Enhanced Recovery Stem-Cell Transplantation: Multidisciplinary Efforts to Improve Outcomes in Older Adults Undergoing Hematopoietic Stem-Cell Transplant

Abstract

PURPOSE: Older adults have unique risk factors for poor outcomes after hematopoietic stem-cell transplant (HSCT). We sought to determine the impact of our multidisciplinary supportive care program, Enhanced Recovery after stem-cell transplant (ER-SCT), on survival outcomes in patients age 65 years and older who underwent HSCT. PATIENTS AND METHODS: In this retrospective study, clinicodemographic data, nonrelapse mortality (NRM), overall survival (OS), and relapse were compared between 64 patients age 65 years and older who underwent allogeneic stem-cell transplant during ER-SCT program's first year, October 2017 through September 2018, and 140 historical controls age 65 years and older who underwent allogeneic HSCT, January 2015 through September 2017. RESULTS: In the ER-SCT cohort, 41% (26 of 64) of patients were women, and the median (range) age was 68 (65-74) years; in the control cohort, 38% (53 of 140) of patients were women, and the median (range) age was 67 (65-79) years. Hematopoietic cell transplant comorbidity index and donor type/cell source were similar between cohorts. The ER-SCT cohort had a lower 1-year NRM rate (13% v 26%, P = .03) and higher 1-year OS rate (74% v 53%, P = .007). Relapse rate did not differ significantly between cohorts. In multivariate analyses, ER-SCT was associated with improved 1-year NRM (hazard ratio, 0.4; 95% CI, 0.2 to 0.9; P = .02) and improved 1-year OS (hazard ratio, 0.5; 95% CI, 0.3 to 0.9; P = .03). CONCLUSION: A multidisciplinary supportive care program may improve NRM and OS in older patients undergoing allogeneic HSCT. Randomized studies are warranted to confirm this benefit and explore which program components most contribute to the improved outcomes.

The Role of Outpatient Physical Medicine and Rehabilitation in a Multidisciplinary Prehabilitation Program for Older Adults before Allogeneic Hematopoietic Stem Cell Transplant

“…Not only has this multidisciplinary ER-SCT program been well received by patients, caregivers, and oncologists, 11 but there is a survival impact with a review of 64 patients during the first year of the program highlighting superior 1-yr overall survival (74%, 95% CI = 62-83 vs. 53%, 95% CI = 45-61, P = 0.007) and nonrelapse mortality (13%, 95% CI = 6-22 vs. 26%, 95% CI = 19-33, P = 0.03) when compared with historical controls. 13 Multidisciplinary supportive care programs have also enhanced patient outcomes in other studies before stem cell transplant 27,28 and before surgery for solid tumors. 29 This study supports PM&R outpatient involvement in multidisciplinary prehabilitation programs that could potentially impact cancer outcomes.…”

“…Cancer prehabilitation, in improving functional status before cancer treatment, is a way to mitigate the impairments related to cancer and its treatment that can lead to significant distress in cancer survivors 18 . With growing evidence showing benefit for patient outcomes 13,20 and cost savings, 20 it is rapidly being adopted worldwide 20 . Physical medicine and rehabilitation physicians should ideally contribute to the cancer prehabilitation team with the evaluation and management of physical and cognitive impairments 18,21 …”

“…com/PHM/C278). 12 This ER-SCT program 11,13 includes older patients 65 yrs or older who received a multidisciplinary prehabilitation program before allo-HSCT. All allo-HSCT candidates 65 yrs and older were automatically referred to all components of this program.…”

Supportive Care of Hematopoietic Stem Cell Donors

“… 1–3 Diligent monitoring, cooperation with the recipient’s family members, and collaboration with the multidisciplinary transplant team can improve post-transplantation outcomes. 2,4,5 …”