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Lin RJ, Dahi PB, Korc-Grodzicki B, Shahrokni A, Jakubowski AA, Giralt SA. Transplantation and Cellular Therapy for Older Adults-The MSK Approach. Curr Hematol Malig Rep 2024; 19:82-91. [PMID: 38332462 PMCID: PMC11126330 DOI: 10.1007/s11899-024-00725-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE OF REVIEW Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers. RECENT FINDINGS Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.
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Affiliation(s)
- Richard J Lin
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA.
- David H. Koch Center for Cancer Care, Memorial Sloan Kettering Cancer Center, 530 E 74th Street, Room 21-142, New York, NY, 10022, USA.
| | - Parastoo B Dahi
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Beatriz Korc-Grodzicki
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Ann A Jakubowski
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
| | - Sergio A Giralt
- Adult Blood and Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, 10065, USA
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Jayani RV. How old is too old? Frailty and geriatric assessments of older patients undergoing allogeneic HCT. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:709-714. [PMID: 38066893 PMCID: PMC10727072 DOI: 10.1182/hematology.2023000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is a curative-intent treatment for many hematologic malignancies but carries a significant risk of morbidity and mortality. An increasing number of older adults are receiving HCT, but current pretransplant evaluations overlook the unique vulnerabilities that older adults face. Oncology-specific geriatric and frailty assessments provide a comprehensive evaluation of older adults, help better weigh the risks of HCT with patients, and guide personalized optimization strategies to minimize vulnerabilities. Geriatric assessments evaluate seven domains: comorbidities, physical function, mental health, cognition, nutrition, medications, and social support. Frailty indices provide unique evaluations into a patient's overall status. Various standardized measures have been used to evaluate these areas in older adults prior to HCT. Different care models exist for the integration of geriatrics and geriatric principles into HCT evaluation: a multidisciplinary consultative clinic, a geriatrician alongside the HCT clinic, or a primary geriatric hematologist/transplant physician. Future studies are needed to investigate the use of geriatric assessments in selecting the conditioning regimen and intensity and measuring the impact of geriatric assessment-driven interventions on quality of life and toxicities post transplant.
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Affiliation(s)
- Reena V. Jayani
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
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Sanchez-Luege S, Landier W, Dai C, Hageman L, Ross ES, Balas NA, Bosworth A, Te HS, Wu J, Francisco L, Wong FL, Forman SJ, Armenian SH, Weisdorf DJ, Bhatia S. Potentially inappropriate medications in geriatric blood or marrow transplantation (BMT) survivors: A BMT Survivor Study report. Cancer 2023; 129:473-482. [PMID: 36413424 PMCID: PMC10898428 DOI: 10.1002/cncr.34554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/24/2022] [Accepted: 09/23/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Blood or marrow transplantation (BMT) is increasingly offered to older individuals with hematologic malignancies. The high prevalence of chronic health conditions in such individuals necessitates use of multiple medications. Beers Criteria represent a list of potentially inappropriate medications (PIMs) shown to increase the risk of health problems in the elderly. We sought to determine the prevalence and predictors of PIM use in older BMT survivors and identify associations with health problems. METHODS Study participants were drawn from the BMT Survivor Study, a cohort study of patients transplanted at three US transplant centers between 1974 and 2014 and surviving ≥2 years. For this report, the survivors were aged ≥65 years. Siblings served as a comparison group. Participants self-reported sociodemographics, chronic health conditions, and medication use. Logistic regression analyses identified predictors of PIM use and associations with health problems. RESULTS Overall, PIM use was comparable between BMT survivors (49.4%) and siblings (49.3%) (odds ratio [OR] = 0.9; 95% CI, 0.7-1.2); however, BMT survivors were more likely to use >1 PIM (17.4% vs. 12.4%; OR = 1.5; 95% CI, 1.01-2.4) and central nervous system-related PIMs (8.3% vs. 4.3%; OR = 2.18; 95% CI, 1.17-4.09). Predictors of PIM use included presence of severe/life-threatening chronic health conditions (OR = 1.5; 95% CI, 1.1-2.0), and chronic graft versus host disease (OR = 1.7; 95% CI, 1.1-2.7). Survivors taking >1 PIM reported more issues with vertigo (OR = 2.3; 95% CI, 1.1-4.7), balance (OR = 2.6; 95% CI, 1.7-4.1), faintness/dizziness (OR = 2.8; 95% CI, 1.8-4.6), and personal care (OR = 4.5; 95% CI, 1.4-14.8). CONCLUSIONS This study shows the health problems associated with PIM use and identifies vulnerable populations at higher risk for PIM use, providing evidence for caution in using PIMs in high-risk populations.
