health in the larger ecosystem and how they may benefit or harm older adult HCT candidates. Herein we define the TE and its individual tenets, the social determinants of transplantation health. We review the available literature while incorporating the expertise of the membership of the American Society for Transplantation and Cellular Therapy (ASTCT) Special Interest Group for Aging. The membership of the ASTCT Special Interest Group for Aging identify knowledge gaps and strategies to address them for each of the described social determinants of transplantation health. The ecosystem is an essential but underappreciated pillar for transplant access and success. We put forth this novel research agenda seeking to gain a better understanding of the complexity of HCT in older adults and develop strategies to improve access to HCT, survival, and quality of life.
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Affiliation(s)
- Sarah A Wall
- Division of Hematology, Ohio State University, Columbus, OH.
| | - Rebecca Olin
- Division of Hematology & Oncology, University of California San Francisco, San Francisco, CA
| | - Vijaya Bhatt
- Division of Hematology & Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Saurabh Chhabra
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Pashna Munshi
- Division of Oncology, Georgetown University Medical Center, Washington, DC
| | - Eileen Hacker
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shahrukh Hashmi
- Division of Hematology, Mayo Clinic Minnesota, Rochester, MN
| | - Hailey Hassel
- National Marrow Donor Program/Be The Match, Minneapolis, MN
| | - Dianna Howard
- Division of Hematology & Oncology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Reena Jayani
- Division of Hematology & Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Richard Lin
- Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Shannon McCurdy
- Division of Hematology & Oncology, University of Pennsylvania, Philadelphia, PA
| | - Asmita Mishra
- Department of Malignant Hematology, Moffitt Cancer Center, Tampa, FL
| | - Hemant Murthy
- Division of Hematology & Oncology, Mayo Clinic, Jacksonville, FL
| | - Uday Popat
- Department of Nursing, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William Wood
- Division of Hematology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ashley E Rosko
- Division of Hematology, Ohio State University, Columbus, OH
| | - Andrew Artz
- Division of Hematology & Hematopoietic Cell Transplantation, City of Hope Comprehensive Cancer Center, Duarte, CA
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4
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Juckett M, Dandoy C, DeFilipp Z, Kindwall-Keller TL, Spellman SR, Ustun C, Waldman BM, Weisdorf DJ, Wood WA, Horowitz MM, Burns LJ, Khera N. How do we improve the translation of new evidence into the practice of hematopoietic cell transplantation and cellular therapy? Blood Rev 2023; 60:101079. [PMID: 37087394 PMCID: PMC10330269 DOI: 10.1016/j.blre.2023.101079] [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: 01/05/2023] [Revised: 04/05/2023] [Accepted: 04/06/2023] [Indexed: 04/24/2023]
Abstract
The field of hematopoietic cell transplantation and cell therapy (HCT/CT) is advancing rapidly to bring an ever-expanding collection of potentially curative therapies to patients with malignant and non-malignant diseases. The impact of these therapies depends on our ability to implement them as new evidence becomes available to advance the quality of care. There is often a long delay between evidence development and adoption of therapies based on that evidence into clinical practice. In this review, we describe the potential factors based on an implementation framework that could act as facilitators or barriers to adoption of therapies in the context of HCT/CT. We highlight two examples, the first to showcase the efforts to improve the efficiency of adoption of new findings and accelerate improvement in care of HCT/CT patients and the second to discuss the challenges in real world implementation of chimeric antigen receptor T cell therapy. We conclude by reviewing strategies to improve translation of evidence and ways to measure their success.
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Affiliation(s)
- Mark Juckett
- University of Minnesota, Minneapolis, MN, United States of America
| | - Christopher Dandoy
- University of Cincinnati College of Medicine, Cincinnati, OH, United States of America
| | | | | | - Stephen R Spellman
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, United States of America
| | - Celalettin Ustun
- Rush University Medical Center, Chicago, IL, United States of America
| | - Bryce M Waldman
- Center for International Blood and Marrow Transplant, Milwaukee, WI, United States of America
| | | | - William A Wood
- University of North Carolina, Chapel Hill, NC, United States of America
| | - Mary M Horowitz
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, United States of America; Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Linda J Burns
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Milwaukee, WI, United States of America
| | - Nandita Khera
- College of Medicine, Mayo Clinic, Phoenix, AZ, United States of America.
