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Recommendations from a Geriatric Assessment (GA) Guided Multidisciplinary Clinic (MDC) in Older Patients for Autologous Hematopoietic Cell Transplant (autoHCT)

Year: 2020

Type: article

Abstract: Introduction AutoHCT recipients age 70+ who attended a GA-guided MDC had favorable outcomes with 0% 1-yr non-relapse mortality (NRM). We now examine vulnerabilities and outcomes in all older autoHCT candidates undergoing MDC, including HCT utilization rates. Methods An HCT MD, advanced practice provider, dietician, PT/OT, social worker, ID MD, and geriatric MD comprised the MDC. All pts received GA-informed optimization. Pts were classified by MDC recommendation: ‘Decline' if unlikely to realize benefits of HCT, ‘Defer' if significant optimization necessary before HCT, and ‘Proceed' if autoHCT could proceed without delay. We compared autoHCT recipients (AR, n=62) to non-autoHCT recipients (non-AR, n=29). Results Differences by ‘Defer' (n=25) vs ‘Proceed' (n=61) included more impairments (median HCT-CI 3 vs 2, p=0.01; more frail 4-meter walk times, 48% v 14%, p=0.001) and more lymphoma (52% vs 30%, p=0.01). AutoHCT occurred in 49/61 (80%) ‘Proceed', 13/25 (52%) ‘Defer', and 0/5 ‘Decline'. AutoHCT recipients (AR) vs non-AR did not differ by age but had fewer impairments as shown in table 1. AR vs non-AR was enriched for plasma cell dyscrasia (PCD, 77% vs 48%, p=0.008). AR had longer OS compared to non-AR (HR 0.26, 95% CI 0.11-0.57, p=0.0012). No AR pts experienced NRM. Within AR, MDC ‘Defer' pts had a longer time from MDC to HCT compared to ‘Proceed' pts (median 41 vs 20 days, p=0.001). Although ‘Defer' AR pts at DC had more frail 4-meter walk times (38% vs 10%, p=0.03) and worse Mental Health Index-5 (p = 0.03), length of hospitalization, readmission rate, skilled nursing facility admission, and mortality did not differ relative to the ‘Proceed' AR group (see figure). 1-yr OS for ‘Defer' AR (n=13) vs ‘Defer' Non-AR (n=12) was 92% vs 60% (p = 0.07); 3-yr OS 55% vs 48% (p = 0.8). Conclusion A GA guided MDC deferred around 27% of older autoHCT candidates likely due to significant impairments, and half went on to receive HCT. Pts pursuing autoHCT after MDC achieved excellent outcomes, even among those initially deferred. Employing GA earlier in the disease trajectory to inform early referral to a GA-guided MDC should be tested to increase utilization and improve outcomes in older autoHCT candidates.

Source: Transplantation and Cellular Therapy

DOI: 10.1016/j.bbmt.2019.12.090