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Dezan MGF, Cavalcante LN, Silva HRC, de Moura Almeida A, Dos Santos de Assis LH, de Freitas TT, de Araújo MAS, Cotrim HP, Lyra AC. Hepatobiliary disease after bone marrow transplant: A cross-sectional study of 377 patients. Aliment Pharmacol Ther 2024; 59:71-79. [PMID: 37833826 DOI: 10.1111/apt.17756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/03/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Bone marrow transplantation (BMT) is a standard treatment for several haematologic conditions. Following BMT, patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischaemic hepatitis, and fulminant hepatitis. AIMS To evaluate the frequency, clinical characteristics, and outcomes of patients with hepatobiliary alterations associated with BMT in a tertiary referral centre. METHODS This was a cross-sectional study with data collected from the medical records of patients undergoing BMT between January 2017 and June 2022. We diagnosed hepatobiliary complications based on established criteria. RESULTS We included 377 patients; 55.7% had hepatobiliary complications. Female gender, pre-BMT hepatobiliary alteration, and haploidentical allogeneic transplantation were associated with increased risk with odds ratios (OR) of 1.8 (p = 0.005), 1.72 (p = 0.013) and 3.25 (p = 0.003), respectively. Patients with hepatobiliary complications spent longer in the hospital than those without (27.7 × 19.3 days, respectively; p < 0.001). Among 210 patients with hepatobiliary complications, 28 died compared to 5 of 167 without complications (OR 4.98; p = 0.001). CONCLUSIONS Hepatobiliary complications are frequent in patients undergoing BMT. There is a greater risk of their occurrence in women, people with pre-BMT liver alterations, and in haploidentical transplants. The occurrence of these complications increases the length of stay and is associated with a higher risk of death.
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Affiliation(s)
- Maria Gabriela Fernandes Dezan
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Lourianne Nascimento Cavalcante
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Hugo Rodrigues Carvalho Silva
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
| | - Alessandro de Moura Almeida
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Hematology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
| | | | - Tiago Thalles de Freitas
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
| | - Marco Aurélio Salvino de Araújo
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Hematology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Hematology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
| | - Helma Pinchemel Cotrim
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
| | - Andre Castro Lyra
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael-Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service-University Hospital Professor Edgard Santos (HUPES), Federal University of Bahia, Salvador, Bahia, Brazil
- Postgraduate Program in Medicine and Health, Federal University of Bahia, Salvador, Bahia, Brazil
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Dezan MGF, Cavalcante LN, Cotrim HP, Lyra AC. Hepatobiliary disease after bone marrow transplant. Expert Rev Gastroenterol Hepatol 2023; 17:129-143. [PMID: 36655915 DOI: 10.1080/17474124.2023.2169671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Bone marrow transplantation (BMT) is the standard treatment for several hematologic pathologies. Post-BMT patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischemic and fulminant hepatitis, among others. AREA COVERED Defining the etiology of hepatobiliary injury is challenging due to the overlapping symptoms. Thus, it is necessary to be aware of and understand the clinical characteristics of these hepatobiliary complications and provide adequate management with possible better outcomes. We reviewed the scientific literature focused on early hepatobiliary complications associated with BMT. We searched the PubMed database using the following descriptors: hepatic complications, drug-induced liver disease, graft-versus-host disease, cholestasis, sepsis, sinusoidal obstruction syndrome, cytomegalovirus, viral hepatitis, bone marrow transplantation, and hematopoietic stem cell transplantation. EXPERT OPINION Post-BMT hepatobiliary complications comprise several differential diagnoses and are challenges for the hepatologist's clinical practice. When evaluating these patients, it is necessary to consider the temporality between the use of certain medications, the increase in liver enzymes, and the presence of infection, in addition to applying diagnostic criteria and complementary tests for a specific diagnosis.
