Results from a multidisciplinary clinic guided by geriatric assessment before stem cell transplantation in older adults

Derman, Benjamin A.; Kordas, Keriann; Ridgeway, Jean; Chow, Selina; Dale, William; Lee, Sang Mee; Aguada, Elingel; Jakubowiak, Andrzej; Jasielec, Jagoda; Kline, Justin; Kosuri, Satyajit; Larson, Richard A.; Liu, Hongtao; Mortel, Mylove; Odenike, Olatoyosi; Pisano, Jennifer; Riedell, Peter A.; Stock, Wendy; Bishop, Michael; Artz, Andrew S.

doi:10.1182/bloodadvances.2019000790

Cited by 71 publications

(49 citation statements)

References 51 publications

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“…Artz and colleagues recently reported that in patients with a median age of 67 undergoing hematopoietic stem cell transplantation for blood cancers, GA-driven interventions implemented by a multidisciplinary geriatrics team improved 1-year overall survival in comparison with conducting a GA alone without a multidisciplinary team to manage any detected vulnerabilities. 32 While provocative, a limitation of this non-randomized study was its use of a historical control group for comparison. In our randomized trial of transplant-ineligible patients age ≥ 75 years undergoing geriatric consultation versus standard oncologic care, we did not find evidence of an effect on 1-year overall survival-even in the frail subgroup.…”

Section: Discussionmentioning

confidence: 99%

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

et al. 2021

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We conducted a randomized controlled trial in older adults with hematologic malignancies to determine the impact of geriatrician consultation embedded in our oncology clinic alongside standard care. From February 2015 to May 2018, transplant-ineligible patients age ii75 years who presented for initial consultation for lymphoma, leukemia, or multiple myeloma at Dana-Farber Cancer Institute (Boston, MA) were eligible. Pre-frail and frail patients, classified based on phenotypic and deficitaccumulation approaches, were randomized to receive either standard oncologic care with or without consultation with a geriatrician. The primary outcome was 1-year overall survival. Secondary outcomes included unplanned care utilization within 6 months of follow-up and documented end of life (EOL) goals of care discussions. Clinicians were surveyed as to their impressions of geriatric consultation. One hundred sixty patients were randomized to either geriatric consultation plus standard care (n = 60) or standard care alone (n = 100). Median age was 80.4 years (SD = 4.2). Of those randomized to geriatric consultation, 48 (80%) completed at least one visit with a geriatrician. Consultation did not improve survival at one year compared to standard care (difference: 2.9%, 95% CI = -9.5% to 15.2%, p = 0.65), and did not significantly reduce the incidence of ED visits, hospitalizations, or days in hospital. Consultation did improve the odds of having EOL goals of care discussions (odds ratio = 3.12, 95% CI = 1.03 to 9.41) and was valued by surveyed hematologiconcology clinicians, with 62.9%-88.2% rating consultation as useful in the management of several geriatric domains.

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Section: Discussionmentioning

confidence: 99%

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

et al. 2021

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“…39 However, these studies are mainly in the context of chimeric antigen receptor T-cell therapies 38,40,41 and bispecific T-cell engagers. 42 CRS is also recognized after haploidentical HCT, particularly when PBSCs are infused as the graft source, [43][44][45] with prognostic implications. 42 CRS in matched donor or MMUD-HCT has not been fully characterized.…”

Section: Discussionmentioning

confidence: 99%

Posttransplant cyclophosphamide as GVHD prophylaxis for peripheral blood stem cell HLA-mismatched unrelated donor transplant

