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Deconditioning in Stem Cell Transplant Cancer Patients Referred to the “Moving on” Physical Rehabilitation Program
Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
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252 Chronic Conditions and Frail Health Among Adult Survivors of Childhood Hematologic Malignancies Treated with Hematopoietic Cell Transplant (HCT): A Report from the St. Jude Lifetime Cohort Study (SJLIFE) Hesham Eissa 1, Lu Lu 1, Malek J. Baassiri 1, Nickhill Bhakta 1, Matthew J. Ehrhardt 1, Daniel A. Mulrooney 1, Brandon M. Triplett 2, Daniel M. Green 1, Leslie L. Robison 1, Melissa M. Hudson 1, Kirsten K. Ness 1. 1 St. Jude Children’s Research Hospital, Memphis, TN; 2 Bone Marrow Transplantation and Cellular Therapy, St Jude Children’s Research Hospital, Memphis, TN Background: Outcomes of hematopoietic cell transplantation (HCT) have markedly improved over the past 2 decades, underscoring a need to better understand the long-term health effects of this intensive treatment modality. We describe the burden of comprehensively assessed chronic medical conditions and frail health among survivors of childhood hematologic malignancies treated with HCT (n = 112) compared to those treated with conventional therapy (n = 1106). Methods: Eligible survivors were diagnosed with a hematologic malignancy between 1/1/1982 and 6/30/2005, treated at St. Jude Children’s Research Hospital, survived ≥10 years from cancer diagnosis, reached ≥18 years of age, and completed an on-campus clinical evaluation as part of the St. Jude Lifetime Cohort Study (SJLIFE), a cohort designed to facilitate longitudinal evaluation of health outcomes among adults previously treated for a pediatric malignancy (Figure 1). Chronic conditions and frail health were clinically ascertained and classified according to a modified version of the Common Terminology Criteria for Adverse Events (version 4.03; grade 1 [mild] to grade 4 [life-threatening]) and the Fried Frailty Criteria. Mean cumulative count was used to estimate cumulative burden of disease. Results: Among HCT recipients, 70.5% (n = 79) had allogeneic transplants, 41 had sibling donors, 34 had unrelated donors, and 4 had related donors other than siblings. Twentyfive of allogeneic HCT survivors (31.6%) had a history of chronic graft versus host disease (cGVHD), only 2 of those had active cGVHD at the time of assessment. One of the 33 (29.5%) autologous transplant recipients had a syngeneic donor. Compared to those treated with conventional therapy, HCT survivors had a higher prevalence of severe, disabling or life threatening (grade 3-4) chronic conditions (81.3% vs 69.2%, P = .007). By the age of 25 years, HCT survivors experienced 148 grade 3-4 events per 100 persons compared to 60 among survivors treated with conventional therapy (P < .001) (Figure 2). Rates of second neoplasms (17.0% vs 7.9%, P = .003),
Figure 1. Consort Diagram.
Figure 2. Mean cumulative count (MCC) of grades 3-4 chronic conditions among HCT survivors compared to conventionally treated participants by attained age.
grade 3-4 cardiovascular (19.6% vs 10.2%, P = .004) and pulmonary (16.1% vs 4.6%, P < .001) conditions, and frail health (7.1% vs 1.6%, P < .001) were higher after HCT than conventional therapy, respectively. Conclusion: Adult survivors of childhood hematologic malignancies treated with HCT have a higher prevalence of severe, disabling or life-threatening chronic health conditions compared to those treated with conventional therapy and are nearly 4.5 times more likely to have frail health. Characterization of the chronic health conditions driving these differences is necessary to inform early detection and intervention strategies.
