This article is more than 5 years old. Information may no longer be current.
Physical evaluation may improve patient selection for bone marrow transplant
Click Here to Manage Email Alerts
SALT LAKE CITY — Endurance limitations appeared significantly associated with greater length of inpatient admission and death during admission for hematopoietic stem cell transplantation, according to study results presented at the BMT Tandem Meetings.
Thus, a formal physical performance assessment could better evaluate a patient’s endurance and physical reserve, improving patient selection and prognostication.
Measures of risk assessment commonly used to predict HSCT outcomes include the validated hematopoietic cell transplantation-specific comorbidity index (HCT-CI) and Karnofsky performance score.
“These indices focus on a patient’s comorbidities and physical functioning,” Shabnam Rehman, MD, clinical fellow with the department of medicine at Roswell Park Comprehensive Cancer Center, told HemOnc Today. “Comorbidities alone do not define the true biological age/functional status of a patient, and Karnofsky performance score can be a subjective measure. Therefore, we assessed whether more objective tests assessed by physical therapists could predict physical functioning and biologic age/functional status better than HCT-CI and Karnofsky performance score.”
Rehman and colleagues evaluated how the results of a comprehensive physical performance status prior to transplant — in addition to HCT-CI and Karnofsky performance status — were associated with day 100 transplant-related mortality, OS, length of inpatient admission, death during admission, readmission and need for rehabilitation after discharge.
The analysis included 349 adults who underwent a first allogeneic HSCT between 2010 and 2016.
One of two dedicated physical therapists conducted a physical performance assessment — which included 25 step-ups per side, unassisted sit-to-stands from an 18-inch chair in 30 seconds, weight-bearing ability, need for assistance with ambulation, motor strength in all four extremities, sensory or coordination impairment, self-reported pain, and time to recovery of heart rate and oxygen saturation to pre-exercise levels — for all patients 4 weeks prior to HSCT.
Length of inpatient admission — defined as duration of hospitalization from inpatient admission, including for receipt of conditioning regimen and hematopoietic cell infusion, to first post-HSCT discharge — appeared significantly associated with donor type ( 30 days vs. < 30 days; P = .009; 60 days vs. < 60 days; P = .02), as well as regular ( 30 days vs. < 30 days, P = .05; 60 days vs. < 60 days, P = .02) and age-adjusted ( 30 days vs. < 30 days, P = .04) HCT-CI.
Death during first admission also appeared linked to donor type (P < .0001), and regular (P = .0004) and age-adjusted (P = .03) HCT-CI.
Patients who self-reported pain experienced significantly shorter OS (P = .04).
Endurance limitations appeared linked to length of admission of 60 days or longer vs. shorter than 60 days (P = .02) and death during HSCT admission (P = .03).
Also, heart rate recovery within 3 minutes of exercise was associated with length of admission ( 30 days vs. < 30 days; P = .03; 60 days vs. < 60 days; P = .02), whereas oxygen saturation recovery was linked to day 100 nonrelapse mortality.
Researchers observed shorter survival among patients unable to perform more than 10 sit-to-stands in 30 seconds (P = .01) and those who needed assistance with ambulation.
“Surprisingly, age was not associated with any of the novel outcomes or objective measures of physical performance,” Rehman said. “We found that HCT-CI risk scoring predicts outcome, and that objective tests assessed by the physical therapists — such as the number of sit-to stands in 30 seconds and the ability to perform 25 step-ups — were equally prognostic. These quantitative measures are prognostic of novel short-term outcomes of length of stay, inpatient mortality during transplant admission and disability.”
The association with limitations on endurance tests and shorter OS persisted when researchers stratified results for the age-adjusted HCT-CI group.
“These physical performance assessments are part of the routine pretransplant workup at our institution,” Rehman said. “We hope that bone marrow transplantation centers may find these tests to be useful in determining a patient’s level of physical reserve and fitness for HSCT, and in predicting short-term outcomes and disability. We are developing a validated risk score incorporating endurance tests in conjunction with the HCT-CI that could be used by other transplant centers.”
The results of these study “should be tested, replicated and validated in a larger population before any generalized conclusions can be drawn from our approach,” study author Theresa Hahn, PhD, professor of oncology in the department of medicine at Roswell Park Comprehensive Cancer Center, told HemOnc Today. “These findings should be tested, for example, in pediatric patients, patients receiving autologous HSCT and in a broader and more ethnically diverse patient base.” – by Alexandra Todak
References:
Rehman S, et al. abstract 19. Presented at: BMT Tandem Meetings; Feb. 21-25, 2018; Salt Lake City.
Sorror ML, et al. J Clin Oncol. 2007;25:4246-4254.
Disclosures: The authors report no relevant financial disclosures.
Perspective
Back to Top
William A. Wood, MD
Rehman and colleagues from Roswell Park presented a very interesting analysis in which they looked at the association of pre-HSCT physical performance testing with post-HSCT outcomes. Despite advances in transplant techniques and supportive care, HSCT remains a relatively morbid procedure with a substantial risk for treatment-related toxicity and even death. Optimal candidate selection for HSCT continues to be an elusive goal.
Because chronological age is an imperfect predictor of treatment tolerance, other metrics have been examined, with the HCT-CI — or Sorror score — arguably the gold standard for transplant-related risk assessment.
Although comorbidity scoring has demonstrated practical utility, it is difficult to intervene upon specific comorbidities before or during HSCT to lower the HCT-CI and improve risk. To this end, other investigators have looked at a variety of other potential prognostic pre-HSCT factors. The upcoming BMT CTN 1704 CHARM study will incorporate comprehensive geriatric assessment into pretransplant evaluation in a large, multicenter effort. Some investigators have looked at other kinds of physical performance tests, ranging from high-intensity testing (eg, maximal aerobic capacity from a cardiopulmonary exercise test, or CPET) to lower-intensity evaluation (eg, 6-minute walk distance testing, or 6MWD). In small to moderately sized studies, higher-intensity testing appears to predict survival, although 6MWD may not.
In this context, the study by Rehman and colleagues is quite interesting — this study has incorporated physical performance tests with read-outs that are probably somewhere in between CPET and 6MWD, but may retain prognostic value. For example, in this retrospective dataset, heart rate and oxygen saturation recovery from a standardized pre-HSCT exercise test was independently associated with early toxicity, including length of stay and death during the inpatient transplant hospitalization. Other physical tests also appeared associated with lower post-HSCT OS.
Ultimately, we don’t know yet which standardized series of pre-HSCT assessments will be the most useful to predict risk and guide clinical decision-making to mitigate risk and improve outcomes. The study presented by Rehman and colleagues, follow-on efforts by this group and others, and the upcoming BMT CTN 1704 CHARM study should help us to address this issue.
Click Here to Manage Email Alerts