Risk Assessment Tool Predicts Survival in Older Patients Undergoing HCT
Older patients are at increased risk for complications and death following allogeneic hematopoietic cell transplantation (alloHCT), and traditional transplant-specific prognostic indices such as the hematopoietic cell transplant comorbidity index (HCT-CI) may not adequately predict survival.
Researchers found that routine pretransplant assessments by interdisciplinary clinical providers, including advanced practice providers and nursing staff, may uncover additional geriatric deficits. Richard J. Lin, MD, PhD, of Memorial Sloan Kettering Cancer Center in New York, NY, discussed the findings at the ASH Annual Meeting on December 1, 2018.
Researchers assessed an institutional database and electronic medical records (EMRs) for adults aged 60 years or older (range = 60–78.7 years) who underwent first alloHCT for hematologic malignancies between 2010 and 2016. They examined the prevalence and prognostic impact of pretransplant geriatric deficits, including functional activity, cognition, medication, nutrition, and mobility, as well as findings from routine laboratory tests.
Of 291 patients, 41% (n = 120) had impaired cognition, 20% (n = 81) experienced a fall within the past 12 months, and 17% (n = 69) lost at least 10 pounds in the past three months. Patients received a median of five medications (range = 0–20 medications), and the researchers noted that 46% of 406 patients (n = 186) were potentially receiving inappropriate medications. Of 351 patients, 11% (n = 37) experienced impaired instrumental activities of daily living (IADL). Pretransplant, 32% of 360 patients (n = 114) had ferritin levels ≥ 1,200 ng/ml (median = 661 ng/ml; range = 10–16,065 ng/ml).
After 39 months of follow-up for survivors, the three-year probability of overall survival (OS) and progression-free survival was 47% (95% confidence interval [CI] = 42–53) and 40% (95% CI = 35–45), respectively. The two-year cumulative incidence of nonrelapse mortality (NRM) was 26% (95% CI = 22–29).
IADL and pretransplant ferritin level ≥ 1,200 ng/ml were independently associated with both increased NRM and inferior OS. Other measures were also associated with NRM and OS outcomes (see Table 1).
The combination of IADL impairment or ferritin ≥ 1,200 ng/ml with HCT-CI further stratifies NRM and OS into distinct risk categories, including a group of highly vulnerable, high-risk patients, according to the investigators. Patients with two or more risk factors had a higher rate of NRM from organ toxicity than patients with zero or one risk factors.
“Our findings establish a rapid and simple assessment tool to risk stratify older patients prior to alloHCT,” the researchers concluded, although this method requires validation. “The geriatric vulnerability index can be easily completed and integrated into outpatient clinics and the electronic medical record.”