AUTOLOGOUS HEMATOPOIETIC STEM CELL TRANSPLANTATION IN ITS MAIN INDICATIONS: A SINGLE-CENTER, RETROSPECTIVE STUDY OF 30 YEARS

Objective: Autologous hematopoietic stem cell transplantation is widely used in patients with hematological cancers and in some solid tumors. We aimed to describe the transplant procedures performed in a single institution along 30 years. Methods: We describe retrospectively the autologous transplants performed from 1987 to 2016 for: acute myeloid leukemia (AML), Hodgkin (HL) and non-Hodgkin lymphoma (NHL), and multiple myeloma (MM). Results: We analyzed 378 consecutive patients, all with neutrophil engraftment, which was faster with higher CD34 counts (p=0.0001) and slower in patients with AML (p=0.003). Five-year overall survival (OS) was 61%. Receiving transplant in the most recent period (2008-2017) was a protective factor (p<0.0001). For MM, the incidence of relapse was significantly higher in patients not achieving a partial response (hazard ratio, HR = 4.02, p = 0.03). For lymphomas, both patients with partial response (p=0.003) and refractory (p=0.007) had higher relapse rates. The 5-year incidence of disease relapse was 42% for AML, 49% for MM, 41% for HL and 41% for NHL (p=0.88). Non-relapse mortality was 13% in 1 year. Conclusion: There was an improvement in the outcomes of patients undergoing autologous transplants for oncological and onco-hematological diseases across the last 30 years in our institution.

Symptom Burden, Perceived Control, and Quality of Life Among Patients Living With Multiple Myeloma

Background: New therapies for multiple myeloma (MM) have improved survival rates but often expose patients to heightened toxicities and prolonged treatment, leading to increasing complications and side effects. We evaluated the association between symptom burden, perceived control over illness, and quality of life (QoL) among a national sample of patients with MM. Methods: For this observational, cross-sectional study, we used data from the Cancer Experience Registry research initiative to examine symptom- and functioning-related concerns among 289 patients with MM across the illness trajectory. We applied hierarchical multiple linear regression analyses to explore associations between symptom burden and perceived control over illness with QoL indicators: depression, anxiety, and social satisfaction. Results: In our sample, 73% of participants with MM reported currently receiving treatment; 39% experienced relapse; 56% received 1 to 2 autologous transplants, 10% received ≥3 autologous transplants, and 4% received allogeneic and autologous transplants; 30% had not received a stem cell transplant. Average time since diagnosis was 4.4 years. The most highly endorsed concerns included eating and nutrition (61%), physical activity (59%), moving around (56%), fatigue (55%), pain (52%), and sleep (46%). Only 27% believed they had control over their disease, whereas 48% perceived having control over the physical side effects of MM. Approximately one-third of the variance in anxiety and depression and nearly two-thirds of variance in social satisfaction were explained by sociodemographic, clinical, and symptom burden variables. Perceived control over illness significantly predicted depression and anxiety, but not social satisfaction. Our results highlight substantial concern among patients with MM about physical symptoms and function. Additionally, greater symptom burden significantly accounted for poorer QoL, and lower perceived control over illness was linked to depression and anxiety. Conclusions: Patients with MM and survivors experience substantive long-term QoL issues. Together, these findings point to the critical need for comprehensive symptom management, integrated palliative care, and enhancement of social and emotional support for individuals with MM.

Opiate and Benzodiazepine Use during Hospitalization for Hematopoietic Stem Cell Transplantation (HSCT) Is Associated with Adverse Health Related Outcomes

