Impact of pre-transplant co-morbidities on outcome after alemtuzumab-based reduced intensity conditioning allo-SCT in elderly patients: A British Society of Blood and Marrow Transplantation study

Abstract

The advent of reduced intensity conditioning (RIC) regimens has permitted the extension of allo-SCT to selected patients into their eighth decade but GVHD remains a major cause of morbidity and mortality. Alemtuzumab is increasingly used to reduce the risk of severe GVHD, but there are concerns that T-cell depletion may compromise outcome particularly in older patients. We therefore studied the impact of pre-transplant factors on the outcome of 187 patients with a haematological malignancy over the age of 60 transplanted using an alemtuzumab-based RIC regimen of whom co-morbidity scoring was possible in 169. Of the patients, 120 had a haematopoietic cell transplantation co-morbidity index (HCT-CI) of 0 or 1 and 49 had a score of 2 or more. The 5-year OS was 33%. In multivariable analysis, OS was determined by co-morbidity score (P = 0.001) and disease status at transplant (P = 0.004) but not by patient age. Non-relapse mortality was determined by co-morbidity score (P = 0.001). Two-year OS for patients with a HCT-CI of 0-1 was 59 versus 6% for patients with a higher score. Alemtuzumab-based RIC allografts can be delivered safely in patients aged over 60 but co-morbidity scoring is mandatory to identify patients who will benefit.

Allogeneic Stem Cell Transplantation for Acute Myeloid Leukemia: Who, When, and How?

“…The widely used, updated HCT-CI score allows some adjustments due to age ( 73 ), and this analysis showed that younger patients with comorbidities were at a significant disadvantage to older fit individuals with no other significant comorbidities. Nonetheless the HCT-CI score is still of importance in this population, as it has been shown that in patients above 60 years of age a HCT-CI score of 2 or greater results in substantially higher TRM than otherwise expected ( 78 ). Future developments to improve assessment of transplant eligibility in this cohort should involve geriatric assessments that encompass an assessment of the functional status of the patient ( 79 ).…”

The Evolving Role of Allogeneic Stem Cell Transplant in the Era of Molecularly Targeted Agents

“…22 It is of particular value in patients older than 60 years in whom transplant decision making can be very complex. 26 Importantly, while the TRM of patients older than 60 years with an HCT-CI of 0 to 1 is broadly similar to that observed in younger patients, it is clear that older patients tolerate comorbidities less well than do younger patients, and the TRM in patients older than 60 years whose HCT-CI is greater than 3 can be as high as 60%. Despite this, predicting the impact of patient fitness on transplant outcome still remains imprecise, particularly in older patients, and the decision to recommend allo-SCT remains bespoke.…”

Optimizing Transplant Approaches and Post-Transplant Strategies for Patients With Acute Myeloid Leukemia

“…An alternative TRM assessment tool is the EBMT scoring system which was first devised to assess outcome of allogenic stem cell transplant for patients with chronic myeloid leukemia ( 55 ), but is now not widely used in assessing patients with AML ( 56 ). Whilst the EBMT scoring and HCT-CI take different parameters into account neither perform particularly well in older patients destined for RIC allografts where studies have shown an excess TRM in patients with an HCT-CI>1 ( 57 ). Attempts to combine the two methods to develop a compounded scoring system has been shown to improve TRM prediction ( 55 , 56 ).…”