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Affiliation(s)
- Maria Gabriela Fernandes Dezan
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil.,Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Lourianne Nascimento Cavalcante
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil.,Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Helma Pinchemel Cotrim
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Andre Castro Lyra
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil.,Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
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Pitfalls and Successes in Trials in Older Transplant Patients with Hematologic Malignancies. Curr Oncol Rep 2022; 24:125-133. [DOI: 10.1007/s11912-022-01194-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/03/2022]
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4
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Kanate AS, Majhail NS, Savani BN, Bredeson C, Champlin RE, Crawford S, Giralt SA, LeMaistre CF, Marks DI, Omel JL, Orchard PJ, Palmer J, Saber W, Veys PA, Carpenter PA, Hamadani M. Indications for Hematopoietic Cell Transplantation and Immune Effector Cell Therapy: Guidelines from the American Society for Transplantation and Cellular Therapy. Biol Blood Marrow Transplant 2020; 26:1247-1256. [PMID: 32165328 DOI: 10.1016/j.bbmt.2020.03.002] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 12/20/2022]
Abstract
The American Society for Transplantation and Cellular Therapy (ASTCT) published its first white paper on indications for autologous and allogeneic hematopoietic cell transplantation (HCT) in 2015. It was identified at the time that periodic updates of indications would be required to stay abreast with state of the art and emerging indications and therapy. In recent years the field has not only seen an improvement in transplantation technology, thus widening the therapeutic scope of HCT, but additionally a whole new treatment strategy using modified immune effector cells, including chimeric antigen receptor T cells and engineered T-cell receptors, has emerged. The guidelines review committee of the ASTCT deemed it optimal to update the ASTCT recommendations for indications for HCT to include new data and to incorporate indications for immune effector cell therapy (IECT) where appropriate. The guidelines committee established a multiple stakeholder task force consisting of transplant experts, payer representatives, and a patient advocate to provide guidance on indications for HCT and IECT. This article presents the updated recommendations from the ASTCT on indications for HCT and IECT. Indications for HCT/IECT were categorized as (1) Standard of care, where indication is well defined and supported by evidence; (2) Standard of care, clinical evidence available, where large clinical trials and observational studies are not available but have been shown to be effective therapy; (3) Standard of care, rare indication, for rare diseases where demonstrated effectiveness exists but large clinical trials and observational studies are not feasible; (4) Developmental, for diseases where preclinical and/or early-phase clinical studies show HCT/IECT to be a promising treatment option; and (5) Not generally recommended, where available evidence does not support the routine use of HCT/IECT. The ASTCT will continue to periodically review these guidelines and update them as new evidence becomes available.
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Affiliation(s)
- Abraham S Kanate
- Hematopoietic Malignancy & Cellular Therapy Program, West Virginia University, Morgantown, West Virginia.
| | - Navneet S Majhail
- Blood & Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher Bredeson
- Division of Hematology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - David I Marks
- Adult BMT Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Paul J Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona
| | - Wael Saber
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
| | - Paul A Veys
- Bone Marrow Transplantation Unit, Great Ormond Street Hospital for Children, London, UK
| | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mehdi Hamadani
- BMT & Cellular Therapy Program, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
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Kanate AS, Nagler A, Savani B. Summary of Scientific and Statistical Methods, Study Endpoints and Definitions for Observational and Registry-Based Studies in Hematopoietic Cell Transplantation. Clin Hematol Int 2019; 2:2-4. [PMID: 34595436 PMCID: PMC8432337 DOI: 10.2991/chi.d.191207.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 12/03/2019] [Indexed: 11/02/2022] Open
Abstract
Due to the increasingly strict word/character restrictions enforced by most scientific publications, we identified a need for a master document illustrating the "Scientific Methods" that may be applicable to the majority of observational and registry-based studies in hematopoietic cell transplantation (HCT). The purpose of this study is to serve as a reference document that describes the data source, study endpoints and statistical analyses utilized most commonly in retrospective studies in HCT. To this end we compile, define and reference the methodology commonly used in HCT research. While it is recognized that the scientific methodology may periodically require updates due to the evolving landscape of transplant research, such as newer study endpoints and statistical methods, this manuscript describes frequently used methodologies.
