Enhanced Recovery Stem-Cell Transplantation: Multidisciplinary Efforts to Improve Outcomes in Older Adults Undergoing Hematopoietic Stem-Cell Transplant.

PURPOSE: Older adults have unique risk factors for poor outcomes after hematopoietic stem-cell transplant (HSCT). We sought to determine the impact of our multidisciplinary supportive care program, Enhanced Recovery after stem-cell transplant (ER-SCT), on survival outcomes in patients age 65 years and older who underwent HSCT. PATIENTS AND METHODS: In this retrospective study, clinicodemographic data, nonrelapse mortality (NRM), overall survival (OS), and relapse were compared between 64 patients age 65 years and older who underwent allogeneic stem-cell transplant during ER-SCT program's first year, October 2017 through September 2018, and 140 historical controls age 65 years and older who underwent allogeneic HSCT, January 2015 through September 2017. RESULTS: In the ER-SCT cohort, 41% (26 of 64) of patients were women, and the median (range) age was 68 (65-74) years; in the control cohort, 38% (53 of 140) of patients were women, and the median (range) age was 67 (65-79) years. Hematopoietic cell transplant comorbidity index and donor type/cell source were similar between cohorts. The ER-SCT cohort had a lower 1-year NRM rate (13% v 26%, P = .03) and higher 1-year OS rate (74% v 53%, P = .007). Relapse rate did not differ significantly between cohorts. In multivariate analyses, ER-SCT was associated with improved 1-year NRM (hazard ratio, 0.4; 95% CI, 0.2 to 0.9; P = .02) and improved 1-year OS (hazard ratio, 0.5; 95% CI, 0.3 to 0.9; P = .03). CONCLUSION: A multidisciplinary supportive care program may improve NRM and OS in older patients undergoing allogeneic HSCT. Randomized studies are warranted to confirm this benefit and explore which program components most contribute to the improved outcomes.

Feasibility and Implementation of a Multimodal Supportive Care Program to Improve Outcomes in Older Patients Undergoing Allogeneic Stem Cell Transplantation.

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.

Impact of an incentive-based mobility program, "Motivated and Moving," on physiologic and quality of life outcomes in a stem cell transplant population.

BACKGROUND: Research suggests that patients experience increased fatigue, reduced physical activity, and diminished quality of life (QOL) after hematopoietic stem cell transplantation (HSCT). Structured exercise during hospitalization has been shown to maintain or improve fatigue. Incentive-based interventions have not been tested to encourage physical activity maintenance. OBJECTIVES: The study's aim was to evaluate the effect of participation in an incentive-based mobility program on fatigue, physical conditioning, performance status, and QOL in individuals undergoing allogeneic HSCT. We hypothesized that program participation would affect these variables and that time spent engaged in physical activity would correlate with improved outcomes. METHODS: A 1-group repeated-measures design used the Brief Fatigue Inventory, 6-minute walk test, and the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale to assess study variables. Repeated-measures models assessed the effect of participation time on these variables. RESULTS: Individuals with higher participation (minutes) significantly increased 6-minute walk test scores throughout hospitalization but had no significant changes in Brief Fatigue Inventory and Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale scores. Fatigue and QOL decreased over hospitalization but improved by discharge. Subjects who demonstrated higher participation averaged fewer hospital days (R = 1.65; P = .005). CONCLUSIONS: This study is unique in examining the impact of an incentive-based mobility program, participation in which may decrease length of hospital stay for HSCT patients. Randomized trials are needed to further validate these findings and assess additional variables that can influence outcomes. IMPLICATIONS FOR PRACTICE: An incentive-based mobility program during hospitalization for HSCT has the potential to minimize fatigue and stabilize, if not improve, QOL.

Hemorrhagic cystitis after allogeneic hematopoietic stem cell transplants is the complex result of BK virus infection, preparative regimen intensity and donor type.

BACKGROUND: Hemorrhagic cystitis is a common cause of morbidity after allogeneic stem cell transplantation, frequently associated with BK virus infection. We hypothesized that patients with positive BK viruria before unrelated or mismatched related donor allogeneic hematopoietic stem cell transplantation have a higher incidence of hemorrhagic cystitis. DESIGN AND METHODS: To test this hypothesis, we prospectively studied 209 patients (median age 49 years, range 19-71) with hematologic malignancies who received bone marrow (n=78), peripheral blood (n=108) or umbilical cord blood (n=23) allogeneic hematopoietic stem cell transplantation after myeloablative (n=110) or reduced intensity conditioning (n=99). Donors were unrelated (n=201) or haploidentical related (n=8). RESULTS: Twenty-five patients developed hemorrhagic cystitis. Pre-transplant BK viruria detected by quantitative PCR was positive in 96 patients. The one-year cumulative incidence of hemorrhagic cystitis was 16% in the PCR-positive group versus 9% in the PCR-negative group (P=0.1). The use of umbilical cord blood or a haploidentical donor was the only significant predictor of the incidence of hemorrhagic cystitis on univariate analysis. There was also a trend for a higher incidence after myeloablative conditioning. Multivariate analysis showed that patients who had a positive PCR pre-transplant and received haploidentical or cord blood grafts with myeloablative conditioning had a significantly higher risk of developing hemorrhagic cystitis (58%) than all other recipients (7%, P<0.001). CONCLUSIONS: Hemorrhagic cystitis is the result of a complex interaction of donor type, preparative regimen intensity, and BK viruria.