Longitudinal trajectory of frailty in blood or marrow transplant survivors: Report from the Blood or Marrow Transplant Survivor Study

Participation in life activities after hematopoietic cell transplantation in older adults

OBJECTIVES

This study aims to measure activity participation and describe barriers and goals for participation in older adults post-HCT.

MATERIALS AND METHODS

In a convergent mixed methods design, we quantitatively assessed four domains of participation (instrumental, low demand leisure, high demand leisure, and social) using the modified Activity Card Sort (ACSm) and described cognitive, physical, and psychosocial function using validated measures. Semi-structured interviews were used to describe barriers and goals for participation.

RESULTS

Eighteen participants with the median age of 66 years (range 60-75 years) completed the ACSm and interview. Seventeen of the 18 participants were > 6 months post-HCT and 44% of the total participants were > 12 months out from transplant. Overall, participants returned to 80% of their total activities. Mean retention was the highest in low-demand leisure activities (89%), followed by instrumental (85%), social (77%), and high-demand leisure activities (59%). Fatigue and impaired physical function were barriers for all activity domains. Participants discussed cognitive function as a barrier for many instrumental and low-demand leisure activities. Side effects, complications (i.e., osteoporosis and GVHD) and immune suppression were barriers to high-demand leisure activities. Participants talked about the meaning and purpose behind activity participation, highlighting the centrality of returning to life activities despite ongoing symptoms. There were multiple goals discussed related to activity participation.

CONCLUSION

Older adults undergoing HCT have diminished functional reserve and need more time to recover from activities that require sustained energy. Physical activity promotion programs targeting activity limitations and participation restrictions in cancer survivors are particularly salient for older adults undergoing HCT.

Frailty assessment and outpatient pre-habilitation for adults undergoing allogeneic hematopoietic cell transplantation

This study reports the preliminary results of a Frailty program involving all allo-HCT candidates, initiated at our institution in April 2021. The program started with the assessment of patients' frailty at first consultation and at transplant admission using the HCT Frailty Scale. After observing the dynamics of the frailty syndrome, in June 2022 the program incorporated an individualized 4-8-weeks pre-habilitation program composed by personalized home-based exercise regimens to mitigate or prevent patients' frailty at transplantation. This study includes the 120 patients transplanted during the program, 58 of them participating in the pre-habilitation program. The results indicate that the distribution of frailty was the same in first consultation and at HCT admission in non-pre-habilitated patients, but it changed from the proportions of fit, pre-frail and frail patients of 22.8%, 66.7%, 10.5% at first consultation, to the proportions 45.6%, 50.9% and 3.5% (P = 0.041) at admission in the pre-habilitated ones. And that the likelihood of OS was lower in the frail than in the fit and the pre-frail groups (1-year OS: 45.7% vs. 77.2%, O = 0.021). Therefore, the study provides preliminary evidence that pre habilitation programs significantly reduces frailty among transplant candidates and, eventually, increase the likelihood of OS.

Restrictive Ventilatory Defects Following Hematopoietic Stem Cell Transplant Are Associated With Increased Mortality

INTRODUCTION

Hematopoietic cell transplantation (HCT) can potentially cure hematologic malignancies, but despite advancements in HCT regimens and graft-versus-host disease (GVHD) management, post-HCT complications, remain a major challenge. The epidemiology of post-HCT pulmonary impairment causing restrictive ventilatory defect (RVD) has not been examined. This study investigates the incidence, etiology, and impact of new-onset RVD following HCT on overall survival (OS) and non-relapse mortality (NRM).

METHODS

We conducted a retrospective review of adult patients who underwent their first allogeneic HCT for primary hematologic malignancies at The University of Texas MD Anderson Cancer Center between February 1999 and March 2018. RVD was defined by a total lung capacity (TLC) <5th percentile of the lower limit of normal. Patient data were analyzed using the Kaplan-Meier method, log-rank tests, and Cox regression models.

