scholarly journals Trends in Allogeneic Hematopoietic Cell Transplantation Utilization and Estimated Unmet Need Among Medicare Beneficiaries with Acute Myeloid Leukemia

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4044-4044
Author(s):  
Lih-Wen Mau ◽  
Jaime M. Preussler ◽  
Christa Meyer ◽  
Mary Senneka ◽  
Sophie Wallerstedt ◽  
...  
Keyword(s):  
Cell Transplantation ◽  
Hematopoietic Cell Transplantation ◽  
Claims Data ◽  
Unmet Need ◽  
Geographic Region ◽  
Medicare Beneficiaries ◽  
Factors Associated ◽  
Number Of Patients ◽  
One Year ◽  
Over Time

Abstract Introduction: Allogeneic hematopoietic cell transplantation (alloHCT) is the only potentially curative treatment available for acute myelogenous leukemia (AML). It is a medically complicated and resource intensive procedure for which there are patient-, provider- and system-related factors that may impact its utilization. While Medicare coverage for alloHCT may help address a major financial barrier to access, there is still an unmet need due to other factors. This study intended to examine trends and factors associated with utilization of alloHCT and to estimate unmet need for alloHCT among Medicare beneficiaries with AML. Methods: This retrospective cohort study included all patients with a diagnosis of AML identified in the Medicare claims data from 2010 through 2016. Primary patient selection criteria included: primary or secondary diagnosis of AML, age limit (65-74), and continuous enrollment (for at least 180 days after AML diagnosis in Part A and Part B fee-for-service programs). To study trends in utilization, the transplant rates were calculated as the number of patients who received an alloHCT within 180 days and one year of diagnosis (numerator) divided by the total number of patients diagnosed with AML within each diagnosis year (denominator). Transplant rates within one year of diagnosis were further adjusted by patient characteristics, including age group, sex, race, residential region, and Elixhauser Comorbidity Index (ECI). A multivariable logistic regression was utilized to identify factors associated with the likelihood of receiving alloHCT within one year of diagnosis. Two approaches were applied to estimate unmet need for alloHCT. The first approach (Approach 1) used claims data to identify the potential need for alloHCT among patients who achieved complete remission for at least 90 days; patients who achieved 90-day remission but did not receive alloHCT at any time point were considered to have unmet need. In the second approach (Approach 2), the total number of patients diagnosed with AML in the claims data was run through the National Marrow Donor Program (NMDP) methodology , which takes estimates of risk level, response to treatment, comorbidity, and early mortality into consideration. Overall estimated need and unmet need from 2010-2015 and over different time periods were evaluated for both approaches. Results: Among the 5,974 patients diagnosed with AML from March 1, 2010 through June 30 th, 2016, 1226 patients (21%) received an alloHCT by the end of 2016. Trend analysis results suggest that utilization of alloHCT increased from 2010 to 2016 (P < 0.0001) (Figure 1). The likelihood of receiving alloHCT within one year of diagnosis was found to be associated with diagnosis year, age, race, geographic region, ECI, and population-level median household income (Table 1). Both approaches estimated that approximately 36% of the diagnosed patients were in need of alloHCT between 2010 and 2015. The overall unmet need was estimated as 59% and 43% based on the claims data approach and the NMDP methodology, respectively. Despite the differences in estimated unmet need between the two approaches, the unmet need for alloHCT was found to trend down over time (Figures 2 & 3). Discussion and Conclusions: Medicare coverage facilitates access to the health care system and receipt of health services when a need for treatment or care is recognized. Utilization of alloHCT has increased over time among Medicare beneficiaries with AML. However, there are persistent differences in utilization of alloHCT by age, race, geographic region, comorbidity, and socioeconomic status, indicating disparities in access to alloHCT among this population. The results of estimated need and unmet need for alloHCT may be affected by the lack of cytogenetics and molecular information in administrative claims. To minimize this limitation, we used NMDP methodology for validation and found a similar estimation of potential need for alloHCT and downward trend in unmet need. Although the unmet need for alloHCT for AML has improved over time, policy efforts, research, and continued education are needed to close the gap between the actual utilization of alloHCT and unmet need for this potentially curative treatment. Figure 1 Figure 1. Disclosures Saber: Govt. COI: Other.