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5
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Yusuf RA, Preussler JM, Meyer CL, Schoeppner K, Sees Coles JA, Ruffin A, McCann M, Devine SM, Auletta JJ. Reducing barriers of access and care related to hematopoietic cell transplantation and cellular therapy: The mission-driven role of the national marrow donor program. Best Pract Res Clin Haematol 2023; 36:101480. [PMID: 37353289 DOI: 10.1016/j.beha.2023.101480] [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: 05/20/2023] [Accepted: 05/23/2023] [Indexed: 06/25/2023]
Abstract
The treatment of malignant and nonmalignant hematologic disorders continues to benefit from significant scientific advancement and progress in the use of hematopoietic cell transplantation and cellular therapies. However, barriers associated with receiving these lifesaving treatments and care remain, which necessitate innovative approaches to overcome, so all persons in need can receive these therapies. This article reviews barriers to receiving hematopoietic cell transplantation and cellular therapies, and highlights novel approaches taken by the National Marrow Donor Program in reducing barriers for all patients in need.
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Affiliation(s)
- Rafeek A Yusuf
- National Marrow Donor Program, Minneapolis, MN, USA; Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA.
| | - Jaime M Preussler
- National Marrow Donor Program, Minneapolis, MN, USA; Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA.
| | - Christa L Meyer
- National Marrow Donor Program, Minneapolis, MN, USA; Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA.
| | | | | | - Amber Ruffin
- National Marrow Donor Program, Minneapolis, MN, USA.
| | - Meggan McCann
- National Marrow Donor Program, Minneapolis, MN, USA.
| | - Steven M Devine
- National Marrow Donor Program, Minneapolis, MN, USA; Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA.
| | - Jeffery J Auletta
- National Marrow Donor Program, Minneapolis, MN, USA; Center for International Blood and Marrow Transplant Research, Minneapolis, MN, USA.
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Hoffmann MS, Hunter BD, Cobb PW, Varela JC, Munoz J. Overcoming Barriers to Referral for Chimeric Antigen Receptor T-Cell Therapy in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma. Transplant Cell Ther 2023:S2666-6367(23)01234-4. [PMID: 37031747 DOI: 10.1016/j.jtct.2023.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/18/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin lymphoma. Although outcomes to frontline therapy are encouraging, patients who are refractory to or relapse after first-line therapy experience inferior outcomes. A significant proportion of patients treated with additional lines of cytotoxic chemotherapy ultimately succumb to their disease as established in the SCHOLAR-1 study. CHIMERIC ANTIGEN RECEPTOR (CAR)-T CELL THERAPY CAR-T cell therapy is a novel approach to cancer management that reprograms a patient's own T cells to better target and eliminate cancer cells. It was initially approved by the US Food and Drug Administration (FDA) for patients with relapsed/refractory (r/r) DLBCL in the third line of treatment. Based on recently published randomized data, CAR-T cell therapy (axicabtagene ciloleucel and lisocabtagene maraleucel) has also been approved in the second line of treatment for patients who are primary refractory or relapse within 12 months of initiation of first-line therapy. Despite the proven efficacy in treating r/r DLBCL with cluster of differentiation (CD)19-directed CAR-T cell therapy, several barriers exist that may prevent eligible patients from receiving treatment. KEY BARRIERS TO CAR-T CELL TREATMENT Barriers to treatment include cost of therapy, patient hesitancy, required travel to academic treatment centers, nonreferrals, lack of understanding of CAR-T cell therapy, lack of caregiver support, knowledge of resources available, and timely patient selection by referring oncologists. CONCLUSION In this review, an overview of the FDA-approved CD19-directed CAR-T cell therapies (tisagenlecleucel, axicabtagene ciloleucel, and lisocabtagene maraleucel) is provided from pivotal clinical trials and supporting real-world evidence from retrospective studies. In both clinical trials and real-world settings CAR-T cell therapy has been shown to be safe and efficacious for treating patients with r/r DLBCL. However, several barriers prevent eligible patients from accessing these therapies. Barriers to referrals for CAR-T cell therapy are presented with recommendations to improve collaboration between community oncologists and physicians from CAR-T cell therapy treatment centers and subsequent long-term care of patients in community treatment centers.