253 Deconditioning in Stem Cell Transplant Cancer Patients Referred to the “Moving on” Physical Rehabilitation Program Suzanne R. Fanning, Sara Roman. Greenville Health System Cancer Institute, Greenville, SC Background: “Moving On” is a 12-week physical rehabilitation program offered through the Center for Integrative Oncology Services (CIOS) at the Greenville Health System Cancer Institute. Cancer patients are routinely referred to Moving On for rehabilitation from fatigue and deconditioning often experienced following cancer treatment. In hematopoietic stem cell transplantation (HSCT), patients receive myeloablative doses of chemotherapy prior to infusion of donor stem cells. For this reason, HSCT is considered a more aggressive treatment compared to other standard cancer therapies. Objective: To determine if patients undergoing myeloablative chemotherapy and HSCT have higher levels of deconditioning compared to non-transplant cancer patients receiving disease-specific standard of care chemotherapeutic treatments. Methods: We retrospectively reviewed data from Moving On referrals (N = 1,057) made between March 2013 to March 2016. Referrals were made upon completion of therapy and included non-transplant cancer patients with either solid or hematologic malignancies and HSCT patients with hematologic malignancies. To assess deconditioning at the time of referral, we utilized Brief Fatigue Inventory scores and 6-minute timed walk (6-MTW) distance. Results: Of 979 non-transplant referrals, 615 (63%) received initial evaluations for the Moving On program; of 78
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Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
HSCT referrals, 43 (55%) underwent evaluation (40 autologous/3 allogeneic). We found a mean fatigue score of 4 in both non-transplant and HSCT populations with SD = 2.8 and 2.7, respectively. Similarly, the mean distance walked in six minutes was 1,311 feet (SD = 286) in non-transplant referrals and 1,337 feet (SD = 299) in HSCT referrals. Essentially, we found no difference in deconditioning by our assessments. Conclusion: All patients referred to Moving On had evidence of deconditioning at the completion of therapy. To our surprise, patients who had undergone myeloablative chemotherapy and HSCT did not have evidence of increased deconditioning when compared to cancer patients who receive standard chemotherapy.
254 Long-Term Healthcare Utilization By Older Survivors of Hematopoietic Cell Transplant (HCT): A Report from BMTSS-2 Eric Kim 1, Lindsey Hageman 1, Jessica Wu 1, Liton Francisco 1, Emily Ness 1, Mariel Parman 1, Michelle Kung 1, Alysia Bosworth 2, Phillip Vartanyan 2, Stephen J. Forman 2, Mukta Arora 3, Saro H. Armenian 2, Smita Bhatia 1. 1 Institute of Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL; 2 City of Hope National Medical Center, Duarte, CA; 3 University of Minnesota, Minneapolis, MN Background: HCT survivors carry a high burden of morbidity. However, the pattern of healthcare utilization by older HCT survivors who are at highest risk for morbidity is not known. Methods: We ascertained self-reported healthcare utilization within the past 2y by 660 2+ y survivors who were ≥65 y at study participation, across three domains: (1) general medical contact with the healthcare system; (2) cancer/HCTrelated visit; and (3) high-intensity visit (emergency room [ER] or urgent care center). Potential risk factors for lack of domain-specific healthcare utilization were examined univariately and included: education, income, primary cancer diagnosis, relapse risk at HCT, TBI, time since HCT, chronic GvHD (allogeneic HCT recipients) health status, and health concern. Variables with P < .1 were included in the multivariable model, which was stratified by HCT type and adjusted for age, gender, and race. Results: Allogeneic HCT (Figure 1A): 216 2 + y survivors were followed for a median of 8.9y (3.6-36.5) from HCT. Among 15 + y survivors, 98% reported medical contact in the last 2y. The prevalence of cancer/HCT-related visits declined over time (2-5y post-HCT: 78%; 15+ y post-HCT: 30%), while the prevalence of high-intensity visits increased (2-5 y: 25%; 15+ y: 47%). Lymphoma patients were more likely to report HCT/ cancer-related visits (OR = 2.98, P = .048) than AML patients. HCT survivors with poorer health status were more likely to report high-intensity visits (OR = 2.3, P = .02). Autologous HCT (Figure 1B): 444 2+ y survivors were followed for a median of 9.6y (3.7-28.6) from HCT. Among 15 + y survivors, 97% reported medical contact in the last 2 y. There was a decline over time in the prevalence of both cancer/HCT-related visits (2-5 y: 70%; 15+ y: 42%) and high-intensity visits (2-5 y: 34%; 15+ y: 28%). Compared to lymphoma patients, myeloma patients were more likely to report cancer/HCT-related visits (OR = 2.1, P = .01), as were patients who were concerned about their health (OR = 2.4, P < .001). Females were more likely to report high-intensity visits (OR = 1.6, P = .04), as were those who reported poorer health (OR = 1.9, P = .01). Conclusion: Primary care physicians are long-term survivors’ main contact with the healthcare system. Furthermore,
Figure 1. Health care utilization trend over time for general medical contact, cancer/HCT-related visit, and high-intesity visit after HCT: (A) for allogeneic HCT only; (B) for autologous HCT only.
at 15+ y after HCT, nearly half of the allogeneic HCT survivors are using the ER or urgent care. A coordinated effort among healthcare providers is needed to ensure efficient and effective healthcare delivery to this vulnerable population.