scholarly journals Health Care Reimbursement and Service Utilization Among Medicare Beneficiaries with Multiple Myeloma Receiving Autologous Hematopoietic Cell Transplantation in Inpatient and Outpatient Settings

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 832-832 ◽  
Author(s):  
Neil Dunavin ◽  
Lih-Wen Mau ◽  
Christa Lea Meyer ◽  
Clint Divine ◽  
Al-Ola Abdallah ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Cell Transplantation ◽  
Service Utilization ◽  
Hematopoietic Cell Transplantation ◽  
Hematopoietic Cell ◽  
Lower Percentage ◽  
Medicare Beneficiaries ◽  
Factors Associated ◽  
Autologous Hct ◽  
Autologous Hematopoietic Cell Transplantation

Abstract Introduction: Inpatient services are the leading drivers of cost for autologous hematopoietic cell transplantation (HCT), and the number of Medicare beneficiaries who receive autologous HCT is increasing. Using a merged dataset of Center for International Blood and Marrow Transplant Research (CIBMTR) transplant and outcomes data and Centers for Medicare and Medicaid Services (CMS) Medicare administrative claims data, we examined reimbursement and service utilization among Medicare beneficiaries with multiple myeloma (MM) who received IP and OP autologous HCT. Methods: This was a multicenter retrospective cohort study. A total of 11,358 HCT recipients from 2010-2012 were identified in the CMS Medicare database; 9,055 (80%) were linked with CIBMTR data. Selection criteria included first HCT for MM, diagnosis-to-HCT time between 0 and 18 months, and continuous enrollment for 30 days prior to index and 100 days post-HCT or until death. For IP-HCT, the index period for reimbursement and service utilization was day of admission for HCT through discharge date. For OP-HCT, the index period was day -2 through HCT date to capture the conditioning regimen. Total IP and OP service days from 30 days prior to index and 100 days post-HCT, and subsequent admissions post the HCT index period were calculated. Total reimbursement consisted of all payments made to providers (Medicare payments for Part A & B services, secondary payer, and patient responsibility of deductibles, coinsurance, and copayments), which was adjusted by a weighted generalized linear model (GLM). Patient responsibility was assessed separately and adjusted by the same GLM. Kaplan-Meier method was used for overall survival (OS) analysis; potential factors associated with OS were adjusted by Cox regression modeling. Results: The final cohort comprised 1,640 patients; 1,445 (88%) received IP-HCT (126 centers) and 195 (12%) OP-HCT (24 centers). Patient characteristics, functional status, disease status, and HCT year were similar between groups except a higher percentage of IP-HCT recipients were 70 years and older (IP-HCT: 31%, OP-HCT: 19%; P=0.0003), and a lower percentage of IP-HCT recipients received full dose melphalan 200 mg/m2 (IP-HCT: 68%, OP-HCT: 90%; P=0.0036). There was a significant difference between the cohorts in the utilization of IP services (IP-HCT group: median 19 days, OP-HCT group: 4 days; P < 0.0001) and OP services (IP-HCT group: median 16 days, OP-HCT group: 33 days; P < 0.0001) at day 100. Adjusted total mean reimbursement for the IP-HCT group ($83,380 [95% CI: $78,958-$88,051]) was higher than the OP-HCT group ($55,721 [95% CI: $38,595-$80,446]) (P= 0.0301) (Figure). Factors associated with total reimbursement in the GLM were transplant setting, age, sex, comorbidity index, diagnosis-to-HCT time, and melphalan dose. Adjusted total patient responsibility for the IP-HCT group was $4,567 (95% CI: $4,210- $4,955) and $7,372 ($4,218- $12,884) (P=0.0902) for the OP-HCT group. Within 100 days post-HCT, 107/195 (55%) OP-HCT recipients had at least one subsequent admission, compared to 348/1,445 (24%) IP-HCT recipients (P < 0.0001). OS at 100 days was high for both HCT settings and adjusted OS was not significantly different by transplant setting (IP-HCT 98% [95% CI: 97%-99%]; OP-HCT 99% [95% CI: 98%-100%; P=0.1903) Conclusions: Reimbursement and service utilization varied by HCT setting for Medicare beneficiaries with MM. Total reimbursement for 100 days post-HCT was $27,659 higher for IP-HCT than OP-HCT, after adjusting for patient and HCT-related characteristics. After the HCT index period, approximately 1 in 4 IP-HCT recipients required re-hospitalization within 100 days, whereas 1 in 2 OP-HCT recipients required subsequent hospitalization. Many factors influence the decision between IP or OP autologous HCT, including: center experience, severity of disease, patient co-morbidities, access to caregivers, proximity of lodging, cost to the patient, and reimbursement for services to the hospital system. The CIBMTR-CMS merged database is a new resource to support ongoing efforts to inform transplant centers and healthcare systems about provision of care options in the Medicare population. Figure. Figure. Disclosures Ganguly: Janssen: Consultancy; Amgen: Consultancy; Seattle Genetics: Speakers Bureau; Daiichi Sankyo: Research Funding.

