Hematopoietic stem cell transplantation (HSCT) is a therapeutic option for many nonmalignant disorders (NMD) and is curative or prevents disease progression. Reduced-intensity conditioning (RIC) in HSCT for NMD may reduce regimen-related acute toxicities and late complications. Myeloablation is often replaced by immune suppression in RIC regimens to support donor engraftment. The pace of immune reconstitution after immune suppression by RIC regimens is influenced by agents used, donor source, and graft-versus-host disease prophylaxis/treatment. In a multicenter trial (NCT 00920972) of HSCT for NMD, a RIC regimen consisting of alemtuzumab, fludarabine, and melphalan was substituted for myeloablation. Alemtuzumab was administered early (days ¡21 to ¡19) to mitigate major lymphodepletion of the incoming graft and the risk of graft rejection. Immune reconstitution and infectious complications were prospectively monitored for 1-year post-HSCT. Seventy-one patients met inclusion criteria for this report and received marrow or peripheral blood stem cell transplants. Immune reconstitution and infections are reported for related donor (RD) and unrelated donor (URD) transplants at 3 time-points (100 days, 6 months, and 1 year post-HSCT). Natural killer cell recovery was rapid, and numbers normalized in both cohorts by day +100. Mean CD3, CD4, and CD8 T-lymphocyte numbers normalized by 6 months after RD HSCT and by 1 year in the URD group. CD4 and CD8 T-lymphocyte counts were significantly higher in patients who received RD HSCT at 6 months and at 1 year, respectively, post-HSCT compared with patients who received URD HSCT. The pace of CD19 B-cell recovery was markedly different between RD and URD cohorts. Mean B-cell numbers were normal by day 100 after RD HSCT but took 1 year post-HSCT to normalize in the URD cohort. Despite these differences in immune reconstitution, the timing and nature of infections did not differ between the groups, presumably because of comparable T-lymphocyte recovery. Immune reconstitution occurred at a faster pace than in prior reports using RIC with T-cell depletion. The incidence of infections was similar for both cohorts and occurred most frequently in the first 100 days post-HSCT. Viral and fungal infections occurred at a lower incidence in this cohort, with "early" alemtuzumab
12121 Background: Specialty palliative care (PC) improves outcomes for patients with advanced cancer, including quality of life and end-of-life (EOL) care utilization. In 2017, the American Society of Clinical Oncology recommended that patients with advanced cancer see specialty PC within 8 weeks of diagnosis. Despite this, inpatient PC referrals exceed outpatient referrals nationwide. Recognizing the importance of earlier PC access, our cancer center implemented a criteria-based PC consultation service in the inpatient oncology setting. We now report pre/post EOL outcomes from this novel care model. Care model: Our center embedded a “Palliative Oncology” consult team on the oncology floor consisting of 1 physician, 1 nurse practitioner (NP), 2 social workers, and 2 spiritual care providers, all with PC specialization. Admitted patients were screened by a floor nurse or PC NP for 2 referral criteria: 1) advanced/metastatic solid cancer, or 2) moderate/severe symptoms. The inpatient oncology team was informed of patients meeting criteria through daily prompting supported by ongoing education. Referrals remained at discretion of the oncology team rather than triggering automatically. Methods: We identified all cancer center decedents with advanced solid cancers who experienced an admission to the oncology floor before (10/1/19-6/30/20) or after (7/1/20-9/30/21) the new model. Six trained abstractors performed chart review. We compared outcomes between patients who died pre- and post-implementation using a t-test (continuous variables) and χ2 test (categorical variables). Results: Of 820 decedents, 186 died pre-intervention and 634 died post-intervention. During the post-intervention period, more decedents saw inpatient PC (72% vs. 59%, p < .001) and outpatient PC (34% vs. 23%, p < .01). Post-intervention decedents had more inpatient PC visits (mean: 11.1 vs. 8.9, p < .05) and had their first PC visit sooner before death (mean: 159 vs. 76 days, p < .001). During the post-intervention period, fewer decedents had ED (41% vs. 52%, p < 0.05), hospital (57% vs. 71%, p < .001), or ICU encounters (17% vs. 25%, p < .01) in the last 30 days of life. For post-intervention decedents, the proportion referred to hospice remained stable (67% vs. 60%, p = .09), but mean hospice length-of-stay increased (36 vs. 22 days, p < .05), as did the proportion who died at home (50% vs. 41%, p < .05). Fewer post-intervention decedents received systemic cancer therapy in the last 14 days of life (5% vs. 9%, p < .05). There were no between-group differences in age at cancer diagnosis, age at death, gender, race/ethnicity, insurance, or primary cancer. Conclusions: A criteria-based “Palliative Oncology” inpatient consult service was associated with earlier, more intense PC and improved EOL quality outcomes, representing a successful effort to enhance PC integration in the inpatient oncology setting.
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