255 Impact of High Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation on the Quality of Life of Elderly Patients Treated for Lymphoma Christopher Lemieux 1, Imran Ahmad 2, Nadia M. Bambace 2, Léa Bernard 2, Sandra Cohen 2, Jean-Sébastien Delisle 3, Thomas L. Kiss 4, Jean Roy 2, Silvy Lachance 2. 1 Médecine, Université Laval, Québec, QC, Canada; 2 Division of Hematology, Oncology and Transplantation, MaisonneuveRosemont Hospital, University of Montreal, Montreal, QC, Canada; 3 Hematology-Oncology, Hôpital MaisonneuveRoseont, Montreal, QC, Canada; 4 Maisonneuve Rosemont Hospital, Montreal, QC, Canada Introduction: High-dose chemotherapy (HDT) followed by AHSCT is safe in elderly patients with chemosensitive nonHodgkin lymphoma (NHL). The goal of this study was to assess the quality of life (QoL) of elderly patients following AHSC. Method: This single-center, research and ethic committee approved study, investigated QoL in survivors following AHSCT for the treatment of NHL in the elderly. Inclusion criteria were defined as patient aged 3 60 who received an AHSCT for NHL at our center between January 1st, 2008 and January 1st, 2015 and survived. Fifty-nine patients from the original cohort of 90 met the inclusion criteria. 79.7% (47) participated in the survey. Patients were required to sign an informed consent. We used the EQ -5D instrument to assess mobility, self-care, usual activities, pain/discomfort and anxiety/depression. We also used the
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252 Chronic Conditions and Frail Health Among Adult Survivors of Childhood Hematologic Malignancies Treated with Hematopoietic Cell Transplant (HCT): A Report from the St. Jude Lifetime Cohort Study (SJLIFE) Hesham Eissa 1, Lu Lu 1, Malek J. Baassiri 1, Nickhill Bhakta 1, Matthew J. Ehrhardt 1, Daniel A. Mulrooney 1, Brandon M. Triplett 2, Daniel M. Green 1, Leslie L. Robison 1, Melissa M. Hudson 1, Kirsten K. Ness 1. 1 St. Jude Children’s Research Hospital, Memphis, TN; 2 Bone Marrow Transplantation and Cellular Therapy, St Jude Children’s Research Hospital, Memphis, TN Background: Outcomes of hematopoietic cell transplantation (HCT) have markedly improved over the past 2 decades, underscoring a need to better understand the long-term health effects of this intensive treatment modality. We describe the burden of comprehensively assessed chronic medical conditions and frail health among survivors of childhood hematologic malignancies treated with HCT (n = 112) compared to those treated with conventional therapy (n = 1106). Methods: Eligible survivors were diagnosed with a hematologic malignancy between 1/1/1982 and 6/30/2005, treated at St. Jude Children’s Research Hospital, survived ≥10 years from cancer diagnosis, reached ≥18 years of age, and completed an on-campus clinical evaluation as part of the St. Jude Lifetime Cohort Study (SJLIFE), a cohort designed to facilitate longitudinal evaluation of health outcomes among adults previously treated for a pediatric malignancy (Figure 1). Chronic conditions and frail health were clinically ascertained and classified according to a modified version of the Common Terminology Criteria for Adverse Events (version 4.03; grade 1 [mild] to grade 4 [life-threatening]) and the Fried Frailty Criteria. Mean cumulative count was used to estimate cumulative burden of disease. Results: Among HCT recipients, 70.5% (n = 79) had allogeneic transplants, 41 had sibling donors, 34 had unrelated donors, and 4 had related donors other than siblings. Twentyfive of allogeneic HCT survivors (31.6%) had a history of chronic graft versus host disease (cGVHD), only 2 of those had active cGVHD at the time of assessment. One of the 33 (29.5%) autologous transplant recipients had a syngeneic donor. Compared to those treated with conventional therapy, HCT survivors had a higher prevalence of severe, disabling or life threatening (grade 3-4) chronic conditions (81.3% vs 69.2%, P = .007). By the age of 25 years, HCT survivors experienced 148 grade 3-4 events per 100 persons compared to 60 among survivors treated with conventional therapy (P < .001) (Figure 2). Rates of second neoplasms (17.0% vs 7.9%, P = .003),
Figure 1. Consort Diagram.
