1.
Primary preventative care of hematopoietic stem cell transplant survivors: time to educate and empower recipients and providers
Fulcher, J., Blanchard, A. P., Bredeson, C., van Walraven, C.
Transplantation and cellular therapy. 2022
Abstract
Increased use of hematopoietic stem cell transplantation (HCT) and improvements in recipient outcomes has led to a steady increase in the number of allogeneic HCT survivors. In addition to complications specific to the transplant process, HCT recipients are at increased risk of developing cardiovascular disease (CVD) and subsequent neoplasms (SN). Strict adherence to general population CVD risk factor and cancer surveillance is recommended as an essential component of long-term follow-up (LTFU) care of HCT survivors but implementation of this has been suboptimal. Models to improve the provision of survivorship care have been proposed including a hybrid/combined care approach where the HCT providers manage transplant-specific complications and the primary care physician (PCP) provides general medical care including surveillance and aggressive management of CVD risk factors and screening for subsequent neoplasm (SN). This model also offers a practical approach to LTFU care for HCT survivors who live at a distance from the HCT center which is a reality for many recipients of HCT at the Ottawa hospital (TOH). As the success of such a hybrid approach to survivorship care is dependent on the engagement of HCT recipients with their PCP and compliance with recommended general population surveillance, the aim of the study reported here was to assess the rates of PCP attendance and adherence to recommended preventive-medicine interventions in the years immediately prior to and following HCT. We hypothesized that rates would be sub-optimal and planned to use these results as a baseline for an educational initiative aimed at increasing awareness of HCT recipients and their PCPs about embracing a preventative survivorship care. This was a single center cohort study of allogeneic HCT recipients transplanted at TOH with linkage to population-based health administrative data. Published clinical practice guidelines were used to define recommended screening for CVD risk factors and cancer. In the 5 years prior to and following HCT, the rates of annual PCP visits and utilization of recommended preventative care interventions were calculated for all eligible patients. Between 2014 and 2020, 409 patients with provincial health care coverage underwent allogeneic HCT at TOH. Median age was 51 (range 15-73) with a male predominance (60.9%). Approximately one quarter of recipients did not attend their PCP in the five years before and after transplant and this proportion increased to one third in the 5(th) year post-HCT. For those recipients who were eligible, only 20-25% underwent recommended screening for dyslipidemia and diabetes. Cancer screening rates were also low at 16-18% for cervical cancer, 18-22% for colon cancer and 30-31% for breast cancer. Results highlight the need to increase awareness of HCT recipients and their PCPs about the risk of developing CVD and SN post-transplant, and to emphasize the potential to mitigate this risk by adhering to recommendations for surveillance to enable prompt intervention. Patient education should incorporate this information and empower HCT survivors to actively engage in their follow-up care and optimize their long-term outcomes.
2.
Predictors of lost to follow-up among pediatric and adult hematopoietic cell transplant survivors: A report from the Center for International Blood and Marrow Transplant Research
Buchbinder, D., Brazauskas, R., Bo-Subait, K., Ballen, K., Parsons, S., John, T., Hahn, T., Sharma, A., Steinberg, A., D'Souza, A., et al
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2019
Abstract
BACKGROUND Follow-up is integral for hematopoietic cell transplant (HCT) care to ensure surveillance and intervention for complications. We characterized the incidence of, and predictors for, being lost to follow-up. METHODS Two-year survivors of first allogeneic (10,367 adults and 3,865 children) or autologous (7,291 adults and 467 children) HCT for malignant/non-malignant disorders from 2002-2013 reported to the Center for International Blood and Marrow Transplant Research were selected. The cumulative incidence of being lost to follow-up (defined as having missed 2 consecutive follow-up reporting periods) was calculated. Marginal Cox models (adjusted for center effect) were fit to evaluate predictors. RESULTS The 10-year cumulative incidence of being lost to follow-up among adult allogeneic and autologous HCT survivors was 13% (95% CI, 12-14) and 15% (95% CI, 14-16), respectively. Among pediatric HCT survivors, estimates were 25% (95% CI, 24-27) and 24% (95% CI, 20-29), respectively. In adult allogeneic HCT survivors, younger age, non-malignant disease, public/no insurance (reference: private), living farther from the HCT center, and being unmarried were associated with being lost to follow-up. For adult autologous HCT survivors, older age and testicular/germ cell tumor (reference: non-Hodgkin lymphoma) were associated with greater risk of being lost to follow-up. Among pediatric allogeneic HCT survivors, older age, public/no insurance (reference: private), and non-malignant disease were associated with being lost to follow-up. Among pediatric autologous HCT survivors, older age was associated with greater risk of being lost to follow-up. CONCLUSION Follow-up focusing on minimizing attrition in high-risk groups is needed to ensure surveillance for late effects.
3.
Are We Choosing Wisely With Autologous Hematopoietic Cell Transplantation Screening? The Utility of Pulmonary Function Testing Prior to Autologous Hematopoietic Cell Transplantation
Li, T., Mallick, R., McCurdy, A., Mulpuru, S., Huebsch, L., Bredeson, C., Allan, D., Kekre, N.
Clinical lymphoma, myeloma & leukemia. 2018
Abstract
INTRODUCTION Despite the risk of morbidity and mortality associated with autologous hematopoietic cell transplantation (ASCT), there are no clear guidelines as to how to screen for these risks. This study sought to determine the utility of pulmonary function tests (PFTs) prior to ASCT on predicting posttransplant clinical outcomes. PATIENTS AND METHODS Patients undergoing ASCT between 2010 and 2012 at the Ottawa Hospital (n = 172) were reviewed. PFT results prior to ASCT were retrieved. The primary outcomes were incidence of intensive care unit (ICU) admission, Seattle Criteria for pulmonary toxicities, and transplant-related mortality (TRM). RESULTS PFTs were performed for 91 (53%) patients prior to ASCT. There were more smokers in the PFT cohort than the non-PFT cohort (41.8% vs. 19.8%, respectively; P < .0001). Pulmonary toxicity as measured by the Seattle Criteria did not correlate with PFT results (normal vs. abnormal, 8.1% and 6.1%, respectively; P = 1.00). There were no differences in incidence of ICU admission by PFT result (normal vs. abnormal, 2.7% vs. 8.2%, respectively; P = .61) and no difference in TRM by PFT result (normal vs. abnormal, 0% vs. 2.0%, respectively; P = 1.00). CONCLUSION Despite testing patients deemed higher risk for pulmonary toxicity, abnormal PFTs did not predict for an increased risk of pulmonary toxicity, ICU admission, or TRM at our center.