Impact of an allied health prehabilitation service for haematologic patients receiving high-dose chemotherapy in a large cancer centre.

PURPOSE: Evaluate the impact of a new multidisciplinary allied health prehabilitation service in haematologic cancer patients receiving high-dose chemotherapy with autologous stem cell transplant (AuSCT). METHODS: In a tertiary cancer centre, 12 months of prospectively collected data was retrospectively analysed. Patients were referred to an allied health service for individualised exercise prescription, nutrition intervention and, if indicated through screening, psychological intervention. Impact and operational success were investigated using the RE-AIM framework: patient uptake of the service and sample representativeness (reach); effectiveness in terms of changes in outcomes from initial to pre-transplant assessment; adoption of the service by key stakeholders; fidelity of the prescribed exercise program (implementation); and the extent to which the new service had become routine practice (maintenance). RESULTS: One hundred and eighty-three patients were referred to the AuSCT service over 12 months, of whom 133 (73%) were referred into the prehabilitation service, 128 (96%) were eligible and 116 (91%) participated. Patients were representative of Australian AuSCT patients. Eighty-nine patients reached pre-transplant assessment by data censoring; 6-min walk distance (n = 45/89, 51%) improved a mean (95% CI) of 39.9 m (18.8 to 61.0, p = < 0.005) from baseline. Fidelity of exercise prescription was moderate with 72% of eligible patients receiving the intended exercise interventions. The referral trend over time (maintenance) was high after the initiation period. CONCLUSION: The prehabilitation service was well adopted by clinicians. Clinically relevant improvements in outcomes were demonstrated. Recommendations, including development of well-integrated discipline-specific assessment intervention and measurement protocols, are highlighted for service improvement. Prehabilitation should be routinely considered to support patients undergoing AuSCT.

A Randomized Trial of Two 2-Dose Influenza Vaccination Strategies for Patients Following Autologous Hematopoietic Stem Cell Transplantation.

BACKGROUND: Seroprotection and seroconversion rates are not well understood for 2-dose inactivated influenza vaccination (IIV) schedules in autologous hematopoietic stem cell transplantation (autoHCT) patients. METHODS: A randomized, single-blind, controlled trial of IIV in autoHCT patients in their first year post-transplant was conducted. Patients were randomized 1:1 to high-dose (HD) IIV followed by standard dose (SD) vaccine (HD-SD arm) or 2 SD vaccines (SD-SD arm) 4 weeks apart. Hemagglutination inhibition (HI) assay for IIV strains was performed at baseline, 1, 2, and 6 months post-first dose. Evaluable primary outcomes were seroprotection (HI titer ≥40) and seroconversion (4-fold titer increase) rates and secondary outcomes were geometric mean titers (GMTs), GMT ratios (GMRs), adverse events, influenza-like illness (ILI), and laboratory-confirmed influenza (LCI) rates and factors associated with seroconversion. RESULTS: Sixty-eight patients were enrolled (34/arm) with median age of 61.5 years, majority male (68%) with myeloma (68%). Median time from autoHCT to vaccination was 2.3 months. For HD-SD and SD-SD arms, percentages of patients achieving seroprotection were 75.8% and 79.4% for H1N1, 84.9% and 88.2% for H3N2 (all P > .05), and 78.8% and 97.1% for influenza-B/Yamagata (P = .03), respectively. Seroconversion rates, GMTs and GMRs, and number of ILI or LCIs were not significantly different between arms. Adverse event rates were similar. Receipt of concurrent cancer therapy was independently associated with higher odds of seroconversion (OR, 4.3; 95% CI, 1.2-14.9; P = .02). CONCLUSIONS: High seroprotection and seroconversion rates against all influenza strains can be achieved with vaccination as early as 2 months post-autoHCT with either 2-dose vaccine schedules. CLINICAL TRIALS REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN12619000617167.

Autologous stem cell transplantation in elderly multiple myeloma patients aged ≥65 years: a two-centre Australian experience.

There are currently limited Australian data on the outcomes of autologous stem cell transplantation (ASCT) in elderly multiple myeloma (MM) patients. We present the largest cohort of elderly MM patients aged ≥65 years undergoing ASCT in Australia and report their outcomes based on our two-centre experience. Our study affirms that ASCT is well tolerated, safe and effective in elderly MM patients aged ≥65 years and should be considered an important component of treatment in patients who are fit enough for the procedure.

Safety and cost benefit of an ambulatory program for patients with low-risk neutropenic fever at an Australian centre.

