Multidisciplinary Geriatric Assessment May Improve Outcomes After Stem-Cell Transplantation

By Will Boggs MD

December 09, 2019

NEW YORK (Reuters Health) - Multidisciplinary, cancer-specific geriatric assessment to create an individualized optimization plan appears to improve outcomes in older patients undergoing hematopoietic cell transplantation (HCT), researchers report.

"We need to move away from the clearance approach for transplant based on calendar age or static measures of health and consider a broader concept of resiliency - the ability of a given patient to handle the stressor of transplant," said Dr. Andrew S. Artz of City of Hope, in Duarte, California.

"Better characterizing health and resiliency through tools such as geriatric assessment in the context of the expected treatment toxicities is the first step," he told Reuters Health by email.

The American Society of Clinical Oncology supports the concept of resilience and recommends geriatric assessment before oncologic treatment to develop an integrated and individualized plan that informs cancer management and identifies non-oncologic problems amenable to intervention.

Dr. Artz and colleagues established a geriatric assessment-guided multidisciplinary-team clinic (MDC) to evaluate and enhance resilience of older adult HCT and cellular-therapy candidates.

The Transplant Optimization Program (TOP) MDC involves about five hours of evaluation, usually scheduled after pretransplant testing and within a two- to six-week window before conditioning.

Team members meet to discuss each patient after clinic. Key topics include optimizing resiliency by mitigating limitations and leveraging strengths from the geriatric assessment, devising recommendations to cushion the stressor of the proposed procedure, and engaging the patient and caregivers in goal-setting.

The process results in one of three nonbinding recommendations: optimize and proceed with HCT (or cellular therapy); optimize and decline HCT because acceptable resilience is unlikely; or optimize and defer HCT until established metrics are met.

Most patients recommended to proceed (122/152, 80%) received their planned treatment, and nearly half of those recommended for deferral (28/61, 46%) eventually received cellular therapy. Only two of those for whom the MDC team recommended against transplant received an allogeneic HCT, both at outside institutions.

Among patients evaluated for allogeneic HCT, an initial deferral was associated with a delayed time to HCT (median, 76 days vs. 35 days with recommendation to proceed).

In the pre-TOP era, outcomes of allogeneic transplantation among patients aged 60 years and older were poor, with 43.2% one-year overall survival and 43.2% nonrelapse mortality.

In the first two years of the TOP era (2013 to 2014), one-year overall survival (44.4%) and nonrelapse mortality (37%) did not change significantly, the researchers report in Blood Advances, online November 14.

In contrast, during the most recent TOP era (2015 to 2018), one-year overall survival was significantly better (70%), as was nonrelapse mortality (18%).

Median length of inpatient stay declined progressively from pre-TOP (19 days) to initial TOP (15 days) to most recent TOP (14 days).

Death rates by day 100 were significantly lower among proceed patients (4%) than among deferred patients (23%). One-year outcomes were nominally, but not statistically significantly, worse among deferred patients (overall survival, 64% for proceed patients vs. 46% for deferred patients; nonrelapse mortality, 22% vs. 39%).

Among the 31 autologous HCT recipients aged 70 years and older, there were no deaths during the initial hospitalization, and there was only one death within 100 days of HCT due to progressive disease. Of the 28 evaluable patients with one year of follow-up, overall survival was 97% and nonrelapse mortality was 0%.

"Prospective multi-institutional studies are needed to validate these results," Dr. Artz said. "Nevertheless, the growth in the number of older patients with blood cancers mandates we invest research efforts into treatment approaches that account for the heterogeneity in health of older patients. I am optimistic about the future of more safely pursuing curative-intent treatments for hematologic malignancies in older adults."

Co-author Dr. Benjamin A. Derman of the University of Chicago told Reuters Health by email, "There are many elements of a geriatric assessment that can be feasibly performed at the bedside to inform risk and recommendations for optimization prior to stem-cell transplantation. Focusing on nuanced ways to optimize patients rather than offer a binary decision about eligibility for transplant is key."

"In addition to institutional buy-in to carve out a space for such a MDC, there also needs to be a dedicated team of trusted providers that are committed to the mission of optimizing older adults for transplant," he said.

Dr. Morgani Rodrigues of Hospital Israelita Albert Einstein, in Sao Paulo, Brazil, who has studied the feasibility of comprehensive geriatric assessment in detecting vulnerabilities in older patients scheduled for allogeneic HCT, told Reuters Health by email, "Having a special clinic that takes care of older adults and related complications before, during, and after transplant is worthwhile. This report showed us that this is possible and that the process is dynamic. In my opinion, each transplant service needs to find a better way to use geriatric tools in his population."

"Integrated care of the older adult may allow more patients to benefit from transplantation, as well as improving potential complicating factors during and after transplantation," she said. "It is an important issue for these patients to preserve their independence and quality of life, so improving their resilience to stressors is essential.​"

"Another point, at least in my country, is to allow older adults to gain access to transplant, since today health-policy regulations have age limitations," Dr. Rodrigues said.

SOURCE: Blood Advances, online November 14, 2019.