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Affiliation(s)
- Abraham S Kanate
- Hematopoietic Malignancy and Cellular Therapy, West Virginia University Cancer Institute, Morgantown, WV, USA
| | - Arnon Nagler
- Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Bipin Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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6
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Mourad N, Michel RP, Marcus VA. Pathology of Gastrointestinal and Liver Complications of Hematopoietic Stem Cell Transplantation. Arch Pathol Lab Med 2019; 143:1131-1143. [PMID: 30838881 DOI: 10.5858/arpa.2018-0282-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
CONTEXT.— Despite advances in therapeutic and preventive measures, hematopoietic stem cell transplant recipients remain at risk for a variety of gastrointestinal and liver complications. OBJECTIVE.— To detail the pathologic features of the various gastrointestinal and liver complications occurring after hematopoietic stem cell transplantation in relation to their clinical context. The specific complications covered include graft-versus-host disease, mycophenolate mofetil-induced injury, timeline of infections, neutropenic enterocolitis, gastrointestinal thrombotic microangiopathy, sinusoidal obstruction syndrome, hepatic iron overload, and the controversy around cord colitis syndrome. DATA SOURCES.— The content of this article is based on pertinent peer-reviewed articles in PubMed, relevant textbooks, and on the authors' personal experiences. CONCLUSIONS.— The final histopathologic diagnosis requires the integration of clinical and histologic findings and the exclusion of other competing causes of injury. Review of the clinical data, including the original disease pretransplant, the type of transplant, the timing of the gastrointestinal and/or liver manifestations, the timing of the biopsy after transplant, the presence of graft-versus-host disease in other organs and sites, the list of drug regimens, and the clinical and laboratory evidence of infection, is the key to reaching the proper histologic diagnosis.
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Affiliation(s)
- Nathalie Mourad
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - René P Michel
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
| | - Victoria A Marcus
- Faculté de médecine, département de biologie moléculaire, de biochimie médicale et de pathologie, Université Laval, Hôpital du Saint-Sacrement - CHU de Québec, Québec, Québec, Canada (Dr Mourad); the Department of Pathology, McGill University and McGill University Health Center, Montreal, Quebec, Canada (Drs Michel and Marcus)
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Autologous Hematopoietic Cell Transplantation for Treatment-Refractory Relapsing Multiple Sclerosis: Position Statement from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:845-854. [PMID: 30794930 DOI: 10.1016/j.bbmt.2019.02.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/14/2019] [Indexed: 12/29/2022]
Abstract
Multiple sclerosis (MS) is a chronic, disabling, immune-mediated, demyelinating and degenerative disease of the central nervous system. Approved disease-modifying therapies may be incompletely effective in some patients with highly active relapsing disease and high risk of disability. The use of immunoablative or myeloablative therapy followed by autologous hematopoietic cell transplantation (AHCT) has been investigated in retrospective studies, clinical trials, and meta-analyses/systematic reviews as an approach to address this unmet clinical need. On behalf of the American Society for Blood and Bone Marrow Transplantation (ASBMT), a panel of experts in AHCT and MS convened to review available evidence and make recommendations on MS as an indication for AHCT. A review of recent literature identified 8 retrospective studies, 8 clinical trials, and 3 meta-analyses/systematic reviews. In aggregate, these studies indicate that AHCT is an efficacious and safe treatment for active relapsing forms of MS to prevent clinical relapse, magnetic resonance imaging-detectable lesion activity, and worsening disability and to reverse disability without unexpected adverse events. Based on the available evidence, the ASBMT recommends that treatment-refractory relapsing MS with high risk of future disability be considered a "standard of care, clinical evidence available" indication for AHCT. Collaboration of neurologists with expertise in treating MS and transplantation physicians with experience performing AHCT for autoimmune disease is crucial for ensuring appropriate patient selection and optimizing transplantation procedures to improve patient outcomes. Transplantation centers in the United States and Canada are strongly encouraged to report baseline and outcomes data on patients receiving AHCT for multiple sclerosis to the Center for International Blood and Marrow Transplant Research.