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Affiliation(s)
- Marc S Hoffmann
- University of Kansas Cancer Center, Division of Hematologic Malignancies and Cellular Therapeutics, Westwood, KS
| | - Bradley D Hunter
- Blood and Marrow Transplantation, LDS Hospital, Intermountain Healthcare, Salt Lake City, UT
| | | | - Juan C Varela
- Blood and Marrow Transplant Program, AdventHealth Hospital, Orlando, FL; Beth Israel Deaconess Medical Center, Dana Farber/Harvard Cancer Center, Boston, MA
| | - Javier Munoz
- Department of Hematology, Mayo Clinic, Phoenix, AZ.
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7
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Mau LW, Preussler JM, Meyer CL, Senneka MK, Wallerstedt S, Steinert P, Khera N, Saber W. Trends in Allogeneic Hematopoietic Cell Transplantation Utilization and Estimated Unmet Need Among Medicare Beneficiaries with Acute Myelogenous Leukemia. Transplant Cell Ther 2022; 28:852-858. [PMID: 36170959 PMCID: PMC10183994 DOI: 10.1016/j.jtct.2022.09.015] [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: 11/05/2021] [Revised: 07/26/2022] [Accepted: 09/20/2022] [Indexed: 12/24/2022]
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) is a resource-intensive procedure and the sole potentially curative treatment available for patients with acute myelogenous leukemia (AML). Although Medicare coverage may help address a major financial barrier to accessing alloHCT, there remains an unmet need for alloHCT owing to sociodemographic disparities. This study examined trends and factors associated with the utilization of alloHCT and the estimated unmet need for alloHCT among Medicare beneficiaries with AML. This retrospective cohort study included patients (age 65 to 74 years) with a diagnosis of AML identified in Medicare claims data from 2010 through 2016. To study trends in utilization, transplantation rates were calculated as the number of patients who underwent alloHCT within 180 days and 1 year of diagnosis (numerator) divided by the total number of patients with AML within each diagnosis year (denominator). A multivariable logistic regression was used to identify factors associated with the likelihood of undergoing alloHCT within 1 year of diagnosis. Two approaches were applied to estimate the unmet need for alloHCT. The first approach used claims data to identify the potential need for alloHCT among patients who achieved complete remission for at least 90 days. The second approach used established National Marrow Donor Program (NMDP) methodology, which considers estimates of risk level, response to treatment, comorbidity, and early mortality, to identify the potential and unmet need for alloHCT. The overall estimated need and unmet need from 2010 to 2015 and over different time periods were evaluated for both approaches. The alloHCT rate within 180 days of diagnosis increased from 8% in 2010 to 15.8% in 2016 (P < .001), and the 1-year alloHCT rate also increased over time, from 11.9% in 2010 to 20.0% in 2015 (P < .001). The likelihood of undergoing alloHCT within 1 year of diagnosis was associated with diagnosis year, age, race, geographic region, Elixhauser Comorbidity Index, and population-level median household income. Between 2010 and 2015, the claims data approach estimated a lower potential need for alloHCT compared with the NMDP methodology estimate (27% versus 36%); both approaches estimated that 43% to 44% of patients with a potential need for alloHCT had an unmet treatment need. Despite the differences in estimated potential need between the 2 approaches, both showed a sustained unmet need but with a downward trend over time. Our data show that utilization of alloHCT has increased over time among Medicare beneficiaries with AML. Two approaches of need analysis were conducted for validation of estimated need and unmet need for alloHCT using claim-identified remission status, given the lack of cytogenetics and molecular information in claims data. Both approaches to estimating the unmet need for alloHCT found a downward trend over time; however, there are differences in utilization of alloHCT by age, race, geographic region, comorbidity, and socioeconomic status, indicating disparities in access to alloHCT among Medicare beneficiaries with AML. This suggests the need for policy efforts, research, and continued education to improve access to alloHCT and to close the gap between the actual utilization of alloHCT and the unmet need.
