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Feasibility of geriatric assessment before transplant conditioning regimen in older HCT recipients

Bone Marrow Transplantation volume 56, pages 726–729 (2021)Cite this article

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We read with interest the work of Dr. Polverelli et al., which concluded that pretransplant adoption of a multidimensional geriatric assessment, the Fondazione Italiana Linfomi (FIL), could be informative about prognosis after allogeneic hematopoietic cell transplant (HCT) [1]. Non-relapse mortality (NRM) rates remain high in older HCT recipients with substantial comorbidities even when receiving reduced-intensity conditioning (RIC) regimens [2]. With this in mind, NRM may decrease by using mathematic modeling to personalize the HCT conditioning or graft-versus-host disease (GVHD) regimens using more accurate measures of biologic age [3]. Such measurements of biologic age include the comprehensive geriatric assessment (CGA), comorbidity burden before HCT, physiologic functional status (e.g., 6-min walk test, 6MWT), body composition (e.g., sarcopenia), blood and other biomarkers of aging. These biologic age measurements may provide more insight than chronological age regarding HCT outcomes. However, limited data exist regarding the feasibility of a multidimensional assessment of biologic age in older patients being evaluated for allogeneic HCT. Potential barriers in completing these assessments shortly before HCT include the limited availability of the patients and their caregivers, and the space and time in the outpatient clinic. Moreover, the required resources, such as the support personnel and time spent to complete these measurements, are mostly unknown.

In an IRB-approved prospective study, we sought to determine the feasibility of conducting a preconditioning HCT-modified geriatric assessment (HCT-MGA)—that is, completing the HCT-MGA before administering the first dose of the conditioning regimen—within our current clinical workflow of assessing patients for HCT eligibility. The preconditioning HCT-MGA components (Table 1) were: (1) the augmented HCT-comorbidity index (HCT-CI) [2]; both sections of the CGA, specifically the sections completed (2) by the patient (patient CGA); or (3) by the healthcare professional (hpCGA) [4]; (4) the 6MWT; (5) the dual-energy X-ray absorptiometry (DEXA) scan; and (6) plasma and urine samples. Older (>50 years old) patients undergoing evaluation for allogeneic HCT from February 15 to April 3, 2019, were eligible for participation; 15 of 22 (68%) consecutive eligible patients agreed to participate. Of these, four did not undergo HCT because of medical reasons (i.e., three pulmonary insufficiency and one renal failure), giving a final cohort of 11 participants. The median age of participants was 60 (range, 52–72) years; the majority (7 of 11) were male. Their self-reported race was 10 Caucasian and 1 African-American; self-reported ethnicity was 10 non-Hispanic and 1 Hispanic. The indication for HCT was acute leukemia/myelodysplasia (8 participants, 72.7%) or lymphoma/other (3 participants, 27.3%); the majority (6 of 11) had their disease in remission at preconditioning. Ten participants had a matched unrelated donor, and 1 participant had a matched sibling donor; 1 participant had a bone marrow graft, and 10 participants had a peripheral blood graft. All participants received fludarabine/melphalan conditioning: intravenous (IV) fludarabine (25 mg/m2/day) on days −8 to −4 and IV melphalan (140 mg/m2) on day −3 with tacrolimus and sirolimus for GVHD prophylaxis.

Table 1 HCT-modified geriatric assessment (HCT-MGA) components.
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Acknowledgements

This research was supported by City of Hope’s Center for Cancer and Aging. Research reported in this publication included some work performed in the Biomarker Analysis and Validation for Population Scientists Core supported by P30CA033572. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors are grateful to the participants. In addition, the authors wish to thank the following staff for their invaluable help in making this work possible: Heeyoung Kim, Jožefa McKiernan, Monica Munaretto, Christine Quinones, Canlan Sun, and Rachel Tran. The thoughtful discussions with Andrew Artz, the late Arti Hurria, and Mina Sedrak are appreciated. The authors also wish to thank all the health care professionals and support personnel for their care of the participants in this study.

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Authors and Affiliations

  1. Department of Population Sciences, Beckman Research Institute at City of Hope, Duarte, CA, USA

    Kai Littlejohn, Saro H. Armenian, Ryotaro Nakamura & Jeannine S. McCune

  2. Department of Hematology & HCT, City of Hope, Duarte, CA, USA

    Kelly Tomlinson, Ryotaro Nakamura & Jeannine S. McCune

  3. Department of Pediatrics, City of Hope, Duarte, CA, USA

    Saro H. Armenian

  4. Clinical Research Division, Fred Hutchinson Cancer Research Center, and Department of Medicine, University of Washington, Seattle, WA, USA

    Mohamed L. Sorror

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Littlejohn, K., Tomlinson, K., Armenian, S.H. et al. Feasibility of geriatric assessment before transplant conditioning regimen in older HCT recipients. Bone Marrow Transplant 56, 726–729 (2021). https://doi.org/10.1038/s41409-020-01064-1

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