Total and out-of-pocket costs for patients undergoing hematopoietic cell transplantation.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18862-e18862
Author(s):  
Nandita Khera ◽  
Ye (Julia) Zhe ◽  
Joan M. Griffin ◽  
Lih-Wen Mau ◽  
Lindsey R. Sangaralingham ◽  
...  
Keyword(s):  
African American ◽  
Cell Transplantation ◽  
Hematopoietic Cell Transplantation ◽  
Financial Burden ◽  
Hematopoietic Cell ◽  
Administrative Claims ◽  
Medicare Advantage ◽  
Patient Level ◽  
Before And After ◽  
One Year

e18862 Background: Hematopoietic cell transplantation (HCT) is a medically complicated, expensive and resource intensive medical technology. High health care costs are usually associated with high Out-of-Pocket (OOP) costs. In this population-based study, using deidentified administrative claims data from OptumLabs Data Warehouse, we describe total and patient level costs for one-year pre and post HCT and describe the characteristics of those with top 25% cost. Methods: Patients who had undergone an autologous or allogeneic HCT in 2015 to 2019 and had continuous health plan coverage for one year prior and post the index date-the date of the first claim for HCT, were included. We examined total costs, patient paid (OOP) and plan paid costs for one year before and after HCT. We also examined inpatient, outpatient, and pharmacy costs for the one year before and after the HCT. Logistic regression models examined factors including age, gender, race/ ethnicity, Charlson comorbidity index, geographic region and costs in the year prior to HCT (baseline costs) for their association with high total costs and high OOP costs (top 25%). Results: A total of 3,346 patients (2,344 commercial plan (CPE) and 1,002 under Medicare Advantage plan (MAPE) enrollees) were included in the study. Median one year post HCT costs for CPE was $ 612,517 (IQR 413,348- 960,456) and for MAPE was $ 521,000 (IQR 347,388-736,685). Median one year post HCT OOP costs were $ 5,407 (IQR 1,584 -10,000) in CPE and $7,199 (IQR 3,485 -16,396) in MAPE group. 625 subjects in the CPE and 253 subjects in MAPE group had overall costs in the top 25%. Median baseline costs were $482,107 vs. $846,943 in the low vs. high cost group in CPE and $278,656 vs. $343,633 in MAPE. There was a low correlation between OOP costs and overall costs (r = 0.17 for CPE and 0.15 for MAPE; p < 0.05). Younger age (OR for age 0.98; p < 0.001) and higher baseline costs (OR1.89; p < 0.001) predicted top 25% total costs post HCT in the CPE group. Not being African American (OR for African American 0.5; p = 0.02) and higher baseline costs (OR 1.07; p < 0.001) predicted top 25% total costs post HCT in MAPE group. Age (OR 0.97; p < 0.001), not being African American (OR 0.5; p = 0.001) and high baseline costs (OR 1.44; p < 0.001) also predicted higher OOP costs in the CPE group. The only factor that was associated with lower likelihood of OOP costs in top 25% in MAPE group was being Hispanic (OR 0.6; p = 0.004). Conclusions: HCT is an expensive treatment modality. High costs prior to HCT are associated with high post HCT costs both for patients on commercial and Medicare Advantage plan. The magnitude of correlation between patient level and total costs was low, likely due to differences in benefit plan. A careful assessment of benefits and costs of HCT is needed for providing high-value care and allow optimum allocation of the finite resources while minimizing patient level financial burden.

