Early transplant referral may improve cell therapy access, outcomes in blood cancers
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Early referral to transplantation can increase access to transplant and cell therapies, as well as improve outcomes among patients with hematologic malignancies, according to a speaker at Chemotherapy Foundation Symposium.
“The process of early referral is essential to be able to improve outcomes for all patients with acute myeloid leukemia,” Sergio Giralt, MD, FACP, Melvin Berlin chair in myeloma research and professor of medicine at Weill Cornell Medical College, said during a presentation. “Yes, we are working on better conditioning regimens and better supportive care, and the issue of post-transplant maintenance is now being studied in multiple randomized trials. However, the single, probably lowest ‘hanging fruit’ is to get patients to transplant earlier.”
Righting a wrong
Giralt said the way in which patients have traditionally been referred to stem cell transplantation in the past is inefficient.
“When a patient with acute myeloid leukemia is diagnosed, induction therapy is initiated and then 30 days later when the patient is in remission, a transplant referral is done. In that timeframe, a donor is identified, and the transplant workup is done in a median time frame from diagnosis to transplant of between 2 to 3 months,” Giralt said. “Even for those patients who we think may not need to go onto transplant, there is a lot of work that needs to be done before the transplant process starts, and a delay of 30 days to see if a patient goes into remission or not has substantial consequences.”
Those consequences include the patient requiring another cycle of chemotherapy because they are not ready to undergo transplant. During that time, there can be infections, organ toxicity or further unresponsiveness, according to Giralt.
“By virtue of doing the transplant consult early — even if it is virtually — we can identify the optimal donor earlier, minimize the amount of pretransplant chemotherapy and address comorbidities and many of the socioeconomic issues that are barriers to transplant,” he said.
Older patients
For patients with high-risk disease who are in remission, the duration of remission can be relatively short, and performing a transplant on a patient in remission vs. a patient in early relapse makes a significant difference in overall outcomes, Giralt said.
This is particularly true for older-aged patients, he added.
“We are performing transplants in more and more patients over the age of 70 years and the outcomes are improving over the years as we improve conditioning regimens,” Giralt said. “Most large transplant programs have incorporated geriatrics programs and we do a lot of prehab to get these older patients into better shape before we proceed to the conditioning regimen and transplant.”
Physician bias
Another challenge in getting patients to transplant earlier is significant physician bias in the field, according to Giralt.
“Physician and patient biases and perception on the role of stem cell transplantation can impact cell therapy utilization,” he said. “Many physicians were trained during a time when we didn’t perform transplants in patients older than 60 years or when transplant outcomes were really bad. A lot of work needs to be done in this area, reflecting the fact that when we look at how many patients are being referred to transplant who are over the age of 60 years, it is anywhere between one in 10 patients to one in 20 patients. The underutilization of this strategy has been shown to change long-term disease control; that is really embarrassing.”
Giralt said many geriatricians in the field are interested in optimizing the situation for older patients who may benefit from transplant.
“One way to do this is to reduce polypharmacy, which makes a significant impact,” Giralt said. “But obviously, particularly for patients with myelodysplastic syndrome, there is time to send them to rehab and improve their performance status, and more importantly, we can find caregivers and improve their social situation at home so that their post-transplant journey is less difficult.”
Looking ahead, Giralt added, “Current prospective studies in the field of transplant will hopefully continue to improve outcomes where transplant can be offered to all patients safely with high-risk and intermediate-risk disease.”
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Giralt S, et al. Improving cell therapy outcomes: Can the referral process affect outcome? Presented at: 40th Annual Chemotherapy Foundation Symposium: Innovative Cancer Therapy for Tomorrow; Nov. 9-11, 2022.
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