Geriatric Assessment Before HSCT Supports Good Outcomes

Neil Osterweil

February 24, 2020

ORLANDO, Florida — Patients age 70 and older with hematologic malignancies who are candidates for autologous stem cell transplants should undergo a geriatric assessment at a multidisciplinary clinic, say experts.

This can help to identify those patients who will benefit from immediate transplant, those who may need transplants deferred to address comorbidities, and those for whom transplant could do more harm than good.

"Geriatric assessment has been shown to identify deficits in older autologous transplant candidates, and we and others have shown that this tracks with outcomes," said Benjamin A. Derman, MD, from the University of Chicago, Illinois.

He reported a 1-year treatment-related mortality rate between 0 and 1% for a cohort of patients 70 and older with hematologic malignancies who were referred for transplant on the recommendation of a geriatric assessment-guided multidisciplinary clinic (GA-MDC).

Derman was speaking here at the Transplantation & Cellular Therapy (TCT) annual meeting.

Session comoderator Mazyar Shadman, MD, MPH, from the Fred Hutchinson Cancer Research Center in Seattle, Washington, said "the concept is important."

The idea behind the geriatric assessment is to identify and "really work on risks that we know will translate into an inferior outcome later, and you can just try to deal with them before transplant," he said.

Shadman told Medscape Medical News that his center doesn't have a formal geriatric assessment clinic, but instead uses clinical trials to test interventions that may help to improve the likelihood of successful transplants for older, higher-risk patients.

Geriatric Assessment

Dr Benjamin Derman

Derman described how the University of Chicago established a GA-MDC in which all patients 70 and older who are candidates for an autologous transplant are given cognitive and strength tests, and are then evaluated by a team including a transplant physician and nurse practitioner, a geriatric oncologist, infectious disease specialist, physical and occupational therapists, a nutritionist, and a social worker.

The clinic services are also available for patients younger than 70 at the referring physician's discretion.

The assessment includes patient-reported surveys prior to the visit, and bedside testing on the day of the visit with a cognitive battery and handgrip testing, followed by visits with the aforementioned clinicians.

"At the end of this half-day worth of clinic, the patient is then evaluated in a multidisciplinary meeting, where consensus recommendations are rendered both to the patient and to the treating clinician," Derman explained.

Proceed, Decline, Defer

All patients get an optimization recommendation, as well as a nonbinding recommendation regarding their fitness for transplant, with the recommendations falling into one of three categories:

  • Proceed: Patients who the team believes can withstand the rigors of transplants in their present state are given the green light.

  • Decline: This category includes patients with a risk/benefit ratio suggesting that the risks will outweigh the benefit, and that the patient is unlikely to realize the benefit of transplant.

  • Defer: Patients in this group fall somewhere in between Proceed and Decline, "where there really is uncertainty as to how they're going to do. Certain vulnerabilities are identified, we've made optimization recommendations, and they ultimately have to decide whether to go through with transplant," Derman explained.

The outcomes that Derman presented at the meeting come from a study conducted at the University of Chicago that involved 91 patients age 70 and older evaluated for an autologous transplant from 2015 through 2018.

Of this group, 5 patients (6%) received a "decline" recommendation, and none went on to transplant.

Of 25 patients (27%) with a "defer" recommendation, 13 went on to have an autograft and 12 did not.

Of the remaining 61 patients (67%) who received the "proceed" go-ahead, 49 went on to transplant and 12 did not.

Comparing the "defer" vs. "proceed" groups, the investigators found that defer-recommended patients were younger than the proceed patients, with a mean age of 68.5 vs. 71 years. However, this age advantage was offset by significantly higher rates of vulnerabilities, including a greater proportion of frail 4-meter walks (P = .001); more restrictions in activities of daily living
(ADL; P = .03), higher rates of depression (P = .001), greater proportion of Karnofsky performance scores (KPS) of 80 or lower, and a higher rate of polypharmacy, defined as more than four medications (P = .03).

When the team looked at those patients who went on to transplant vs those who did not, they saw that patient age was similar between the groups, but significantly more patients with plasma cell disorders were transplanted than patients with non-Hodgkin lymphoma (P = .008). In addition, the transplanted patients were significantly more likely to have had either a complete or partial remission (P = .05).

They also found that patients who did not get a transplant had significantly higher proportions of vulnerabilities, including frail 4-meter walk pace, patient-reported lower KPS, more prescribed medications, frail grip strength, greater cognitive impairment, and higher degrees of difficulty with ADL (P = .05 or less for all comparisons).

Three-year overall survival (OS) was 76% for patients who underwent transplant vs 44% for those who did not (P = .0004), with 0% transplant-related mortality.

"This points to a selection component to the clinic, that we are certainly selecting out high-risk patients from receiving a transplant, which is accounting in part for the excellent outcomes we see in transplant recipients," Derman said.

Looking at the higher-risk, deferred patients, they found that 1-year OS was 92% for those who ultimately received a transplant vs 60% for those who did not. However, this analysis involved only 25 patients, so the seemingly large difference was not statistically significant.

This finding suggests that there is — in addition to a selection component — an optimization component to the clinic, because it allowed certain high-risk patients to proceed to transplant and have excellent outcomes, Derman contended.

In univariate analysis of baseline characteristics among only those patients who had a transplant, frail grip strength was associated with a higher risk for disease progression (hazard ratio [HR], 4.05; P = .003) and worse OS (HR, 6.0; P = .004). In addition, provider-reported KPS scores of 80 or lower were associated with higher risk for progression (HR, 4.4; P = .004) and worse OS (HR, 8.75; P = .01).

"The other interesting thing we found is that deferred patients took about twice as long to make it to transplant, so from the time they were evaluated in clinic to the time they received the transplant was 41 days compared with 20 days among the proceed patients. However, this did not result in a difference in the length of inpatient hospitalization for their transplant encounter, did not result in a difference in readmission rate within day 100, or in skilled nursing facility admissions by day 100," Derman said.

Importantly, this difference did not translate into differences in outcomes, with overall survival comparable between the 'defer' and 'proceed' patients, again suggesting an optimization component to the clinic.

A Good Concept, Hard to Implement

This is a good idea in theory, but difficult to put into practice, commented an adult transplant specialist who was not involved in the study but is familiar with the University of Chicago clinic.

"I think the data is very compelling that with more scrupulous evaluations of elderly patients we probably can do a better job of risk-stratifying who's more likely to do  better with transplant, who might struggle with transplant, or run into other issues," said Zachariah DeFilipp, MD, from the Massachusetts General Hospital Cancer Center in Boston.

He acknowledged the University of Chicago's leadership in this area, but also pointed out that a dedicated geriatric assessment clinic for transplant centers is a resource-draining proposition for most centers.

"The question becomes who's going to administer these geriatric assessments and spend all the time to evaluate them," he said.

"One thing that's being looked at in the field of geriatric assessments is whether there are ways to narrow down the assessment to make it less burdensome, so that they can be done more quickly in clinic, and still get a useful readout, and that would be more applicable to most transplant centers," he said.

Session comoderator Yago Nieto, MD, PhD, from the University of Texas MD Anderson Cancer Center in Houston, told Medscape Medical News that other centers wishing to adopt a similar approach to assessment of older transplant candidates need to be willing to commit both time and resources.

"It has to be formalized," he emphasized. "It has to be a special group of physicians and nurses and nurse practitioners who are committed to this endeavor."

The study was internally funded. Derman, Nieto, Shadman, and DeFilipp have disclosed no relevant financial relationships.

Transplantation & Cellular Therapy Meetings of ASTCT and CIBMTR 2020: Abstract 26. Presented February 19, 2020.

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