scholarly journals Factors Associated with Self-Reported Physical and Mental Health after Hematopoietic Cell Transplantation

2010 ◽  
Vol 16 (12) ◽  
pp. 1682-1692 ◽  
Author(s):  
John R. Wingard ◽  
I-Chan Huang ◽  
Kathleen A. Sobocinski ◽  
Michael A. Andrykowski ◽  
David Cella ◽  
...  
Keyword(s):  
Mental Health ◽  
Cell Transplantation ◽  
Hematopoietic Cell Transplantation ◽  
Hematopoietic Cell ◽  
Physical And Mental Health ◽  
Factors Associated

Incorporation of Posttransplant Cyclophosphamide (PCy) As Part of Standard Immunoprophylaxis (IP) for All Allogeneic Transplants: A Retrospective, Single Institution Study

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4485-4485
Author(s):  
Dennis Cooper ◽  
Jackie Manago ◽  
Vimal Patel ◽  
Dale Schaar ◽  
Tracy Krimmel ◽  
...  
Keyword(s):  
Stem Cells ◽  
Stem Cell ◽  
Cell Transplantation ◽  
Disease Risk ◽  
Conflicts Of Interest ◽  
Risk Index ◽  
Chronic Gvhd ◽  
Number Of Patients ◽  
One Year ◽  
Disease Free