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Shah GL, Majhail N, Khera N, Giralt S. Value-Based Care in Hematopoietic Cell Transplantation and Cellular Therapy: Challenges and Opportunities. Curr Hematol Malig Rep 2018; 13:125-134. [PMID: 29484578 DOI: 10.1007/s11899-018-0444-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW Improved tolerability and outcomes after hematopoietic cell transplantation (HCT), along with the availability of alternative donors, have expanded its use. With this growth, and the development of additional cellular therapies, we also aim to increase effectiveness, efficiency, and the quality of the care provided. Fundamentally, the goal of value-based care is to have better health outcomes with streamlined processes, improved patient experience, and lower costs for both the patients and the health care system. HCT and cellular therapy treatments are multiphase treatments which allow for interventions at each juncture. RECENT FINDINGS We present a summary of the current literature with focus on program structure and overall system capacity, coordination of therapy across providers, standardization across institutions, diversity and disparities in care, patient quality of life, and cost implications. Each of these topics provides challenges and opportunities to improve value-based care for HCT and cellular therapy patients.
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Affiliation(s)
- Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 298, New York, NY, 10065, USA.
| | - Navneet Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, OH, USA
| | - Nandita Khera
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, AZ, USA
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Box 298, New York, NY, 10065, USA
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Sullivan KM, Majhail NS, Bredeson C, Carpenter PA, Chatterjee S, Crofford LJ, Georges GE, Nash RA, Pasquini MC, Sarantopoulos S, Storek J, Savani B, St Clair EW. Systemic Sclerosis as an Indication for Autologous Hematopoietic Cell Transplantation: Position Statement from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2018; 24:1961-1964. [PMID: 29953945 DOI: 10.1016/j.bbmt.2018.06.025] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 06/19/2018] [Indexed: 12/29/2022]
Abstract
Systemic sclerosis is a progressive inflammatory disease that is frequently fatal and has limited treatment options. High-dose chemotherapy with autologous hematopoietic cell transplantation (AHCT) has been evaluated as treatment for this disease in observational studies, multicenter randomized controlled clinical trials, and meta-analyses. On behalf of the American Society for Blood and Marrow Transplantation (ASBMT), a panel of experts in transplantation and rheumatology was convened to review available evidence and make a recommendation on AHCT as an indication for systemic sclerosis. Three randomized trials have compared the efficacy of AHCT with cyclophosphamide only, and all demonstrated benefit for the AHCT arm for their primary endpoint (improvement in the American Scleroderma Stem Cell versus Immune Suppression Trial, event-free survival in Autologous Stem Cell Transplantation International Scleroderma trial, and change in global rank composite score in Scleroderma: Cyclophosphamide or Transplantation trial). AHCT recipients also had better overall survival and a lower rate of disease progression. These findings have been confirmed in subsequent meta-analyses. Based on this high-quality evidence, the ASBMT recommends systemic sclerosis should be considered as a "standard of care" indication for AHCT. Close collaboration between rheumatologists and transplant clinicians is critical for optimizing patient selection and patient outcomes. Transplant centers in the United States are strongly encouraged to report patient and outcomes data to the Center for International Blood and Marrow Transplant Research on their patients receiving AHCT for this indication.
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Affiliation(s)
- Keith M Sullivan
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina.
