Team-based approach before stem cell transplantation may improve outcomes for older adults
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Evaluation by a multidisciplinary team clinic prior to hematopoietic stem cell transplantation appeared to reduce transplant-related morbidity and mortality among older adults with blood cancers, according to results of a prospective survey-based study published in Blood Advances.
The team included transplant physicians, transplant nurse practitioners, geriatricians or geriatric oncologists, infectious disease physicians, dieticians and social workers, all guided by patient-completed surveys.
“We can help the patient achieve better results without sacrificing the treatment,” Andrew S. Artz, MD, associate clinical professor at City of Hope National Medical Center, said in a press release. “In the past, physicians might give a lower intensity regimen or not offer transplant as their main treatment option. Now, we can strengthen the patient so we can offer the treatments that best address not only the patient’s disease but also their individual needs and goals.”
The majority of blood cancers treatable with HSCT occur in older adults. Additionally, the proportion of autologous and allogeneic transplants performed in adults aged 70 years and older has risen almost 10-fold over the past 10 to 20 years.
“Although older adults may be at higher risk for nonrelapse mortality relative to young adults, they can still safely undergo HSCT and T-cell therapies for a variety of disease-specific indications,” Artz told Healio.
Researchers established a transplant optimization program for older adults that included a geriatric assessment-guided multidisciplinary team clinic (MDC) to evaluate HSCT or adoptive T-cell therapy feasibility and formulate personalized optimization plans for 247 older adults (median age, 67.9 years; range, 43-83).
Results showed 1-year OS improved from 43% in the period prior to the MDC (2005-2012) to 70% in the modern MDC period (2015-2017). Researchers also observed a decrease in 1-year nonrelapse mortality, from 43% to 18%, between the pre-MDC and post-MDC periods.
Among 31 autologous HSCT recipients aged 70 years or older optimized by the MDC, results showed 0% nonrelapse mortality and 97% OS at 1 year.
Healio spoke with Artz about the results of the study, the role of the multidisciplinary team and the next steps for research on the benefits of this approach.
Question: Why did you conduct this study?
Answer: We know older adults suffer substantial complication when pursuing curative-intent procedures such as allogeneic transplant, with estimates of 20% to 25% nonrelapse mortality at 1 year. Among patients aged 70 years and older, 33% will die within 2 years because of complications related to the transplant. We have limited data on functional impairments or quality of life, a question often asked by patients. Therefore, nonrelapse mortality, death without relapse of the disease, has been our primary measure of serious transplant complications. Nevertheless, nonrelapse mortality remains quite high and limits wider application of transplantation in older patients.
In the field of geriatrics, team-based approaches have been used for decades to improve outcomes. There are many different models of team-based approaches throughout the field of medicine. One major difference in our approach was that this was an embedded multidisciplinary team, meaning we were part of the transplant team along with the geriatric oncologist. The team members seeing the patients were transplant professionals who usually saw patients individually instead of in a team setting.
Q: How did you conduct this study?
A: We constructed a team of transplant professionals that would ideally see a patient to prepare for the transplant, rather than after complications developed. The team included transplant physicians, transplant nurse practitioners, geriatric oncologists, infectious disease physicians, dieticians and social workers. Patients filled out self-assessment surveys on their physical, social and emotional health and underwent clinic tests on mobility and cognition. The multidisciplinary team then used the results to supplement an in-person evaluation. Patients were seen on a single coordinated day followed by a team meeting enabling individualized and integrated recommendations to optimize patient health and prepare for potential transplantation. Initially, we looked at patients aged 60 years or older being evaluated for allogeneic HSCT. Based on a perceived benefit, we expanded that to include patients aged 70 years and older being considered for autologous HSCT and CAR T-cell therapy.
Q: Can you describe the results?
A: Compared with before we instituted the clinic, patients who underwent allogeneic transplant did much better. We observed better survival at 1 year and lower relapse mortality at 1 year. We also saw an improvement in the rate of patients needing skilled nursing facilities and a reduction in hospital days. Although the approach and data are promising for a single-center study without a control arm, we need further controlled trials to better determine the benefits of this approach. The drawbacks of additional time for the patients seemed relatively modest considering the benefits.
Q: Is there anything else you would like to add?
A: Investigators and physicians have concerns about the effort it takes to establish a clinic like this. No doubt, this requires effort and resources to coordinate. Considering the high costs, morbidity and mortality of transplantation or cellular therapy, I think the investment is well worth it. – by John DeRosier
Reference:
Derman BA, et al. Blood. 2019;doi:10.1182/bloodadvances.2019000790.
For more information:
Andrew S. Artz, MD, can be reached at aartz@coh.org.
Disclosures: Artz reports research funding from Miltenyi Biotec. Please see the study for all other authors’ relevant financial disclosures.