Background: The incorporation of PCy in IP has allowed transplantation of stem cells from haploidentical (HI) family members such that nearly all patients have a potential donor. Thus far, HI stem cell transplantation with PCy appears to yield comparable results to matched unrelated (MUD) and matched sibling donors (MSD) who have been treated with conventional GVHD regimens, but with less chronic GVHD (cGVHD). Particularly in light of the low incidence of cGVHD, which has not been achieved with other IP strategies after T cell-replete products, PCy is being investigated after MUD and MSD transplantation where complications from cGVHD remain the major cause of non-relapse mortality. A recent study from the BMTCTN showed that in patients conditioned with reduced intensity regimens and who received MSD and MUD stem cells, the addition of PCy to standard IP (SIP) was superior to either bortezomib or maravoric in the composite endpoint of graft-versus-host disease-free, relapse-free survival (GRFS). However, this study did not include patients who received ablative conditioning regimens and did not report on the percentage of patients who were disease-free and off immunosuppression (DFOI) at 1 year after transplant. In the present study, we have compared our experience with the addition of PCy for essentially all allogeneic stem cell transplants treated over a 2 year period with the results of patients treated with SIP in the prior two year span. Outcomes of interest included one-year overall survival (OS) and one-year GRFS as well as the percentage of patients DFOI at one year. Methods: With the exception of patients receiving umbilical cord blood transplants, beginning in April 2016, all but two patients who received allogeneic transplants were given mobilized peripheral blood stem cells and then treated with PCy on days +3 and +4 followed by tacrolimus and mycophenolate on day 5. In the absence of GVHD, mycophenolate was stopped at days +35-50 and tacrolimus was tapered beginning after day +100 unless there was low donor chimerism or a suspicion of relapse in which case tacrolimus could be tapered sooner. In order to have at least one-year follow-up, the last patient included in the study was treated before April 2018. During this time period, MSD were prioritized over MUD which in turn were chosen over haploidentical donors. For comparison, we looked at the prior 2 year period (2014-2016) in which patients were treated with SIP (including ATG in patients who received MUD stem cells). Because of a higher percentage of patients with an advanced disease risk index (DRI) in the years 2014-2016, we restricted our analysis in the SIP cohort to those patients with low and intermediate risk disease but included all patients in the more recent period who received PCy. Results: There were 68 patients treated in the PCy group, including 2 patients who received PCy after HI transplants in the years 2014 and 2015. After eliminating patients with high DRI there were 40 patients in the earlier SIP cohort of patients. The resulting patient groups were similar with respect to median age (53) and diagnosis (approximately 80% of patients with AML and ALL). There was a slightly higher percentage of patients in the SIP group with hematopoietic cell transplantation-comorbidity index scores of 3 or more (52.5 vs 48.5). In the PCy group the number of patients with early, intermediate and advanced DRI were 2, 53 and 13, whereas in the (modified) SIP category 2 patients had a low DRI and 38 had intermediate DRI. In the PCy group, HI donors comprised 26.5% of the total compared to 19.1% MSD and 54.4% MUD donors. In the SIP group, MSD and MUD donors accounted for 30% and 70% of the donors. One-year percentages of OS, GRFS and DFOI were 79.4, 47.1 and 44.1 in the PCy group compared to 72, 45 and 35 in the SIP cohort. If the analysis of the PCy group is limited to the 50 patients with MSD and MUD donors (as in the SIP cohort), the one-year OS, GRFS and DFOI are 88, 52 and 52. Conclusions: PCy in combination with SIP resulted in at least comparable results as SIP despite the inclusion of 19% of patients with a high DRI and 26.5% HI donors. The results with the addition of PCy are excellent in patients with MSD and MUD donors with more than half of the patients GRFS and DFOI at one year. Future studies on GVHD prophylaxis should report DFOI as the latter status may be the best platform for posttransplant strategies aimed at eliminating minimal residual disease and for improving QOL. Disclosures No relevant conflicts of interest to declare.

Treosulfan-Based Myeloablative Conditioning Prior to Allogeneic Hematopoietic Cell Transplantation Is Associated with Reduced Toxicity without Increased Risk of Relapse.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 1152-1152
Author(s):  
Sebastian Giebel ◽  
Jerzy Wojnar ◽  
Malgorzata Krawczyk-Kulis ◽  
Iwona Wylezol ◽  
Miroslaw Markiewicz ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Cell Transplantation ◽  
Hematopoietic Cell Transplantation ◽  
Hematopoietic Cell ◽  
Allogeneic Hematopoietic Cell Transplantation ◽  
Platelet Recovery ◽  
Grade Ii ◽  
One Year ◽  
Reduced Toxicity ◽  
Risk Of Relapse