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Cleveland Clinic, Cleveland, Ohio
| | | | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Soumya Chatterjee
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio
| | - Leslie J Crofford
- Division of Rheumatology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - George E Georges
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Richard A Nash
- Blood and Marrow Transplant Program, Colorado Blood Cancer Institute, Denver, Colorado
| | - Marcelo C Pasquini
- Department of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee, Wisconsin
| | - Stefanie Sarantopoulos
- Department of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Jan Storek
- Blood and Marrow Transplant Program, University of Calgary, Calgary, Alberta, Canada
| | - Bipin Savani
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E William St Clair
- Department of Rheumatology and Immunology, Duke University School of Medicine, Durham, North Carolina
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10
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Steps to Enhance Early Recovery After Hematopoietic Stem Cell Transplantation: Lessons Learned From a Physical Activity Feasibility Study. CLIN NURSE SPEC 2018; 32:152-162. [PMID: 29621110 DOI: 10.1097/nur.0000000000000374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS This pilot study tested and refined a free-living physical activity intervention. The investigators evaluated the acceptability and feasibility of the intervention after hematopoietic stem cell transplantation and determined preliminary effects on physical activity, fatigue, muscle strength, functional ability, and quality of life. DESIGN This pilot study used a 1-group, pretest-posttest design. METHODS The free-living physical activity intervention consisted of an education component and 6 weeks of gradually increasing physical activity after discharge from the hospital. The intervention was designed to increase steps by 10% weekly. Subjects were assessed before transplantation and during the seventh week after discharge from the hospital after completing the intervention. Pretest-posttest scores were analyzed with paired t tests. RESULTS Subject wore the physical activity tracker for an average of 38 of 42 days and met their physical activity goals 57% of the time. Subjects reported significantly less physical fatigue after the free-living physical activity intervention compared with baseline (P = .05). Improvements in quality of life approached significance (P = .06). CONCLUSION The findings demonstrate that the free-living physical activity intervention implemented during the very early recovery period after transplantation is feasible and acceptable. The intervention potentially reduces fatigue and improves quality of life. The positive results must be interpreted cautiously given the pilot nature of the study. The evidence supports continued investigation.
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11
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Gajewski JL, McClellan MB, Majhail NS, Hari PN, Bredeson CN, Maziarz RT, LeMaistre CF, Lill MC, Farnia SH, Komanduri KV, Boo MJ. Payment and Care for Hematopoietic Cell Transplantation Patients: Toward a Specialized Medical Home for Complex Care Patients. Biol Blood Marrow Transplant 2017; 24:4-12. [PMID: 28963077 DOI: 10.1016/j.bbmt.2017.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 09/20/2017] [Indexed: 12/15/2022]
Abstract
Patient-centered medical home models are fundamental to the advanced alternative payment models defined in the Medicare Access and Children's Health Insurance Plan Reauthorization Act (MACRA). The patient-centered medical home is a model of healthcare delivery supported by alternative payment mechanisms and designed to promote coordinated medical care that is simultaneously patient-centric and population-oriented. This transformative care model requires shifting reimbursement to include a per-patient payment intended to cover services not previously reimbursed such as disease management over time. Payment is linked to quality measures, including proportion of care delivered according to predefined pathways and demonstrated impact on outcomes. Some medical homes also include opportunities for shared savings by reducing overall costs of care. Recent proposals have suggested expanding the medical home model to specialized populations with complex needs because primary care teams may not have the facilities or the requisite expertise for their unique needs. An example of a successful care model that may provide valuable lessons for those creating specialty medical home models already exists in many hematopoietic cell transplantation (HCT) centers that deliver multidisciplinary, coordinated, and highly specialized care. The integration of care delivery in HCT centers has been driven by the specialty care their patients require and by the payment methodology preferred by the commercial payers, which has included bundling of both inpatient and outpatient care in the peritransplant interval. Commercial payers identify qualified HCT centers based on accreditation status and comparative performance, enabled in part by center-level comparative performance data available within a national outcomes database mandated by the Stem Cell Therapeutic and Research Act of 2005. Standardization across centers has been facilitated via voluntary accreditation implemented by Foundation for the Accreditation of Cell Therapy. Payers have built on these community-established programs and use public outcomes and program accreditation as standards necessary for inclusion in specialty care networks and contracts. Although HCT centers have not been described as medical homes, most HCT providers have already developed the structures that address critical requirements of MACRA for medical homes.
