Patients Receiving Integrative, Multidisciplinary Treatment Show Improved Transplantation Outcomes

Older adults diagnosed with hematological malignancies (blood cancers) may benefit from a team-based, holistic evaluation before undergoing transplantation. This is the conclusion based on a study published in Blood Advances, a peer-reviewed, open access journal of the American Society of Hematology (ASH).[1]

The study found that patients treated with this team-based approach experienced better transplantation outcomes and survival rates.

Age as consideration
Most hematological malignancies that can be treated with hematopoietic cell transplantation (HCT) occur more frequently in patients who are 60 years of age or older. HCT has been shown to be relatively effective for medically cleared older patients, but many physicians are hesitant to refer older patients for transplant due to concerns about potential complications.

Traditionally age, comorbidity, and rudimentary assessments of performance status have been used to describe the fitness of older patients to assess eligibility for HCT. Physiologic status and social support were not necessarily included in these assessments. However, the study results show that in addition to the traditional assessment, other factors, including disability, frailty, nutritional status, systemic inflammation and geriatric syndromes (e.g., falls, delirium) play a larger role in describing the physiologic age of the patient.[2][3][4][5]


Geriatric assessment (GA) to guide a multidisciplinary team clinic (MDC) evaluation to optimize older adult candidates for hematopoietic cellular therapy … is feasible and practical… and … holds promise to mitigate transplant-related morbidity and mortality…


The multidisciplinary clinic (MDC) at the University of Chicago Medical Center aimed to improve patient resiliency prior to transplant so that older patients were not excluded from the treatment based on age alone.

A team of care providers—including transplant physicians, transplant nurse practitioners, geriatricians or geriatric oncologists, infectious disease physicians, dieticians, and social workers—was assembled for patients being evaluated for transplant.

As part of the process, patients took self-assessment surveys on their physical, social, and emotional health, as well as clinic tests on mobility and cognition. The multidisciplinary team used the results to coordinate their recommendations and create integrative, individualized treatment plans.

Initially, the team at the clinic assessed patients 60 years of age and older being evaluated for allogeneic HCT.

Based on the results, the approach was later expanded to include patients 70 years of age and older being evaluated for autologous HCT as well as Chimeric Antigen Receptor (CAR) T-Cell Therapy. Some younger HCT patients were also electively referred to the clinic by their physician.

The median age of all 247 patients referred to the clinic was 67.9 years.


Andrew Saul Artz, MD, MS, is Associate Clinical Professor, Department of Hematology & Hematopoietic Cell Transplantation (HCT) at City of Hope Comprehensive Cancer Center in Duarte, CA. Photo Courtesy 2019: City of Hope Comprehensive Cancer Center.

The researchers noted that compared to patients who had undergone transplants at the center prior to the establishment of the MDC, patients in the multidisciplinary setting experienced fewer complications, fewer admissions to nursing facilities, shorter hospital stays, and better survival.

In additions, the improved outcomes occurred without a reduction in the transplant regimen strength: 90% of autologous transplant patients 70 years and older received full doses of the drugs administered as preparation for HCT.

“We can help the patient achieve better results without sacrificing the treatment,” noted Andrew S. Artz, MD, of City of Hope National Medical Center, formerly of University of Chicago Medical Center, and the study’s senior author.

“In the past, physicians might give a lower intensity regimen or not offer transplant as their main treatment option. Now, we can strengthen the patient so we can offer the treatments that best address not only the patient’s disease but also their individual needs and goals,” Artz added.

Although the findings are promising, the study is not a randomized controlled trial. This means that follow-up research is required.

The researchers hope that if subsequent studies confirm the findings, there will be wider, safer use of transplantation among older adults.

“Our main goal is to allow more older patients who could benefit from transplant to be able to consider it as a treatment option. Deploying staff in this type of coordinated pre-transplant approach requires organization and effort, but we hope the upfront investment of time and energy might prevent more expensive problems later,” Artz concluded.

References
[1] Derman BA, Kordas K, Ridgeway J, Chow S, Dale W, Lee SM, Aguada E, et al. Results from a multidisciplinary clinic guided by geriatric assessment before stem cell transplantation in older adults. Blood Advances. DOI: 10.1182/bloodadvances.2019000790. [Article]
[2] Artz AS. Biologic vs physiologic age in the transplant candidate. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):99-105. [Pubmed]
[3] Muffly LS, Kocherginsky M, Stock W, Chu Q, Bishop MR, Godley LA, Kline J, Liu H, et al. Geriatric assessment to predict survival in older allogeneic hematopoietic cell transplantation recipients. Haematologica. 2014 Aug;99(8):1373-9. doi: 10.3324/haematol.2014.103655. [Pubmed]
[4] Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004 Mar;59(3):255-63. [Pubmed]
[5] Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007 May;55(5):780-91. [Pubmed]