Abstract The goal of this study was to evaluate toxicity and efficacy of allogeneic hematopoietic cell transplantation (alloHCT) with Treosulfan (alkylyting agent, soluble Busulfan-derivative)-based conditioning as a preparative regimen. The outcome of 27 patients (CML-15, AML-9, ALL-1, SAA-2) given Treosulfan 3x14 g/m2 + Fludarabine 5x30 mg/m2 (n=15) or cyclofosfamide (CTX) 120 mg/kg (n=12) was compared with that of 146 patients treated with Busulfan 16 mg/kg + CTX 120 mg/kg between 2000–2004. In case of unrelated donor (URD)-HCT patients were additionally given anti-thymocyte globulin. GVHD prophylaxis consisted of cyclosporin A and short-course Methotrexate. The indications for alloHSCT were comparable for both subgroups. The patients age was 35(14–56)y and 30(14–55)y, the proportion of URD-HCT was 55% and 45%, peripheral blood was used as a source of stem cells in 33% and 11% of cases, and the proportion of patients with advanced disease (AML and ALL &gt;CR1; CML &gt; CP1) equaled 26% and 19%, respectively. The cumulative incidence of non-relapse mortality at one year was 8% for the Treosulfan (EBV-LPD n=1, cerebral hemorrhage n=1) and 32% for the Busulfan group (p=0.11). Grade II-IV neutropenic infections occurred in 5% and 13% (p=NS) and grade II-IV mucositis in 9% and 61% of patients (p&lt;0.001), respectively. Other serious adverse events were infrequent. Both subgroups did not differ in terms of time to neutrophil and platelet recovery, as well as for need of RBC and platelet transfusions. Median hospital stay since the date of alloHCT was shorter after Treosulfan- compared to Busulfan-based conditioning (31 (21–55) d. vs. 40.5 (21–153) d., p&lt;0.001). The overall survival and disease-free survival at one year equaled 92% vs. 67% (p=0.11), and 92% vs. 66% (p=0.09) for the Treosulfan group and the Busulfan group, respectively. None of the patients experienced hematologic relapse among Treosulfan- compared to 3% among Busulfan-treated alloHCT recipients. However, in two CML patients given Treosulfan-based regimen, the immunosuppression taper and interferon or imatinib therapy was neccessary to establish complete chimera. We conclude that Treosulfan + Fludarabine (or CTX) +/− ATG conditioning regimen is characterized by reduced toxicity resulting in shorter hospital stay and low transplat-related mortality. The pattern of hematopoietic recovery is similar to that of Busulfan + CTX indicating myeloablative character of the Treosulfan-based regimen. The risk of relapse is low and comparable for both kinds of treatment.

Prospective Study of Changes in Bone Mineral Density and Turnover in Children after Hematopoietic Cell Transplantation.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 1115-1115
Author(s):  
Anna Petryk ◽  
Tracy L. Bergemann ◽  
Kristen M. Polga ◽  
Kami J. Ulrich ◽  
Susan K. Raatz ◽  
...  
Keyword(s):  
Bone Mineral Density ◽  
Bone Loss ◽  
Prospective Study ◽  
Cell Transplantation ◽  
Bone Mineral ◽  
Hematopoietic Cell Transplantation ◽  
Hematopoietic Cell ◽  
Standard Normal Distribution ◽  
Mineral Density ◽  
Number Of Patients

Abstract Osteoporosis is common in adults after hematopoietic cell transplantation (HCT). The data on bone mineral density (BMD) in children after HCT are limited. The goals of this prospective study were to determine the incidence, timing, magnitude and possible predictors of bone loss in children following HCT. The study population included 49 patients (age 5–18 years) who were eligible to receive HCT at the University of Minnesota. The patients were evaluated at baseline, 100 days, 6 months, and 1 year after HCT. Lumbar BMD (BMDL) was assessed by dual-energy x-ray absorptiometry. The number of patients with osteopenia increased from 18% at baseline to 33% one year after HCT, and with osteoporosis from 16% to 19%. Mean areal BMDL z-score decreased from −0.56 to −1.1 by 6 months and at 1 year was −0.94, which was significant compared to standard normal distribution (p=0.004 and p=0.022, respectively). The absolute loss of bone mineral corresponded to 5.3% reduction in areal BMDL and 4.8% reduction in volumetric BMDL. The level of bone-specific alkaline phosphatase decreased by 30% by day 100 (p=0.009), followed by recovery toward baseline by 6 months. The level of osteocalcin &gt;6.5 ng/mL at day 100 predicted recovery from the initial bone loss by 1 year. A reduction in BMDL at 6 months correlated with a cumulative dose of glucocorticoids. In conclusion, this study demonstrates that bone loss is common in children after HCT and is primarily due to suppression of bone formation. Further studies are necessary to validate osteocalcin as a predictive biomarker.

scholarly journals Administrative Claims Data for Cost Analyses in Hematopoietic Cell Transplantation: The Good, the Bad and the Ugly