RESULTS

Among 3030 patients, 50 had pre-HCT RVD and 1275 developed new pulmonary impairment post-HCT, of which, we found 270 cases of new-onset RVD. The most common causes of post-HCT RVD were respiratory tract infections (23%), interstitial lung disease (15%) and truncal sclerosis (11%). Multivariate analysis indicated increased age (HR 1.03 per year, 95% CI 1.03-1.04, P < .001), matched unrelated donor transplant (HR 1.29, 95% CI 1.04-1.60, P = .02), mismatched related transplant (HR 2.04, 95% CI 1.33-3.14, P = .001), cord blood stem cell source (HR 3.02, 95% CI 2.26-4.05, P < .001), RVD (HR 2.27, 95% CI 1.77-2.90, P < .001) and cGVHD (HR 1.72, 95% CI 1.44-2.05, P < .001) were associated with higher mortality. More severe restriction (HR 4.04, 95% CI 2.83-5.77, P < .001), progressive RVD (5.04, 95% CI 1.88-13.52, P = .001), and RVD onset within 1 year of HCT (HR 2.61, 95% CI 1.72-3.98, P < .001) were associated with higher mortality.

CONCLUSION

New-onset RVD post-HCT is associated with increased mortality. These findings emphasize the importance of identifying RVD through proactive pulmonary function monitoring to improve post-HCT outcomes.

MicroRNA Profiles in Hematopoietic Stem Cell Transplant Recipients

Background: Hematopoietic Stem Cell Transplant (HCT) is a potentially curative treatment for hematologic malignancies, including multiple myeloma. Biomarker investigation can guide identification of HCT recipients at-risk for poor outcomes. MicroRNAs (miRNAs) are a class of non-coding RNAs involved in the modulation and regulation of pathological processes and are emerging as prognostic and predictive biomarkers for multiple health conditions. This pilot study aimed to examine miRNA profiles associated with HCT-related risk factors and outcomes in patients undergoing autologous HCT. Methods: Patients eligible for autologous HCT were recruited and blood samples and HCT-related variables were collected. Differential expression analysis of miRNA was conducted on 24 patient samples to compare changes in miRNA profile in HCT eligible patients before and after transplant. Results: Unsupervised clustering of differentially expressed (p < .05) miRNAs pre- and post- HCT identified clusters of up- and down-regulated miRNAs. Four miRNAs (miR-125a-5p, miR-99b-5p, miR-382-5p, miR-145-5p) involved in hematopoiesis (differentiation of progenitor cells, granulocyte function, thrombopoiesis, and tumor suppression) were significantly downregulated post-HCT. Correlation analyses identified select miRNAs associated with risk factors (such as frailty, fatigue, cognitive decline) and quality of life pre- and post-HCT. Select miRNAs were correlated with platelet engraftment. Conclusion: Future studies should examine miRNA signatures in larger cohorts in association with HCT outcomes; and expand investigations in patients receiving allogeneic transplants. This will lead to identification of biomarkers for risk stratification of HCT recipients.

Association of geriatric measures and global frailty with cognitive decline after allogeneic hematopoietic cell transplantation in older adults

INTRODUCTION

Allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, and its potential impact on cognition in this population is understudied. This work aims to evaluate the ability of cancer-specific geriatric assessments (cGA) and a global frailty index based on accumulation of deficits identified in the cGA to predict the risk of cognitive decline after alloHCT in older adults.

MATERIALS AND METHODS

AlloHCT recipients aged 50 years or older completed a cGA, including a cognitive evaluation by the Blessed Orientation Memory Concentration (BOMC) test, at baseline prior to alloHCT and then at 3, 6, and 12 months after transplant. Baseline frailty was assessed using a deficit accumulation frailty index (DAFI) calculated from the cGA. A multinomial logit model was used to examine the association between predictors (individual cGA measures, DAFI) and the following three outcomes: alive with stable or improved cognition, alive with cognitive decline, and deceased. In post-hoc analyses, analysis of variance was used to compare BOMC scores at baseline, 3, 6, and 12 months across frailty categories.

RESULTS

In total, 148 participants were included, with a median age of 62 (range 50-76). At baseline, 12% had cognitive impairment; at one year, 29% of survivors had improved BOMC scores, 33% had stable BOMC, and 37% had worse BOMC. Prior to transplant, 25% were pre-frail and 11% were frail. Individual baseline cGA measures were not associated with cognitive change at one year as assessed by BOMC. Adjusting for age, sex, and education, those who were frail at baseline were 7.4 times as likely to develop cognitive decline at one year than those who were non-frail, although this finding did not reach statistical significance (95% confidence interval [CI] 0.74-73.8, p = 0.09). The probability of being alive with stable/improved cognition at 12 months for the non-frail, pre-frail, and frail groups was 43%, 34%, and 8%, respectively.