Figure 2. Mean cumulative count (MCC) of grades 3-4 chronic conditions among HCT survivors compared to conventionally treated participants by attained age.
grade 3-4 cardiovascular (19.6% vs 10.2%, P = .004) and pulmonary (16.1% vs 4.6%, P < .001) conditions, and frail health (7.1% vs 1.6%, P < .001) were higher after HCT than conventional therapy, respectively. Conclusion: Adult survivors of childhood hematologic malignancies treated with HCT have a higher prevalence of severe, disabling or life-threatening chronic health conditions compared to those treated with conventional therapy and are nearly 4.5 times more likely to have frail health. Characterization of the chronic health conditions driving these differences is necessary to inform early detection and intervention strategies.
253 Deconditioning in Stem Cell Transplant Cancer Patients Referred to the “Moving on” Physical Rehabilitation Program Suzanne R. Fanning, Sara Roman. Greenville Health System Cancer Institute, Greenville, SC Background: “Moving On” is a 12-week physical rehabilitation program offered through the Center for Integrative Oncology Services (CIOS) at the Greenville Health System Cancer Institute. Cancer patients are routinely referred to Moving On for rehabilitation from fatigue and deconditioning often experienced following cancer treatment. In hematopoietic stem cell transplantation (HSCT), patients receive myeloablative doses of chemotherapy prior to infusion of donor stem cells. For this reason, HSCT is considered a more aggressive treatment compared to other standard cancer therapies. Objective: To determine if patients undergoing myeloablative chemotherapy and HSCT have higher levels of deconditioning compared to non-transplant cancer patients receiving disease-specific standard of care chemotherapeutic treatments. Methods: We retrospectively reviewed data from Moving On referrals (N = 1,057) made between March 2013 to March 2016. Referrals were made upon completion of therapy and included non-transplant cancer patients with either solid or hematologic malignancies and HSCT patients with hematologic malignancies. To assess deconditioning at the time of referral, we utilized Brief Fatigue Inventory scores and 6-minute timed walk (6-MTW) distance. Results: Of 979 non-transplant referrals, 615 (63%) received initial evaluations for the Moving On program; of 78
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Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391
HSCT referrals, 43 (55%) underwent evaluation (40 autologous/3 allogeneic). We found a mean fatigue score of 4 in both non-transplant and HSCT populations with SD = 2.8 and 2.7, respectively. Similarly, the mean distance walked in six minutes was 1,311 feet (SD = 286) in non-transplant referrals and 1,337 feet (SD = 299) in HSCT referrals. Essentially, we found no difference in deconditioning by our assessments. Conclusion: All patients referred to Moving On had evidence of deconditioning at the completion of therapy. To our surprise, patients who had undergone myeloablative chemotherapy and HSCT did not have evidence of increased deconditioning when compared to cancer patients who receive standard chemotherapy.