2015 ◽  
Vol 21 (2) ◽  
pp. S359-S360
Author(s):  
Jaime M. Preussler ◽  
Lih-Wen Mau ◽  
Ellen M. Denzen ◽  
Navneet S. Majhail ◽  
Stephanie A. Farnia ◽  
...  
Keyword(s):  
Cell Transplantation ◽  
Hematopoietic Cell Transplantation ◽  
Claims Data ◽  
Hematopoietic Cell ◽  
Administrative Claims ◽  
Cost Analyses ◽  
Administrative Claims Data

scholarly journals Late Effects of High-Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation (HDT-AHCT) in Elderly Patients with Lymphoma

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4620-4620
Author(s):  
Parastoo B. Dahi ◽  
Chikaodi Obioha ◽  
Sheila Kenny ◽  
Patrick Hilden ◽  
Molly Maloy ◽  
...  
Keyword(s):  
Cell Transplantation ◽  
Median Time ◽  
Hematopoietic Cell Transplantation ◽  
Hematopoietic Cell ◽  
Disease Stage ◽  
High Dose ◽  
Long Term Effects ◽  
Post Transplant ◽  
Number Of Patients

Abstract Background: High-dose chemotherapy and autologous hematopoietic cell transplantation (HDT-AHCT) is an established treatment for non-Hodgkin lymphoma (NHL). Incidence of NHL is highest in patients over 60 years of age, however, limited data is available on long-term effects of HDT-AHCT in older patients. This study is conducted to evaluate the late cardiopulmonary effects and overall outcomes of HDT-AHCT in older patients. Methods: This is a single-center, retrospective study examining late cardiopulmonary effects, and overall outcomes of HDT-AHCT in 41 patients age 70 years and older, with NHL, between January 2000 and December 2016. Clinical data and comorbidities were correlated with outcomes. Pre- and post-transplant pulmonary function tests (PFT) and echocardiograms were compared. Overall survival (OS) and progression-free survival (PFS) were analyzed according to age, gender, disease histology, disease stage at diagnosis, number of lines of treatment, Karnofsky Performance Status (KPS), hemoglobin adjusted diffusing capacity of lungs for carbon monoxide (DLCO), left ventricular ejection fraction (LVEF), and hematopoietic cell transplantation comorbidity index (HCT-CI) at the time of HDT-AHCT. Results: A total of 41 patients underwent HDT-AHCT for follicular or diffuse large B-cell lymphoma (FL / DLBCL n=18 44%), mantle cell lymphoma (MCL n=15 37%) and T-cell or other NHL subtypes (n=8 19%). The median age was 72 (range 70-77). Eight (19%), 6 (15%) and 27 (66%) patients had a low (0), intermediate (1-2) and high (≥3) HCT-CI score, respectively, at transplant. All patients except 1, had received anthracycline as part of initial treatment. BEAM and RR-BEAM were the most common conditioning regimens (n=38 93%). Pre-transplant LVEF was within normal range in all patients except 1 (45%). The median (range) pre- and post-transplant LVEF was 63% (45-74%) and 64% (39-71%), respectively. Of the 23 patients who had a post-transplant echocardiogram (median time between the pre- and post-transplant echocardiogram was 423 days), a mild decrease in LVEF was noted in 3. Only 1 patient had a significant decline of 19% in LVEF. Pulmonary artery pressure (PAP) was within normal range pre- and post-transplant in all. The median (range) of pre-transplant DLCO, FEV1 and FVC were 70% (48-125%), 97% (83-141%), and 98% (57-123%), respectively. Of the 10 patients who underwent post-transplant PFT (median time between the pre- and post-transplant PFT was 405 days), DLCO decline of >10% was the most common abnormality, and developed in 4 out of 10 patients. In 5 patients DLCO improvement of >10% was observed. A greater than 15% improvement in FEV1 and FVC was observed in 5 of 10 and 4 of 10 patients respectively. The median improvements in FVC, FEV1 and DLCO were 4%, 6% and 10%, respectively. With a median follow-up of 58 months (range 5-123) for survivors, PFS and OS at 3 years were 84% (95% CI, 67-92%) and 94% (95% CI, 80-99%), respectively. In a univariate analysis, age, gender, histology, disease stage, number of lines of treatment, DLCO, LVEF, and HCT-CI score did not affect OS or PFS. However, KPS ≥90 was associated with worse OS (p=0.008). The small sample size may have been a contributor to this unexpected finding. Relapse occurred in 11 patients (27%), 8 of whom died. Median time to relapse was 38 months (range 26-100). Secondary malignancies developed in 4 patients (8%) which included acute myeloid leukemia in 2, melanoma in 1, and esophageal cancer in 1, and led to death in 3. Conclusion: In this cohort of elderly patients with NHL who underwent HDT-AHCT, the late declines in cardiopulmonary function were minimal, and none resulted in mortality. Secondary malignancy was the only cause of non-relapse mortality. This can be explained by age being the biggest single risk factor for cancer development in general, in addition to the effects of HDT. We show that the most common cause of long-term mortality after HDT-AHCT continues to be lymphoma recurrence. Our data though limited by small number of patients and its retrospective nature, suggest that age alone is not predictive of post-transplant late effects and outcomes, and therefore should not be used to preclude HDT-AHCT in elderly. While prospective studies with larger number of patients are needed to evaluate long-term effects of HDT-AHCT on different organ functions in older adults, strategies to mitigate risk of relapse remain the most important area to improve outcomes. Disclosures Sauter: Juno Therapeutics: Consultancy, Research Funding; Sanofi-Genzyme: Consultancy, Research Funding; Spectrum Pharmaceuticals: Consultancy; Novartis: Consultancy; Precision Biosciences: Consultancy; Kite: Consultancy.