DISCUSSION

Baseline geriatric measures and frailty were not significantly associated with cognitive change as assessed by BOMC in adults aged 50 or older after alloHCT. However, the study was underpowered to detect clinically meaningful differences, and future work to elucidate potential associations between frailty and cognitive outcomes is warranted.

HCT frailty scale for younger and older adults undergoing allogeneic hematopoietic cell transplantation

The HCT Frailty Scale is an easy prognostic tool composed of (a) Clinical Frailty Scale; (b) Instrumental Activities of Daily Living; (c) Timed-up-and-Go test; (d) Grip Strength; (e) Self-Health Rated Questionnaire; (f) Falls tests; (g) Albumin and C-reactive protein levels. This scale was designed to classify allogeneic hematopoietic cell transplant (alloHCT) candidates into fit, pre-frail and frail groups, irrespective of age. This study evaluates the ability of this frailty classification to predict overall survival (OS) and non-relapse mortality (NRM) in adult patients of all ages, in a prospective sample of 298 patients transplanted between 2018 and 2020. At first consultation, 103 (34.6%) patients were fit, 148 (49.7%) pre-frail, and 47 (15.8%) were frail. The 2-year OS and NRM of the three groups were 82.9%, 67.4%, and 48.3% (P < 0.001), and 5.4%, 19.2%, and 37.7% (P < 0.001). For patients younger than 60 years (n = 174), the 2-year OS and NRM of fit, pre-frail, and frail groups were 88.4%, 69.3% and 53.1% (P = 0.002), and 5.8%, 22.8%, and 34.8% (P = 0.005), respectively; and in patients older than 60 (n = 124), OS and NRM were 75.5%, 63.8% and 41.4% (P = 0.006), and 4.9%, 16.4%, and 42.1% (P = 0.001). In conclusion, frailty predicted worse transplant outcomes in both younger and older adults.

Frailty in Patients with Chronic Graft-versus-Host Disease

Frailty is an increasingly recognized clinical diagnosis associated with high risk of disability and mortality. Frailty in patients after hematopoietic cell transplantation (HCT) is associated with increased nonrelapse mortality (NRM) and decreased overall survival (OS). Frailty has not been studied extensively in patients with chronic graft-versus-host disease (cGVHD). The objectives of the present study were to assess the prevalence and clinical correlates of frailty and the association of frailty with NRM and OS in patients enrolled in the Chronic GVHD Consortium. Patients were characterized as frail if they met the Fried definition of ≥3 of the following criteria at enrollment: unintentional weight loss, exhaustion, slow walking speed, low physical activity, and weakness. Frailty was assessed retrospectively using surrogate measures for the 5 domains of frailty. Frailty, cGVHD organ scores, and patient-reported outcomes were measured at the time of enrollment. The study included 399 patients from 9 centers in the United States, with 32% characterized as frail and 68% as not frail. The median duration of follow-up from enrollment was 9 years (interquartile range, 7 to 11 years). Frail patients were more likely to be older (P = .004), to have a lower Karnofsky Performance Status (P < .001), to have severe cGVHD (P < .001), and to have gastrointestinal (P < .001), liver (P = .04), or lung cGVHD (P = .002). In a multivariable analysis, older age, increased cGVHD global severity, and thrombocytopenia were statistically significantly associated with frailty when cGVHD organ involvement was excluded. A separate analysis excluding cGVHD severity and including organ involvement showed that lung and liver cGVHD and older age were associated with frailty. Neither corticosteroid use at the time of enrollment nor the maximum recorded dose of corticosteroids before enrollment was associated with frailty. Frail patients had higher NRM than nonfrail patients (P < .001), with a 10-year cumulative incidence of 41% (95% confidence interval [CI], 32% to 49%) versus 22% (95% CI, 17% to 28%). Reciprocally, frailty also was associated with a significantly lower OS (P < .001), with a 10-year OS of 43% (95% CI, 35% to 53%) in frail patients versus 63% (95% CI, 57% to 69%) in nonfrail patients. In multivariable analysis that included the individual domains of frailty, weakness, low physical activity, and slow walking speed were associated with survival. Frail patients also had worse scores on various measures of patient-reported outcomes, including the Short Form (SF)-36, the Lee Symptom Scale, and the trial outcome of the Functional Assessment of Cancer Therapy-Bone Marrow Transplantation (FACT-BMT) index score. Frail patients with cGVHD have significantly worse outcomes than nonfrail patients. Such clinical features as older age and lung and liver cGVHD are associated with frailty. Earlier clinical recognition of frailty in patients with cGVHD may prompt interventions to counteract frailty that could be beneficial for this population.