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Affiliation(s)
- James L Gajewski
- Department of Health Policy and Strategic Relations, American Society for Blood and Marrow Transplantation, Chicago, Illinois.
| | - Mark B McClellan
- Duke University Margolis Center for Health Policy, Durham, North Carolina
| | - Navneet S Majhail
- Blood and Marrow Transplant Program, Division of Hematology & Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Parameswaran N Hari
- Center for International Blood and Marrow Transplantation Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Richard T Maziarz
- Stem Cell Transplantation Program, Division of Hematology & Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | | | - Michael C Lill
- Stem Cell and Bone Marrow Transplant Program, Division of Hematology and Medical Oncology, Samuel Oschin Comprehensive Cancer Center, Los Angeles, California
| | - Stephanie H Farnia
- Department of Health Policy and Strategic Relations, American Society for Blood and Marrow Transplantation, Chicago, Illinois
| | - Krishna V Komanduri
- Adult Hematopoietic Stem Cell Transplant Program, Division of Hematology, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Michael J Boo
- National Marrow Donor Program, Minneapolis, Minnesota
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12
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Patient-centered care coordination in hematopoietic cell transplantation. Blood Adv 2017; 1:1617-1627. [PMID: 29296802 DOI: 10.1182/bloodadvances.2017008789] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 07/19/2017] [Indexed: 11/20/2022] Open
Abstract
Hematopoietic cell transplantation (HCT) is an expensive, resource-intensive, and medically complicated modality for treatment of many hematologic disorders. A well-defined care coordination model through the continuum can help improve health care delivery for this high-cost, high-risk medical technology. In addition to the patients and their families, key stakeholders include not only the transplantation physicians and care teams (including subspecialists), but also hematologists/oncologists in private and academic-affiliated practices. Initial diagnosis and care, education regarding treatment options including HCT, timely referral to the transplantation center, and management of relapse and late medical or psychosocial complications after HCT are areas where the referring hematologists/oncologists play a significant role. Payers and advocacy and community organizations are additional stakeholders in this complex care continuum. In this article, we describe a care coordination framework for patients treated with HCT within the context of coordination issues in care delivery and stakeholders involved. We outline the challenges in implementing such a model and describe a simplified approach at the level of the individual practice or center. This article also highlights ongoing efforts from physicians, medical directors, payer representatives, and patient advocates to help raise awareness of and develop access to adequate tools and resources for the oncology community to deliver well-coordinated care to patients treated with HCT. Lastly, we set the stage for policy changes around appropriate reimbursement to cover all aspects of care coordination and generate successful buy-in from all stakeholders.
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13
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Farnia S, Ganetsky A, Silver A, Hwee T, Preussler J, Griffin J, Khera N. Challenges around Access to and Cost of Life-Saving Medications after Allogeneic Hematopoietic Cell Transplantation for Medicare Patients. Biol Blood Marrow Transplant 2017; 23:1387-1392. [PMID: 28412517 DOI: 10.1016/j.bbmt.2017.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/09/2017] [Indexed: 12/16/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an expensive, medically complicated, and potentially life-threatening therapy for multiple hematologic and nonhematologic disorders with a prolonged trajectory of recovery. Similar to financial issues in other cancer treatments, adverse financial consequences of HCT are emerging as an important issue and may be associated with poor quality of life and increased distress in HCT survivors. Prescription medicine coverage for HCT for Medicare and some Medicaid beneficiaries, especially in the long-term, remains suboptimal because of inadequate payer formularies or prohibitive copays. With an increasing number of older patients undergoing HCT and improvement in the overall survival after HCT, the problem of financial burden faced by Medicare beneficiaries with fixed incomes is going to worsen. In this article, we describe the typical financial burden borne by HCT recipients based on estimated copayment amounts attached to the categories of key medications as elucidated through 2 case studies. We also suggest some possible solutions for consideration to help these patients and families get through the HCT by minimizing the financial burden from essential medications needed during the post-HCT period.