BACKGROUND: Neutropenic fever (NF) is a common complication of cancer chemotherapy. Patients at low risk of medical complications from NF can be identified using a validated risk assessment and managed in an outpatient setting. This is a new model of care for Australia. This study described the implementation of a sustainable ambulatory program for NF at a tertiary cancer centre over a 12-month period. METHODS: Peter MacCallum Cancer Centre introduced an ambulatory care program in 2014, which identified low-risk NF patients, promoted early de-escalation to oral antibiotics, and early discharge to a nurse-led ambulatory program. Patients prospectively enrolled in the ambulatory program were compared with a historical-matched cohort of patients from 2011 for analysis. Patient demographics, clinical variables (cancer type, recent chemotherapy, treatment intent, site of presentation) and outcomes were collected and compared. Total cost of inpatient admissions was determined from diagnosis-related group (DRG) codes and applied to both the prospective and historical cohorts to allow comparisons. RESULTS: Twenty-five patients were managed in the first year of this program with a reduction in hospital median length of stay from 4.0 to 1.1 days and admission cost from Australian dollars ($AUD) 8580 to $AUD2360 compared to the historical cohort. Offsetting salary costs, the ambulatory program had a net cost benefit of $AUD 71895. Readmission for fever was infrequent (8.0%), and no deaths were reported. CONCLUSION: Of relevance to hospitals providing cancer care, feasibility, safety, and cost benefits of an ambulatory program for low-risk NF patients have been demonstrated.

The development of a home-based therapeutic platform for multiple myeloma.

BACKGROUND: Multiple Myeloma (MM) accounts for 1-2% of all malignancies but is the second most common hematological malignancy. It is characterized by a proliferation of malignant plasma cells. The treatment paradigm of MM in Australia is traditionally hospital-based, complex, and costly. While MM comprises 1-2% of cancer diagnoses, it appears in the top 10 cancer diagnoses requiring hospital admission. The cumulative time spent receiving treatment is a significant burden for patients. The ability to receive treatment at home and maximize time away from hospital-based settings is a key preference for patients receiving anticancer therapies over a prolonged period of time. METHODS: The Peter MacCallum Cancer Centre and Royal Melbourne Hospital's combined Clinical Hematology Unit has collaborated with their Hospital in the Home departments to develop several innovative programs to address this. RESULTS: We describe our current active programs and potential developments in home-based MM therapy. CONCLUSION: We have enabled large numbers of patients to receive complex therapies in their own home and the COVID-19 pandemic has increased the pace of the roll out without any compromise in safety. We anticipate that the next raft of immunotherapies will be able to transition into the @Home treatment setting in the coming years.

The choice of multiple myeloma induction therapy affects the frequency and severity of oral mucositis after melphalan-based autologous stem cell transplantation.

INTRODUCTION/BACKGROUND: Mucositis is a common complication of high-dose melphalan (HDM) used before autologous stem cell transplantation (ASCT) for multiple myeloma (MM). Mucositis rates are influenced by previous chemotherapy (CT) exposure. We examined the effect of induction therapy before ASCT on ASCT mucositis rates. PATIENTS AND METHODS: Patients undergoing first 200 mg/m(2) HDM ASCT were assessed. Those receiving < 200 mg/m(2), or those with previous ASCT were excluded. Patients were evaluated depending on type of induction therapy (CT, immunomodulatory drug [IMiD], or proteasome inhibitor [PI]) before ASCT. A case record review was performed and data collected on response to induction, rates of Grade 3/4 mucositis, and days of total parenteral nutrition (TPN) or parenteral opiate analgesia. RESULTS: One hundred twenty-eight patients with ASCT were assessed. Induction therapy was CT- (n = 62), IMiD- (n = 51), or PI-based (n = 15) therapy. Patient characteristics were overall similar, including median age, MM stage, and CD34(+) cell dose. IMiD-based therapy patients had lower rates of mucositis (33% vs. 53%; P = .03) and less opiate requirements (10% vs. 31%; P = .02) compared with those treated with CT. Rates of mucositis and opiate use in the PI group were not different to the CT cohorts (33% vs. 53%; P = .6 and 13% vs. 31%; P = .13), likely due to concurrent anthracycline exposure. TPN usage was similar (CT, 42%; IMiD, 35%; and PI, 20%), as was neutropenia duration and antibiotic usage. CONCLUSION: Patients treated with IMiD-based regimens before HDM ASCT had significantly lower rates of mucositis than those treated with CT-based therapy. There were too few patients who received PI therapy to evaluate the effect.

Bortezomib with high dose melphalan conditioning for autologous transplant is safe and effective in patients with heavily pretreated and high risk multiple myeloma.

There are no uniform guidelines for the treatment of relapsed refractory multiple myeloma (MM), however autologous stem cell transplant (SCT) remains an important treatment modality. Although a number of modifications to high dose melphalan (HDM) conditioning have been evaluated, improvement in overall survival has not been demonstrated. We now report our experience of 23 patients with heavily pretreated MM (median lines of prior treatment 3 [range 1-6]) who underwent SCT with bortezomib and high dose melphalan (BorHDM). The overall response rate (at least partial response [PR]) was 65.4%. Median overall survival (OS) was 24 months. A subset of patients who relapsed ≤ 12 months after initial SCT had significantly longer OS after BorHDM SCT compared to a historical control group who received HDM conditioning alone (14.5 vs. 8 months, respectively, p = 0.011). In summary, BorHDM SCT produces very good response rates in heavily pretreated MM, and may increase survival in the salvage setting in patients who relapse early after initial SCT. We propose that its use should be explored as part of a tandem approach in patients undergoing initial SCT who are at high risk of early relapse.