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Transplant Physicians’ Attitudes on Candidacy for Allogeneic Hematopoietic Cell Transplantation (HCT) in Older Patients: The Need for a Standardized Geriatric Assessment (GA) Tool
Biology of Blood and Marrow Transplantation ( IF 5.609 ) Pub Date : 2020-01-23 , DOI: 10.1016/j.bbmt.2019.12.115
Asmita Mishra , Jaime M. Preussler , Zeina Al-Mansour , Veronika Bachanova , Vijaya Raj Bhatt , Christopher Bredeson , Saurabh Chhabra , Anita D'Souza , Parastoo B. Dahi , Zack DeFilipp , Lohith Gowda , Eileen Danaher Hacker , Shahrukh K. Hashmi , Dianna S. Howard , Ann A. Jakubowski , Reena Jayani , Laura Johnston , Thuy Koll , Richard J. Lin , Shannon R. McCurdy , Laura C. Michaelis , Lori Muffly , Nitya Nathwani , Rebecca L. Olin , Uday R. Popat , Cesar Rodriguez , Ashley Rosko , Lyndsey Runaas , Mitchell Sabloff , Tsiporah B. Shore , Leyla Shune , Mohamed L. Sorror , Anthony D. Sung , Celalettin Ustun , William Wood , Linda J. Burns , Andrew S. Artz

Background

Despite improvements in conditioning regimens and supportive care having expanded the curative potential of HCT, underutilization of HCT in older adults persists (Bhatt VR et al, BMT 2017). Therefore, we conducted a survey of transplant physicians (TP) to determine their perceptions of the impact of older age (≥60 years) on HCT candidacy and utilization of tools to gauge candidacy.

Methods

We conducted a 23-item, online cross-sectional survey of adult physicians recruited from the Center for International Blood and Marrow Transplant Research between May and July 2019.

Results

175/770 (22.7%) TP completed the survey; majority of respondents were 41-60 years old, male, and practicing in a teaching hospital. Over 75% were at centers performing ≥50 HCT per year. When considering regimen intensity, most (96%, n=168) had an upper age limit (UAL) for using a myeloablative regimen (MAC), with only 29 physicians (17%) stating they would consider MAC for patients ≥70 years. In contrast, when considering a reduced intensity/non-myeloablative conditioning (RIC/NMA), 8%, (n=13), 54% (n=93), and 20% (n=35) stated that age 70, 75, and 80 years respectively would be the UAL to use this approach, with 18% (n=31) reporting no UAL. TP agreed that Karnofsky Performance Score (KPS) could exclude older pts for HCT, with 39.1% (n=66), 42.6% (n=72), and 11.4% (n=20) requiring KPS of ≥70, 80, and 90, respectively. The majority (n=92, 52.5%) indicated an HCT-comorbidity index threshold for exclusion, mostly ranging from ≥3 to ≥ 5. Almost all (89.7%) endorsed the need for a better health assessment of pre-HCT vulnerabilities to guide candidacy for pts ≥60 with varied assessments being utilized beyond KPS (Figure 1). However, the majority of centers rarely (33.1%) or never (45.7%) utilize a dedicated geriatrician/geriatric-oncologist to assess alloHCT candidates ≥60 yrs. The largest barriers to performing GA included uncertainty about which tools to use, lack of knowledge and training, and lack of appropriate clinical support staff (Figure 2). Approximately half (n=78, 45%) endorsed GA now routinely influences candidacy.

Conclusions

The vast majority of TP will consider RIC/NMA alloHCT for patients ≥70 years. However, there is heterogeneity in assessing candidacy. Incorporation of GA into a standardized and easily applied health assessment tool for risk stratification is an unmet need. The recently opened BMT CTN 1704 may aid in addressing this gap.



中文翻译:

移植医师对老年患者同种异体造血细胞移植(HCT)候选资格的态度:需要标准化的老年医学评估(GA)工具

背景

尽管条件治疗方案的改进和支持治疗扩大了HCT的治疗潜力,但老年人中HCT的利用不足仍然存在(Bhatt VR等人,BMT 2017)。因此,我们对移植医师(TP)进行了一项调查,以确定他们对年龄(≥60岁)对HCT候选资格的影响的理解,并利用工具来评估候选资格。

方法

我们对2019年5月至7月间从国际血液和骨髓移植研究中心招募的成年医师进行了23个项目的在线横断面调查。

结果

TP 175/770(22.7%)完成了调查;大部分受访者是41-60岁的男性,在教学医院实习。每年执行HCT≥50的中心超过75%。考虑方案强度时,大多数(96%,n = 168)有采用清髓方案(MAC)的年龄上限(UAL),只有29位医生(17%)表示他们会考虑≥70岁患者的MAC。相反,当考虑降低强度/非清髓性调理(RIC / NMA)时,有8%(n = 13),54%(n = 93)和20%(n = 35)的人表示70、75岁,则使用此方法的UAL分别为80岁和80岁,其中18%(n = 31)表示没有UAL。TP同意Karnofsky绩效得分(KPS)可以排除较老的HCT得分,其中39.1%(n = 66),42.6%(n = 72)和11.4%(n = 20)要求KPS ≥70、80和90。多数(n = 92,52。5%)表示排除的HCT合并症指数阈值范围在≥3至≥5之间。几乎所有(89.7%)的人都同意对HCT之前的漏洞进行更好的健康评估,以指导≥60的pts候选资格KPS以外的其他评估(图1)。但是,大多数中心很少(33.1%)或从未(45.7%)会聘请专门的老年科医生/老年肿瘤学家来评估≥60岁的alloHCT候选者。执行GA的最大障碍包括不确定使用哪种工具,缺乏知识和培训以及缺乏合适的临床支持人员(图2)。现在,大约一半(n = 78,45%)认可的GA例行地影响候选人资格。7%)同意有必要对HCT之前的漏洞进行更好的健康评估,以指导≥60岁的患者的候选资格,并且采用了除KPS以外的各种评估方法(图1)。但是,大多数中心很少(33.1%)或从未(45.7%)会聘请专门的老年科医生/老年肿瘤学家来评估≥60岁的alloHCT候选者。执行GA的最大障碍包括不确定使用哪种工具,缺乏知识和培训以及缺乏合适的临床支持人员(图2)。现在,大约一半(n = 78,45%)认可的GA例行地影响候选人资格。7%)同意有必要对HCT之前的漏洞进行更好的健康评估,以指导≥60岁的患者的候选资格,并且采用了除KPS以外的各种评估方法(图1)。但是,大多数中心很少(33.1%)或从未(45.7%)会聘请专门的老年科医生/老年肿瘤学家来评估≥60岁的alloHCT候选者。执行GA的最大障碍包括不确定使用哪种工具,缺乏知识和培训以及缺乏合适的临床支持人员(图2)。现在,大约一半(n = 78,45%)认可的GA例行地影响候选人资格。执行GA的最大障碍包括不确定使用哪种工具,缺乏知识和培训以及缺乏合适的临床支持人员(图2)。现在,大约一半(n = 78,45%)认可的GA例行地影响候选人资格。执行GA的最大障碍包括不确定使用哪种工具,缺乏知识和培训以及缺乏合适的临床支持人员(图2)。现在,大约一半(n = 78,45%)认可的GA例行地影响候选人资格。

结论

TP的绝大部分将考虑对≥70岁的患者进行RIC / NMA alloHCT。但是,评估候选人资格存在异质性。将GA纳入标准化且易于应用的健康评估工具中以进行风险分层是尚未满足的需求。最近开放的BMT CTN 1704可能有助于解决这一差距。

更新日期:2020-01-23
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