Italian consensus conference for the outpatient autologous stem cell transplantation management in multiple myeloma

Abstract

Multiple myeloma (MM) is the leading indication for autologous stem cell transplantation (ASCT) worldwide. The safety and efficacy of reducing hospital stay for MM patients undergoing ASCT have been widely explored, and different outpatient models have been proposed. However, there is no agreement on the criteria for selecting patients eligible for this strategy as well as the standards for their clinical management. On the basis of this rationale, the Italian Group for Stem Cell Transplantation (GITMO) endorsed a project to develop guidelines for the management of outpatient ASCT in MM, using evidence-based knowledge and consensus-formation techniques. An expert panel convened to discuss the currently available data on the practice of outpatient ASCT management and formulated recommendations according to the supporting evidence. Evidence gaps were filled with consensus-based statements. Three main topics were addressed: (1) the identification of criteria for selecting MM patients eligible for outpatient ASCT management; (2) the definition of standard procedures for performing outpatient ASCT (model, supportive care and monitoring during the aplastic phase); (3) the definition of the standard criteria and procedures for re-hospitalization during the aplastic phase at home. Herein, we report the summary and the results of the discussion and the consensus. INTRODUCTIONMultiple myeloma (MM) remains the leading indication for highdose chemotherapy and autologous stem cell transplantation (ASCT) worldwide 1,2 and the International Guidelines recommend that ASCT should be offered at some point during the treatment program for a medically fit patient. 3,4 High-dose melphalan (HDM) at 200 mg/m 2 is the standard conditioning for ASCT 5,6 and, today, the treatment should be considered a safe procedure with a very low transplant-related mortality (TRM). 7-9 The significant increase in the waiting lists generated concerns about the appropriate use of health care resources and, over the past years, some studies have investigated the safety, efficacy and potential cost advantages of reducing hospital stay for patients undergoing ASCT. [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] The ease of administering HDM, the relatively low extra-hematological toxicity and the short period of neutropenia 5,6 make MM patients ideal candidates for outpatient ASCT programs. Standardization of criteria for the outpatient ASCT policy is a relevant goal of the Italian hematology and transplant community and may facilitate comparison of retrospective and prospective data. The Italian Group for Stem Cell Transplantation (GITMO) endorsed a panel of 10 experts in the transplant field (MMa, RML, CG, LC, BB, MO, IL, MMo, GM and AO) to propose a consensus for the selection criteria and management of MM patients for ASCT procedure in the outpatient setting. METHODSA working group of 10 experts from 7 GITMO centers, with specific expertise in the field of ASCT, convened four times to: (a) identify common criteria for selecti...

Inpatient vs outpatient autologous hematopoietic stem cell transplantation for multiple myeloma

“…Although there are some guiding resources that have been published, at our institution, there is no defined algorithm for determining inpatient vs outpatient treatment. However, it appears that those patients chosen for outpatient management were carried out so appropriately, as their toxicities were not worse than their inpatient counterparts.…”

“…Multiple myeloma (MM) is the second most common adult hematologic malignancy and is the most common indication for autologous hematopoietic stem cell transplantation (auto‐HCT) In the current era of novel therapeutics, this treatment is still considered beneficial, with significant improvements in progression‐free survival (PFS) . The process of high‐dose chemotherapy and auto‐HCT has thus become routine at most cancer centers and has given rise to the paradigm of outpatient auto‐HCT …”

Hematopoietic Stem Cell Transplantation in Multiple Myeloma in the Era of Novel Therapies

“…The median times for engraftment following noncryopreserved autografts were 9-14 days for neutrophils and 14-25 days for platelets [79,81]. Other recent studies on noncryopreserved autologous HSCT in patients with MM have shown the following results: neutrophil engraftment between 10 and 14 days and platelet engraftment between 13 and 25 days postautologous HSCT [85][86][87][88][89][90][91][92].…”

Small Centers with Big Ventures: Autologous Stem Cell Transplantation Survival Data

“…There are fewer acute and chronic transplant-related complications and no graft-vs-host disease (GVHD), albeit at the expense of higher relapse rate (Pasquini and Wang, 2013). There are also less healthcare resources consumed and, hence, it is being performed both in the inpatient as well as outpatient settings globally (Martino et al, 2016;Abid et al, 2017). In addition, ASCT may yet rarely be performed at the secondary-level healthcare centres which may house facilities and manpower to perform ASCT and adhere to international standards [The Foundation for the…”