254 Long-Term Healthcare Utilization By Older Survivors of Hematopoietic Cell Transplant (HCT): A Report from BMTSS-2 Eric Kim 1, Lindsey Hageman 1, Jessica Wu 1, Liton Francisco 1, Emily Ness 1, Mariel Parman 1, Michelle Kung 1, Alysia Bosworth 2, Phillip Vartanyan 2, Stephen J. Forman 2, Mukta Arora 3, Saro H. Armenian 2, Smita Bhatia 1. 1 Institute of Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL; 2 City of Hope National Medical Center, Duarte, CA; 3 University of Minnesota, Minneapolis, MN Background: HCT survivors carry a high burden of morbidity. However, the pattern of healthcare utilization by older HCT survivors who are at highest risk for morbidity is not known. Methods: We ascertained self-reported healthcare utilization within the past 2y by 660 2+ y survivors who were ≥65 y at study participation, across three domains: (1) general medical contact with the healthcare system; (2) cancer/HCTrelated visit; and (3) high-intensity visit (emergency room [ER] or urgent care center). Potential risk factors for lack of domain-specific healthcare utilization were examined univariately and included: education, income, primary cancer diagnosis, relapse risk at HCT, TBI, time since HCT, chronic GvHD (allogeneic HCT recipients) health status, and health concern. Variables with P < .1 were included in the multivariable model, which was stratified by HCT type and adjusted for age, gender, and race. Results: Allogeneic HCT (Figure 1A): 216 2 + y survivors were followed for a median of 8.9y (3.6-36.5) from HCT. Among 15 + y survivors, 98% reported medical contact in the last 2y. The prevalence of cancer/HCT-related visits declined over time (2-5y post-HCT: 78%; 15+ y post-HCT: 30%), while the prevalence of high-intensity visits increased (2-5 y: 25%; 15+ y: 47%). Lymphoma patients were more likely to report HCT/ cancer-related visits (OR = 2.98, P = .048) than AML patients. HCT survivors with poorer health status were more likely to report high-intensity visits (OR = 2.3, P = .02). Autologous HCT (Figure 1B): 444 2+ y survivors were followed for a median of 9.6y (3.7-28.6) from HCT. Among 15 + y survivors, 97% reported medical contact in the last 2 y. There was a decline over time in the prevalence of both cancer/HCT-related visits (2-5 y: 70%; 15+ y: 42%) and high-intensity visits (2-5 y: 34%; 15+ y: 28%). Compared to lymphoma patients, myeloma patients were more likely to report cancer/HCT-related visits (OR = 2.1, P = .01), as were patients who were concerned about their health (OR = 2.4, P < .001). Females were more likely to report high-intensity visits (OR = 1.6, P = .04), as were those who reported poorer health (OR = 1.9, P = .01). Conclusion: Primary care physicians are long-term survivors’ main contact with the healthcare system. Furthermore,
Figure 1. Health care utilization trend over time for general medical contact, cancer/HCT-related visit, and high-intesity visit after HCT: (A) for allogeneic HCT only; (B) for autologous HCT only.
at 15+ y after HCT, nearly half of the allogeneic HCT survivors are using the ER or urgent care. A coordinated effort among healthcare providers is needed to ensure efficient and effective healthcare delivery to this vulnerable population.
255 Impact of High Dose Chemotherapy and Autologous Hematopoietic Cell Transplantation on the Quality of Life of Elderly Patients Treated for Lymphoma Christopher Lemieux 1, Imran Ahmad 2, Nadia M. Bambace 2, Léa Bernard 2, Sandra Cohen 2, Jean-Sébastien Delisle 3, Thomas L. Kiss 4, Jean Roy 2, Silvy Lachance 2. 1 Médecine, Université Laval, Québec, QC, Canada; 2 Division of Hematology, Oncology and Transplantation, MaisonneuveRosemont Hospital, University of Montreal, Montreal, QC, Canada; 3 Hematology-Oncology, Hôpital MaisonneuveRoseont, Montreal, QC, Canada; 4 Maisonneuve Rosemont Hospital, Montreal, QC, Canada Introduction: High-dose chemotherapy (HDT) followed by AHSCT is safe in elderly patients with chemosensitive nonHodgkin lymphoma (NHL). The goal of this study was to assess the quality of life (QoL) of elderly patients following AHSC. Method: This single-center, research and ethic committee approved study, investigated QoL in survivors following AHSCT for the treatment of NHL in the elderly. Inclusion criteria were defined as patient aged 3 60 who received an AHSCT for NHL at our center between January 1st, 2008 and January 1st, 2015 and survived. Fifty-nine patients from the original cohort of 90 met the inclusion criteria. 79.7% (47) participated in the survey. Patients were required to sign an informed consent. We used the EQ -5D instrument to assess mobility, self-care, usual activities, pain/discomfort and anxiety/depression. We also used the