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Affiliation(s)
- Sebastian Sanchez-Luege
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Wendy Landier
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chen Dai
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lindsey Hageman
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Elizabeth S Ross
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nora A Balas
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alysia Bosworth
- Department of Population Sciences, City of Hope, Duarte, California, USA
| | - Hok Sreng Te
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jessica Wu
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Liton Francisco
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - F Lennie Wong
- Department of Population Sciences, City of Hope, Duarte, California, USA
| | - Stephen J Forman
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Saro H Armenian
- Department of Pediatrics and Department of Population Sciences, City of Hope, Duarte, California, USA
| | - Daniel J Weisdorf
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Smita Bhatia
- Department of Pediatrics and Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kennedy VE, Huang CY, Kaplan LD, Andreadis C, Ai WZ, Olin RL. Geriatric assessment in adults age 50 years and older undergoing autologous hematopoietic cell transplantation for lymphoma. J Geriatr Oncol 2022; 13:644-647. [DOI: 10.1016/j.jgo.2022.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/22/2021] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
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Lin RJ, Artz AS. Allogeneic hematopoietic cell transplantation for older patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:254-263. [PMID: 34889392 PMCID: PMC8791130 DOI: 10.1182/hematology.2021000257] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Hematologic malignances are more common and often higher risk in older patients. Allogeneic hematopoietic cell transplantation (alloHCT) best enables long-term disease control for patients with poor risk or relapsed/refractory hematologic malignancies such as acute myeloid leukemia, myelodysplastic syndromes, or myelofibrosis. Rates of alloHCT among older patients, while still relatively low compared with younger patients, have risen sharply over the past decade. Accumulating evidence supports alloHCT for patients ≥60 years of age relative to non-HCT therapies based on improved overall and disease-free survival. However, a significant proportion of older adults have limitations characterized by geriatric assessment. A systematic process to evaluate and optimize older patients may improve decision making, transplant outcomes, and alloHCT access. We present case-based studies to illustrate a stepwise and rational approach to proper older patient evaluation, pretransplant optimization, and posttransplant care with attention to important geriatric issues and quality of life.
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Affiliation(s)
- Richard J Lin
- Memorial Sloan Kettering Cancer Center, New York, NY
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Kennedy VE, Olin RL. Haematopoietic stem-cell transplantation in older adults: geriatric assessment, donor considerations, and optimisation of care. LANCET HAEMATOLOGY 2021; 8:e853-e861. [PMID: 34624239 DOI: 10.1016/s2352-3026(21)00231-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/20/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
Haematopoietic stem-cell transplantation (HSCT) has seen substantial growth among older adults. Chronological age is no longer viewed as an absolute barrier to HSCT, and alternative methods for assessing pre-transplantation fitness are increasingly used. In this Series paper, we summarise the metrics for pre-transplantation risk assessment in older adults, including both traditional metrics and geriatric assessment, and the ability of these metrics to predict post-transplantation outcomes. We also discuss strategies to broaden the utility of geriatric assessment, including in chronologically younger HSCT candidates and to guide individualised pre-transplantation interventions. Finally, we discuss donor considerations in older adults, including use of older sibling donors, haploidentical donors, and emerging data for donor-associated clonal haematopoiesis of indeterminate potential.
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Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rebecca L Olin
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
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Szewczyk NA, Ngo-Huang A, Soones TN, Adekoya LM, Fontillas RC, Ferguson JK, Gale-Capps HE, Kurse BC, Lindsay RJ, Ombres R, Rivera ZR, Gulbis AM, Neumann JL, Braveman BH, Marin D, Shigle TL, Whited L, Wallis WD, Sullivan H, Cao L, Champlin RE, Shpall E, Popat UR. Feasibility and Implementation of a Multimodal Supportive Care Program to Improve Outcomes in Older Patients Undergoing Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2021; 27:1008-1014. [PMID: 34537421 DOI: 10.1016/j.jtct.2021.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
Increasingly, patients age ≥65 years are undergoing allogeneic hematopoietic stem cell transplantation (allo-SCT). Although age alone is a well-documented predictor of overall survival (OS) and nonrelapse mortality (NRM), growing evidence suggests that poor functional status and frailty associated with aging may have roles as well. Our goal in the present study was to identify and improve these and other aging-related maladies by developing a multimodal supportive care program for older allo-SCT recipients. We designed and implemented a multimodal supportive care program, Enhanced Recovery in Stem Cell Transplant (ER-SCT), for patients age ≥65 years undergoing allo-SCT. The ER-SCT program consists of evaluation and critical interventions by key health care providers from multiple disciplines starting before hospital admission for transplantation and extending through 100 days post-allo-SCT. We determined the feasibility of implementing this program in a large stem cell transplantation center. After 1 year of ongoing process improvements, multiple evaluations, and enrollment, we found that a dedicated weekly clinic was necessary to coordinate care and evaluate patients early. We successfully enrolled 57 of 64 eligible patients (89%) in the first year. Our data show that a multimodal supportive care program to enhance recovery for older patients undergoing allo-SCT is feasible. © 2021 American Society for Transplantation and Cellular Therapy. Published by Elsevier Inc.
