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Should age affect eligibility for autologous stem cell transplant in elderly lymphoma patients?

Lova Sun of Massachusetts General Hospital, and colleagues, published results of 16 years of retrospective chart review for outcomes of autologous stem cell transplant (ASCT) in patients over 70 years old.  The review was published in the online edition of The Oncologist December 28, 2017. 

ASCT is the standard treatment for chemotherapy-sensitive relapsed lymphoma patients.  Medical practitioners may be hesitant to offer transplant to older patients due to concerns for higher risk for poor outcomes due to infections, organ toxicities or non-relapse mortality (NRM).  The purpose of this review was to observe safety outcomes over an extended period and determine if any clinical factors influence favorable versus poor outcomes in elderly lymphoma patients.

 Patient Population
  • N = 107 patients
  • Median age = 72 years
  • Stem cell transplant ≥ 1 year after diagnosis = 70%
  • Two or more prior chemotherapy regimens = 78.5%
  • Hematopoietic cell transplant comorbidity index
    • Low risk = 30.8%
    • Intermediate risk = 26.1%
    • High risk = 42.9%
  • Year of ASCT
    • 2000-2005 = 9.3%
    • 2006-2010 = 31.7%
    • 2011-2016 = 58.8%
Results
  • Median time to neutrophil engraftment = 10 days
  • Median time to platelet engraftment = 12 days
  • 100-day NRM = 2% (95% CI, 0.4%-6%)
  • Five-year follow up
    • Progression-free survival (PFS) = 47%
    • Overall survival (OS) = 52%
    • NRM = 13%
    • Relapse = 40%
  • Toxicity and mortality
    • Mortality ≤ day +100 = 2.8%
    • Mortality ≥ day +100 = 40.1%
    • Infection = 22.4%
    • Neurologic toxicity = 11.2%
    • Pneumonitis = 2.8%
    • Acute kidney injury = 6.5%
    • Liver toxicity = 1.8%
  • Factors influencing outcomes
    • PFS: ASCT in CR1 vs PR/active disease ([HR 3.28], 95% CI, 1.21-8.92)
    • Relapse: PR/active disease vs CR1 ([HR 5.09, 95% CI, 1.51-17.18)
    • NRM: ASCT 2000-2005 vs 2011-2016 ([HR 6.54, 95% CI, 1.37-31.31)

This study demonstrated that elderly patients are still viable candidates for ASCT, with good clinical outcomes and acceptable expected toxicities. Survival status has improved in recent years, which likely reflects improvements in supportive care, toxicity management and infection prophylaxis.  The authors recommended that elderly lymphoma patients should be selected based on individual patient characteristics for ASCT and not excluded as candidates based on age alone. 

References
  1. Sun L, et al. Autologous Stem Cell Transplantation in Elderly Lymphoma Patients in Their 70s: Outcomes and Analysis. The Oncologist 2017; doi:10.1634/theoncologist.2017-0499. [Epub ahead of print]