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Affiliation(s)
- Lih-Wen Mau
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota.
| | - Jaime M Preussler
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Christa L Meyer
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Mary K Senneka
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota
| | | | - Patricia Steinert
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin; Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nandita Khera
- Department of Hematology/Oncology, Mayo Clinic Arizona, Phoenix, Arizona
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin; Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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8
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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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9
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Kennedy VE, Olin RL. Haematopoietic stem-cell transplantation in older adults: geriatric assessment, donor considerations, and optimisation of care. LANCET HAEMATOLOGY 2021; 8:e853-e861. [PMID: 34624239 DOI: 10.1016/s2352-3026(21)00231-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
Haematopoietic stem-cell transplantation (HSCT) has seen substantial growth among older adults. Chronological age is no longer viewed as an absolute barrier to HSCT, and alternative methods for assessing pre-transplantation fitness are increasingly used. In this Series paper, we summarise the metrics for pre-transplantation risk assessment in older adults, including both traditional metrics and geriatric assessment, and the ability of these metrics to predict post-transplantation outcomes. We also discuss strategies to broaden the utility of geriatric assessment, including in chronologically younger HSCT candidates and to guide individualised pre-transplantation interventions. Finally, we discuss donor considerations in older adults, including use of older sibling donors, haploidentical donors, and emerging data for donor-associated clonal haematopoiesis of indeterminate potential.
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Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rebecca L Olin
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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10
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Mishra A, Preussler JM, Bhatt VR, Bredeson C, Chhabra S, D'Souza A, Dahi PB, Hacker ED, Gowda L, Hashmi SK, Howard DS, Jakubowski A, Jayani R, Koll T, Lin RJ, Olin RL, Popat UR, Rodriguez C, Rosko A, Sabloff M, Sorror ML, Sung AD, Ustun C, Wood WA, Burns L, Artz A. Breaking the Age Barrier: Physicians' Perceptions of Candidacy for Allogeneic Hematopoietic Cell Transplantation in Older Adults. Transplant Cell Ther 2021; 27:617.e1-617.e7. [PMID: 33836312 PMCID: PMC8254775 DOI: 10.1016/j.jtct.2021.03.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
Despite continuing increases in the use of allogeneic hematopoietic cell transplantation (alloHCT) in older adults, no standardized geriatric assessment (GA) has been established to risk stratify for transplantation-related morbidity. We conducted a survey of transplant physicians to determine perceptions of the impact of older age (≥60 years) on alloHCT candidacy, and utilization of tools to gauge candidacy. This 23-item online cross-sectional survey was distributed to HCT physicians caring for adults in the United States between May and July 2019. Of the 770 invited HCT physicians, 175 (22.7%) completed the survey. The majority of respondents were age 41 to 60 years and male and practiced in a higher-volume teaching hospital. When considering regimen intensity, 29 physicians (17%) stated they would consider a myeloablative regimen for patients age ≥70 years, and 141 (82%) would consider reduced-intensity/nonmyeloablative conditioning for patients age ≥70 years. Almost all (90%) endorsed the need for a specialized assessment of pre-HCT vulnerabilities to guide candidacy decisions for older adults. Most physicians reported that their centers rarely (33%) or never (46%) use a dedicated geriatrician/geriatric-oncologist to assess alloHCT candidates age ≥60 years. Common barriers to performing a GA included uncertainty about which tools to use, lack of knowledge and training, and lack of appropriate clinical support staff. Many alloHCT physicians will consider alloHCT in patients up to age 75 years and not uncommonly in patients older than that. However, the application of tools and domains to assess candidacy in older adults varies widely. Incorporation of a standardized pretransplantation health assessment tool for risk stratification is a significant unmet need.
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Affiliation(s)
- Asmita Mishra
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida.
| | - Jaime M Preussler
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | | | | | | | | | | | | | | | - Dianna S Howard
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ann Jakubowski
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reena Jayani
- Vanderbilt Ingram Cancer Center, Nashville, Tennessee
| | - Thuy Koll
- University of Nebraska Medical Center, Omaha, Nebraska
| | - Richard J Lin
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rebecca L Olin
- University of California San Francisco, San Francisco, California
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Cesar Rodriguez
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ashley Rosko
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | | | | | - Anthony D Sung
- Duke University School of Medicine, Durham, North Carolina
| | | | - William A Wood
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda Burns
- National Marrow Donor Program/Be The Match, Minneapolis, Minnesota; Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
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