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Affiliation(s)
- Stephanie Farnia
- Health Policy and Strategic Relations, American Society for Blood and Marrow Transplantation, Arlington Heights, Illinois
| | - Alex Ganetsky
- Blood and Marrow Transplantation Program, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alicia Silver
- Payer Policy and Legislative Relations, National Marrow Donor Program, Minneapolis, Minnesota
| | - Theresa Hwee
- Payer Policy and Legislative Relations, National Marrow Donor Program, Minneapolis, Minnesota
| | - Jaime Preussler
- Payer Policy and Legislative Relations, National Marrow Donor Program, Minneapolis, Minnesota
| | - Joan Griffin
- Division of Health Care Policy and Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic Rochester, Rochester, Minnesota
| | - Nandita Khera
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
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14
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Hashmi SK, Bredeson C, Duarte RF, Farnia S, Ferrey S, Fitzhugh C, Flowers MED, Gajewski J, Gastineau D, Greenwald M, Jagasia M, Martin P, Rizzo JD, Schmit-Pokorny K, Majhail NS. National Institutes of Health Blood and Marrow Transplant Late Effects Initiative: The Healthcare Delivery Working Group Report. Biol Blood Marrow Transplant 2016; 23:717-725. [PMID: 27713091 DOI: 10.1016/j.bbmt.2016.09.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 09/30/2016] [Indexed: 12/16/2022]
Abstract
Hematopoietic cell transplantation (HCT) survivors are at risk for development of late complications and require lifelong monitoring for screening and prevention of late effects. There is an increasing appreciation of the issues related to healthcare delivery and coverage faced by HCT survivors. The 2016 National Institutes of Health Blood and Marrow Transplant Late Effects Initiative included an international and broadly representative Healthcare Delivery Working Group that was tasked with identifying research gaps pertaining to healthcare delivery and to identify initiatives that may yield a better understanding of the long-term value and costs of care for HCT survivors. There is a paucity of literature in this area. Critical areas in need of research include pilot studies of novel and information technology supported models of care delivery and coverage for HCT survivors along with development and validation of instruments that capture patient-reported outcomes. Investment in infrastructure to support this research, such as linkage of databases including electronic health records and routine inclusion of endpoints that will inform analyses focused around care delivery and coverage, is required.
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Affiliation(s)
| | - Christopher Bredeson
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Rafael F Duarte
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | | | - Mary E D Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | | | | | | | - J Douglas Rizzo
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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15
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Majhail NS, Farnia SH, Carpenter PA, Champlin RE, Crawford S, Marks DI, Omel JL, Orchard PJ, Palmer J, Saber W, Savani BN, Veys PA, Bredeson CN, Giralt SA, LeMaistre CF. Indications for Autologous and Allogeneic Hematopoietic Cell Transplantation: Guidelines from the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2015; 21:1863-1869. [PMID: 26256941 DOI: 10.1016/j.bbmt.2015.07.032] [Citation(s) in RCA: 265] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 07/31/2015] [Indexed: 02/07/2023]
Abstract
Approximately 20,000 hematopoietic cell transplantation (HCT) procedures are performed in the United States annually. With advances in transplantation technology and supportive care practices, HCT has become safer, and patient survival continues to improve over time. Indications for HCT continue to evolve as research refines the role for HCT in established indications and identifies emerging indications where HCT may be beneficial. The American Society for Blood and Marrow Transplantation (ASBMT) established a multiple-stakeholder task force consisting of transplant experts, payer representatives, and a patient advocate to provide guidance on "routine" indications for HCT. This white paper presents the recommendations from the task force. Indications for HCT were categorized as follows: (1) Standard of care, where indication for HCT is well defined and supported by evidence; (2) Standard of care, clinical evidence available, where large clinical trials and observational studies are not available but HCT has been shown to be effective therapy; (3) Standard of care, rare indication, for rare diseases where HCT has demonstrated effectiveness but large clinical trials and observational studies are not feasible; (4) Developmental, for diseases where preclinical and/or early phase clinical studies show HCT to be a promising treatment option; and (5) Not generally recommended, where available evidence does not support the routine use of HCT. The ASBMT will periodically review these guidelines and will update them as new evidence becomes available.
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Affiliation(s)
| | | | - Paul A Carpenter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - David I Marks
- Adult BMT Unit, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Paul J Orchard
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, AZ
| | - Wael Saber
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI
- Center for International Blood and Marrow Transplant Research, Milwaukee, WI
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Paul A Veys
- Bone Marrow Transplantation Unit, Great Ormond Street Hospital for Children, London, UK
| | | | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY
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