BARRIERS to AN ALLOGENEIC HSCT in OLDER AML PATIENTS ACHIEVING REMISSION with INTENSIVE CHEMOTHERAPY: INSIGHTS from the UK NCRI AML 18 TRIAL.
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All Authors
Mehta, P.
Thomas, I.
Alumina, N.M.
Freeman, S.
Raj, K.
Byrne, J.
Kelly, R.
Knapper, S.
Russell, N.
LTHT Author
Kelly, Richard
LTHT Department
Oncology
Haematology
Haematology
Non Medic
Publication Date
2024
Item Type
Conference Abstract
Language
Subject
ADULT , AGED , HAEMATOPOIETIC STEM CELL TRANSPLANTATION , COMORBIDITY , COVID-19 , DIAGNOSIS , DRUG THERAPY , WOMEN , FRAILTY , GERIATRIC ASSESSMENT , AGE GROUPS , MEN , MYELODYSPLASTIC SYNDROMES , PANDEMICS , REFERRAL AND CONSULTATION , PSYCHOLOGICAL PHENOMENA AND PROCESSES , SURVEYS AND QUESTIONNAIRES , REMISSION INDUCTION
Subject Headings
Abstract
Background: Allogeneic stem cell transplant (SCT) rate in older patients with AML in the UK is increasing (32% in AML18 vs 15% in the previous AML16 trial) but barriers still exist in taking older AML patients to SCT. We report the findings of a questionnaire to AML18 trial investigators in the UK on patients who received intensive chemotherapy (IC) and achieved a CR with/without count recovery (CR/CRi) but did not progress to SCT Aims: To describe the patient, disease and transplant process related factors affecting the decision to not transplant 60-75 yr old patients treated with IC in the AML 18 trial. Method(s): The NCRI AML18 trial addressed therapeutic questions in older patients with AML or high-risk MDS (>10% blasts) who were fit for intensive therapy. Based on findings of AML16 trial, non CBF patients were to be considered for transplant in CR1 if they had a suitably matched donor.1 We designed a questionnaire for investigators about patients who met the criteria: <75 yrs old, alive, achieved a CR/CRi and not transplanted in CR1. We investigated if and at what stage specialist transplant teams were involved and what factors influenced the decision not to transplant. Evaluated factors included 1) patient-based: patient choice, age, frailty, comorbidities, social, psychological factors and 2) disease-based: cytogenetic/genomic profile (favourable or unfavourable), MRD status (positivity or negativity). Where multiple factors were selected for a single patient, these were weighted equally. Result(s): Of 1935 patients entering the AML18 trial, 1356 were <75yrs in whom overall transplant rate was 32% (41% in <70yrs; 11% in >70yrs ). Responses from 41 centres were received for 193 of the 309 patients who met survey criteria. Survey showed that 81 (42%) of these 193 patients were deemed unsuitable for transplant at diagnosis and for a further 48 (25%) unsuitability was decided after induction. 86 (45%) patients did not have a transplant team involved in the decision to not transplant. Formal referral to transplant team was 52% for pts treated in a transplant centre versus 24% for pts treated in non-transplant centres. Only 40 (21%) pts were referred for transplant at PC1 or earlier. Figure1 shows the reasons for not transplanting (combined PC1 and PC2) in both age groups. Comorbidities did not change much between course 1 and 2 but decline in performance score (PS) and infections post induction were factors for not pursuing SCT in 38% in >70 and 28% in <70 yrs. 'Too old or frail', irrespective of PS, accounted for 12% to not transplant. MRD negativity was given as a reason in 12% of patients. Relapse occurred in 14 (7%) pts before a transplant could be delivered. Patient's wishes, social or psychological factors were reasons for not transplanting in 13% of the patients while lack of a suitable donor was a reason only in 1%. 'Other' included delay in donor availability and Covid pandemic. Summary/Conclusion: In this study of older AML patients fit for IC, 67% were considered unsuitable for SCT at diagnosis or following induction. Decline in PS and infections are frequent reasons to not transplant but the survey also showed subjective observations like 'not suitable' and 'too old/frail' as barriers to transplant. Declining transplant for MRD negativity excludes patients potentially most likely to benefit. Relapse prior to transplant can be mitigated by earlier transplant planning and donor search. Objective geriatric assessment and early referral for transplant needs to be implemented for this group of patients for whom a survival benefit from transplant has been demonstrated (Figure present).
Journal
HemaSphere