DNA Methylation Changes in Autologous Hematopoietic Stem Cell Transplant Patients

BACKGROUND

Blood cancers may be potentially cured with hematopoietic stem cell transplantation (HCT); however, standard pre-assessments for transplant eligibility do not capture all contributing factors for transplant outcomes. Epigenetic biomarkers predict outcomes in various diseases. This pilot study aims to explore epigenetic changes (epigenetic age and differentially methylated genes) in patients before and after autologous HCT, that can serve as potential biomarkers to better predict HCT outcomes.

METHODS

This study used a prospective longitudinal study design to compare genome wide DNA methylation changes in 36 autologous HCT eligible patients recruited from the Cellular Immunotherapies and Transplant clinic at a designated National Cancer Center.

RESULTS

Genome-wide DNA methylation, measured by the Illumina Infinium Human Methylation 850K BeadChip, showed a significant difference in DNA methylation patterns post-HCT compared to pre-HCT. Compared to baseline levels of DNA methylation pre-HCT, 3358 CpG sites were hypo-methylated and 3687 were hyper-methylated. Identified differentially methylated positions overlapped with genes involved in hematopoiesis, blood cancers, inflammation and immune responses. Enrichment analyses showed significant alterations in biological processes such as immune response and cell structure organization, however no significant pathways were noted. Though participants had an advanced epigenetic age compared to chronologic age before and after HCT, both epigenetic age and accelerated age decreased post-HCT.

CONCLUSION

Epigenetic changes, both in epigenetic age and differentially methylated genes were observed in autologous HCT recipients, and should be explored as biomarkers to predict transplant outcomes after autologous HCT in larger, longitudinal studies.

Impact of lung function impairment after allogeneic hematopoietic stem cell transplantation

Late-onset noninfectious pulmonary complications (LONIPC) are a major cause of morbidity and mortality after allogeneic hematopoietic stem cell transplantation (HSCT). However, the clinical impact of lung function deterioration itself in long-term adult survivors of HSCT remains to be fully investigated. This retrospective, longitudinal study aimed to investigate pulmonary function following HSCT in terms of its change and the clinical significance of its decline. We examined 167 patients who survived for at least 2 years without relapse. The median follow-up period was 10.3 years. A linear mixed-effects model showed that the slope of pulmonary function tests values, including percent vital capacity (%VC), percent forced expiratory volume in one second (%FEV₁), and FEV₁/forced VC ratio (FEV₁%), decreased over time. The cumulative incidence of newly obstructive and restrictive lung function impairment (LFI) at 10 years was 15.7% and 19.5%, respectively. Restrictive LFI was a significant, independent risk factor for overall survival (hazard ratio 7.11, P = 0.007) and non-relapse mortality (hazard ratio 12.19, P = 0.003). Our data demonstrated that lung function declined over time after HSCT and that the decline itself had a significant impact on survival regardless of LONIPC.

Cancer-related accelerated ageing and biobehavioural modifiers: a framework for research and clinical care

A growing body of evidence indicates that patients with cancer who receive cytotoxic treatments (such as chemotherapy or radiotherapy) have an increased risk of accelerated physical and cognitive ageing. Furthermore, accelerated biological ageing is a suspected driving force behind many of these observed effects. In this Review, we describe the mechanisms of biological ageing and how they apply to patients with cancer. We highlight the important role of specific behavioural factors, namely stress, sleep and lifestyle-related factors such as physical activity, weight management, diet and substance use, in the accelerated ageing of patients with cancer and cancer survivors. We also present a framework of how modifiable behaviours could operate to either increase the risk of accelerated ageing, provide protection, or promote resilience at both the biological level and in terms of patient-reported outcomes.