scholarly journals 288What proportion of patients with chronic noncancer pain are prescribed an opioid medicine?

2021 ◽  
Vol 50 (Supplement_1) ◽  
Author(s):  
Stephanie Mathieson ◽  
Graeme Wertheimer ◽  
Christopher G Maher ◽  
Christine Lin ◽  
Andrew J McLachlan ◽  
...  
Keyword(s):  
Cancer Pain ◽  
The United States ◽  
Geographic Region ◽  
Risk Of Bias ◽  
Chronic Noncancer Pain ◽  
Factors Associated ◽  
Opioid Prescribing ◽  
Meta Regression ◽  
Quality Evidence ◽  
Over Time

Abstract Background Guidelines now discourage opioid analgesics for chronic non-cancer pain because the benefits frequently do not outweigh the harms. This review determined the proportion of patients with chronic non-cancer pain who are prescribed an opioid, the types prescribed, and factors associated with prescribing. Methods Database searches were conducted from inception to 29th October 2018 without restrictions. We included observational studies of adults with chronic non-cancer pain measuring opioid prescribing. Opioids were categorised as weak (e.g. codeine) or strong (e.g. oxycodone). Risk of bias assessed study quality. Results were pooled using a random-effects model. Meta-regression investigated study-level factors associated with prescribing. The overall evidence quality was assessed using GRADE criteria. Results Of the 42 studies (5,059,098 participants) included, majority (n = 28) from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic non-cancer pain prescribed opioids was 30.7% (95%CI 28.7% to 32.7%, 42 studies, moderate-quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95%CI 16.0% to 21.0%, n = 15 studies, low-quality evidence), versus 8.5% (95%CI 7.2% to 9.9%, n = 15 studies, low-quality evidence)). Meta-regression determined opioid prescribing was associated with year of sampling (more prescribing in recent years) (p = 0.014) and not geographic region (p = 0.056). Conclusions Opioid prescribing for patients with chronic non-cancer pain is common and has increased over time. Key message Opioid prescribing for patients with chronic non-cancer pain and has increased over time. This review is the first systematic review to synthesized such data.

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