Malki¹,

Tsai²,

Palmer³

et al. 2021

Blood Advances

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Efficacy of PTCy after mismatched unrelated donor (MMUD) HCT is unknown. In this pilot clinical trial, we enrolled 38 patients with hematologic malignancies scheduled to undergo MMUD-HCT (≥6/8 HLA-matched donors) onto 1 of 2 conditioning strata: myeloablative using fludarabine and fractionated total body irradiation (n = 19) or reduced intensity with fludarabine/melphalan (n = 19). Graft source was peripheral blood stem cells (PBSCs), and GVHD prophylaxis was PTCy, tacrolimus, and mycophenolate mofetil. Patients’ median age was 53 years (range, 21-72 years). Median number of HLA mismatches was 2 (range, 1-4) of 12 loci. Twenty-three patients (61%) were considered racial (n = 12) or ethnic (n = 11) minorities. Median time to neutrophil engraftment was 16 days (range, 13-35 days). With a median follow-up of 18.3 months (range, 4.3-25.0 months) for surviving patients, 1-year overall survival (OS) and GVHD-free/relapse-free survival (GRFS) were 87% (95% confidence interval [CI]: 71-94) and 68% (95% CI: 51-81), respectively. Cumulative incidence of nonrelapse mortality at 100 days and 1 year were 0% and 11% (95% CI: 4-27), respectively, whereas relapse/progression was 11% (95% CI: 4-27). Cumulative incidence of 100-day acute GVHD grades 2-4 and 3-4 and 1-year chronic GVHD were 50% (95% CI: 36-69), 18% (95% CI: 9-36), and 48% (95% CI: 34-68), respectively. The rate of moderate/severe chronic GVHD was 3% in the entire cohort. We showed highly promising OS/GRFS rates with an acceptable risk profile after PBSC-MMUD-HCT with PTCy. This trial was registered at www.clinicaltrials.gov as #NCT03128359.

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“…Second, the concept that frailty is dynamic is important given the high degree of symptom burden that often accompanies a diagnosis of a hematologic malignancy as well as the possibility that it may be reversible with intervention and optimization of individual vulnerabilities. 11…”

Section: Concepts Of Geriatrics In the Oncology Clinic: Geriatric Assessment And Frailtymentioning

confidence: 99%

Characterize, Optimize, and Harmonize: Caring for Older Adults With Hematologic Malignancies

Wildes¹,

Artz

2021

American Society of Clinical Oncology Educational Book

Self Cite

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With the aging of the population, the number of older adults with hematologic malignancies is growing, and treatment paradigms for these patients are rapidly evolving. Use of allogeneic stem cell transplant has been expanding to include septuagenarians but remains a potentially morbid procedure, creating an opportunity for a geriatric-focused evaluation to improve assessment of the individual’s risk in undergoing the procedure. Although age alone should not be the sole determinant for transplant eligibility, geriatric assessment often identifies vulnerabilities that are not captured in assessing performance status and comorbidities alone. Those vulnerabilities may be optimized in an approach employing three sequential steps: characterize resiliency, bolster resilience, and harmonize with patient goals. Data are emerging that show that this approach is associated with lower nonrelapse mortality, shorter length of stay, and better survival after transplant. In older adults with myeloma, treatment recommendations also aim to balance the expected efficacy and toxicity profile and incorporate the patient’s goals and preferences. Assessment of frailty allows for more personalized estimates of risk of toxicity. Currently, the European Myeloma Network currently recommends using the International Myeloma Working Group frailty scale as a standard approach to defining frail or at-risk populations with myeloma. In addition to treatment selection, the care of older adults with myeloma must include consideration of other issues, including reducing early mortality with antibiotic prophylaxis, polypharmacy, depression, cognition, and falls. Overall, appreciation of the aging-associated vulnerabilities will allow for the ultimate personalized care and treatment of older adults with hematologic malignancies.

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Results from a multidisciplinary clinic guided by geriatric assessment before stem cell transplantation in older adults

Abstract: Key Points GA to guide an MDC evaluation to optimize older adult candidates for hematopoietic cellular therapy is feasible and practical. An MDC evaluation for older adults before transplantation holds promise to mitigate transplant-related morbidity and mortality.

Cited by 71 publications

References 51 publications

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

Posttransplant cyclophosphamide as GVHD prophylaxis for peripheral blood stem cell HLA-mismatched unrelated donor transplant

Characterize, Optimize, and Harmonize: Caring for Older Adults With Hematologic Malignancies

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