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Age no longer a barrier to hematopoietic stem cell transplantation
Sorror ML. JAMA. 2011;306:1874-1883.
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With the use of a minimally toxic nonmyeloablative regimen for allogeneic hematopoietic cell transplantation, patients aged older than 60 years may have an effective treatment for hematologic malignancies, according to the results of a recently published study.
Historically, older age when undergoing allogeneic hematopoietic cell transplantation (HCT) has been associated with increased mortality. However, for younger patients, it is the most likely opportunity for a cure.
In this study, researchers sought to examine the safety and efficacy of a new non-myeloablative conditioning regimen for allogeneic HCT. The new regimen “relies on graft-vs-tumor effects to cure cancer and consists of fludarabine and a low dose of total-body irradiation before HCT and a course of immunosuppression with mycophenolate mofetil and calcineurin inhibitor after HCT.”
The study included 372 patients aged 60 to 75 years with advanced hematologic malignancies diagnosed between 1998 and 2008. The patients were enrolled at 18 centers. The median age of the patients was 64.1 years. Older patients were more likely to be treated for leukemia or myelodysplastic syndromes. Younger patients were more likely to be treated for lymphoma or myeloma.
After a median follow-up of 55 months, patients had a 5-year cumulative incidence of nonrelapse mortality of 27% and a cumulative incidence for relapse of 41%. The 5-year OS was 35% (95% CI, 30 - 40) and the 5-year PFS was 32% (95% CI, 27-37). These outcomes were similar between all three age groups examined (see Table).
In addition, the three age groups had similar rates of graft-versus-host disease and hospitalization. Overall, only 54% of patients aged 60 to 64 years were hospitalized, 36% of patients aged 65 to 69 years were hospitalized, and 55% of patients aged 70 years or older were hospitalized.
“These results are encouraging given the poor outcomes with nontransplantation treatments, especially for patients with high-risk AML, fludarabine-refractory CLL or progressive lymphoma,” the researchers wrote.
In an accompanying editorial, Shin Mineishi, MD, of the Blood and Marrow Transplant Program at the University of Michigan in Ann Arbor, said the refinement of this approach has been a large accomplishment in the field of HCT during the last 15 years.
However, OS and PFS outcomes among this older age group now appear to be similar to those in younger patients, but questions still remain about this treatment, Mineishi wrote.
“Although age alone should no longer be considered a limiting factor for allogeneic HCT, more questions have been raised, and more problems need to be resolved for achieving optimal outcomes for older patients receiving allogeneic HCT,” Mineishi wrote.
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