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Affiliation(s)
| | - An Ngo-Huang
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tacara N Soones
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Latoya M Adekoya
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jill K Ferguson
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Brittany C Kurse
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Rachel Ombres
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zandra R Rivera
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alison M Gulbis
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joyce L Neumann
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brent H Braveman
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - David Marin
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Laura Whited
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Whitney D Wallis
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hilary Sullivan
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lihui Cao
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Elizabeth Shpall
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday R Popat
- The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Sugidono M, Lo M, Young R, Rosario K, Jung Y, Huang CY, Sheng Y, Huang LW, Olin RL. Impact of Polypharmacy Prior to Allogeneic Hematopoietic Stem Cell Transplantation in Older Adults. Transplant Cell Ther 2021; 27:344.e1-344.e5. [PMID: 33836888 DOI: 10.1016/j.jtct.2021.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/10/2020] [Accepted: 01/03/2021] [Indexed: 11/28/2022]
Abstract
Polypharmacy is common in older adults with cancer, but there is little evidence evaluating the impact of polypharmacy and other medication hazards on allogeneic hematopoietic cell transplantation (alloHCT) outcomes. A small number of prior studies have evaluated the impact of potentially inappropriate medication (PIM) use in the setting of alloHCT, with mixed results. We evaluated the effects of pre-alloHCT polypharmacy, PIM use, and drug-drug interactions (DDIs) on post-alloHCT outcomes, including overall survival (OS), progression-free survival (PFS), non-relapse mortality (NRM), hospital length of stay (LOS), number of non-hematologic grade ≥3 adverse events (AEs) within 100 days after alloHCT, and number of readmissions within the first 100 days after alloHCT. The study population was a single-center prospective cohort of 148 patients ≥ 50 years of age. Pre-alloHCT medication lists were retrospectively collected from the electronic medical record, including both scheduled and as-needed medications. PIMs were defined by a modified 2019 American Geriatrics Society Beers Criteria. DDIs were analyzed using Lexi-Interact. Polypharmacy was common in this population; the median number of medications was seven (range, 0 to 23). Fifty-two patients (35%) were prescribed nine or more medications, and 73 patients (49%) had at least one PIM prescribed. The median number of DDIs was three (range, 0 to 31), and the most common severity was major (48%). After adjusting for age and Hematopoietic Cell Transplant Comorbidity Index (HCTCI), both the number of all medications and number of scheduled medications were associated with inferior OS, with hazard ratios (HRs) of 1.07 (95% confidence interval [CI], 1.01 to 1.12; P = .02) and 1.08 (95% CI, 1.00 to 1.15; P = .04), respectively. Receipt of nine or more scheduled medications was associated with inferior OS (HR, 1.92; 95% CI, 1.11 to 3.32; P = .02). The number of PIMs was also significantly associated with OS (HR, 1.24; 95% CI, 1.00 to 1.54, P = .05). After adjusting for age, HCTCI, and total number of medications, a greater number of DDIs were significantly associated with longer hospital length of stay (difference, 0.74 days; 95% CI, 0.09 to 1.40, P = .03). In adjusted analyses, there were no significant polypharmacy-related predictors of NRM, LOS, or non-hematologic grade ≥3 AEs. These data demonstrate the utility of pre-alloHCT polypharmacy, PIM use, and DDIs as important prognostic factors and support routine pre-alloHCT medication review by physicians and pharmacists with a goal of appropriate de-prescribing where possible.
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Affiliation(s)
- Matthew Sugidono
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California
| | - Mimi Lo
- Department of Pharmaceutical Services, University of California San Francisco Medical Center, San Francisco, California
| | - Rebecca Young
- Department of Pharmaceutical Services, University of California San Francisco Medical Center, San Francisco, California
| | - Kimberly Rosario
- School of Pharmacy, University of California San Francisco, San Francisco, California
| | - Yoonie Jung
- School of Pharmacy, University of California San Francisco, San Francisco, California
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Ying Sheng
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Li-Wen Huang
- Division of Hematology/Oncology, Department of Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco California
| | - Rebecca L Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco California; Division of Hematology and Medical Oncology, Department of Medicine, University of California San Francisco, San Francisco, California.
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Knight TG. Improving Hematopoietic Stem Cell Transplant in the Elderly: Can We Finally Start to Impact Nonrelapse Mortality? Biol Blood Marrow Transplant 2020; 26:e303-e304. [PMID: 33065250 DOI: 10.1016/j.bbmt.2020.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Thomas G Knight
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina.
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