INTRODUCTION: Significant burden of pain syndromes are reported in patients with hematological malignancies undergoing HSCT mostly due to underlying disease and associated treatments. Opioid analgesics and benzodiazepines are routinely used for symptomatic management in this patient population. The use of narcotic analgesics and benzodiazepines in non-transplant hospitalized patients has been shown to adversely affect health related outcomes such as length-of-stay (LOS), falls and other complications. However, there is a significant knowledge gap regarding the patterns of opioid and benzodiazepine use and their impact on health outcomes in HSCT patients. METHODS: We identified 275 patients from the year 2015-2018 who underwent HSCT (allogeneic and autologous transplants) at our center for a variety of hematological malignancies. Opioid exposure was defined in three groups of patients 1) Opioid naïve: those did not report prior use of opioid at admission and who were not prescribed opioid during hospitalization, 2) Previous Opioid users: those who reported active use of opioid at admission and continued during hospitalization 3) New Opioid users: Patients who did not report opioid use at admission but were prescribed opioid during hospitalization. Multivariable analysis was performed to identify differences in opioid status, opioid use, benzodiazepine use, disease diagnosis, Karnofsky score, gender, age, race, and marital status with associated complications (Poisson regression), emergency department visits (Logistic Regression) and length of stay (Ordinal Logistic Regression) Figure 1 and Figure 2. RESULTS: The median age of patients was 59 (range: 25-74 ) years with slight male predominance (57%). Patients undergoing autologous transplants for multiple myeloma (MM) comprised 48% of the population. The majority (72 %) were exposed to opioid during hospitalization. Ninety two percent of the opioid naïve population (28% of the total population) underwent autologous transplant. Conversely, 36% of patients undergoing autologous transplants never received opiates during hospitalization as compared to 7% of those who received an allogeneic transplant. Median morphine milligram equivalent daily dose was 3.1 mg. Median diazepam equivalent daily dosage in patients that were opiate exposed was 2.07 milligram. Of the total transplant population, 55% received benzodiazepine concurrently with opiates during hospitalization. 76 % of the population was exposed to both opioid and benzodiazepine. Twenty five percent of those who were exposed to opioid did not receive benzodiazepines. Sixty four percent of the MM patients were exposed to opioid of which majority (59%) were previous opioid users. Of the non-MM patients undergoing HSCT, 80% were exposed to opioid of which 36% were previous opioid users and 64% were new users. A wide range of complications from neutropenic fever to death, were seen in 89% of all patients (opioid users and non-users) but all the falls occurred in patients who were on opioid medications. Autologous transplant recipients had higher odds of having a greater number of complications compared to Allogeneic transplant patients (OR 1.25, 95% CI: 1.01 - 1.55, p=0.04), as well as a reduced odds of having a medium or high length of stay (OR 0.03, 95% CI: 0.02 - 0.07). Of the opioid naïve patients, 6% presented to the ED within 30 days of discharge versus 15% of those that were exposed to opiates during hospitalization. Benzodiazepine use at admission for HSCT was associated with greater odd of presenting to ED within 30 days of discharge (OR 3.94, 95% CI: 1.55-10.04) and this was more significant in patients with MM (OR 4.08, 95% CI: 1.01-16.44). Finally, we also saw a trend towards longer stay in patients who were exposed to opioids as compared to opioid naïve (40% vs. 17%). CONCLUSION: Our study, albeit limited due to its retrospective design, is among the first to report the patterns of use and the impact of opioids and benzodiazepines in patients undergoing HSCT. Our results indicate that the use of these medications is frequent in this population and as in the non-transplant hospitalized patients and is associated with more emergency room visits post discharge, along with other potentially adverse outcomes. Disclosures Kharfan-Dabaja: Incyte Corp: Speakers Bureau; Seattle Genetics: Speakers Bureau; Alexion Pharmaceuticals: Speakers Bureau. Ailawadhi:Amgen: Consultancy; Pharmacyclics: Research Funding; Celgene: Consultancy; Takeda: Consultancy; Janssen: Consultancy.

Redesigning care to lower episode costs in bone marrow transplantation.

16 Background: Increased scrutiny over costs of cancer care has led to the introduction of episode-based payment by federal and commercial insurers. National average billed charges for autologous and allogeneic transplant episodes of care are approximately $375K and $925K, respectively. Through comprehensive analysis of claims data, we identified leading drivers of cost in BMT episodes (which span 30 days before transplant through 60-100 days post-transplant) and cost reduction opportunities. By redesigning care delivery, we can reduce post-transplant admissions and potentially improve the health and patient experience for this population. Methods: From September 1, 2013 – February 28, 2015, SHC performed 221 allogeneic and 241 autologous transplants. We analyzed internal claims data to map costs of BMT episodes, including pre-transplant, transplant (index), and post-transplant phases of care using standardized cost categories including room accommodations, medications, medical and surgical supplies, imaging, and labs. Results: 67% of episode cost was associated with pre-transplant and index phases. In both phases, patients’ treatment closely matched defined protocols. Imaging, medications, and blood utilization met clinical indications. The largest opportunity was seen in the post-transplant phase for patients with multiple myeloma who received autologous transplants. On average, episodes with post-transplant admissions were 35% more costly than episodes without post-transplant admissions. Many of these patients are admitted 5-9 days after transplant due to neutropenic fever, have short LOS, and receive empiric antibiotics. An estimated 37% of post-transplant admissions, totaling $790,000 in annualized cost, may be prevented with additional outpatient support. Conclusions: A multidisciplinary team proposed redesigning care to safely shift treatment from the inpatient to outpatient setting. Strategies include expanding Infusion Treatment Area and home pharmacy capacity and partnering with home health agencies.