176 - Outpatient-Based Autologous Stem Cell Transplantation: Feasible, Safe and Cost-Effective Approach

Abstract

Given the improvements in the supportive care, autologous hematopoietic stem cell transplantation (AHSCT) could be performed in outpatient basis, for selected patients (pts), offering the benefit of shorter hospitalization, less exposure to hospital pathogens, saving nosocomial beds, demonstrating thus not only a safe but also a cost-effective profile. To evaluate the feasibility and safety of this approach, we performed 29 AHSCTs on outpatient basis, in a total of 22 pts, previously diagnosed with Hodgkins lymphoma (n = 5) or Multiple Myeloma (n = 17); 7 pts underwent AHSCT twice in the context of a tandem transplant program. Six were females and 16 males aged of a median 51 (27-68) ys. The eligibility criteria for the outpatient AHSCT, were the standard clinical and laboratory tests, plus psychosocial evaluation, patient's compliance assessment, 24 hours caregiver availability, timely access to the hospital and signed informed consent. The conditioning regimen consisted from single agent Melphalan of 200 (n = 21) or 140 mg/m2 (n = 8), graft infusion and supportive care were given in an allocated room. The antimicrobial, antifungal and antiviral prophylaxis was administered from day -2 and filgrastim 5 mcg/kg from day +5 till neutrophils recovery. If no infection was documented the antimicrobial and antifungal prophylaxis were discontinued upon stable neutrophils recovery while antiviral prophylaxis was continued for 10-12 months. Patients were evaluated daily or every 2 days in the outpatient clinic. The criteria for admission were fever >38oC, intractable nausea/vomiting or diarrhea, mucositis needing total parenteral nutrition and any other toxicity WHO > grade 3. The median day for neutrohils >1000/mm3 was 11(11-18) and for platelets >20000/ mm3 was 11(0-21); in 2 pts platelets never dropped lower than 25000/mm3. Totally, 14 admissions were required, 9 for inability for food/fluid uptake due to severe mucositis, 4 for febrile neutropenia and 1 for engraftment syndrome. The infections successfully treated with broad spectrum antibiotics and no pt was admitted to intensive care unit. For the whole 29 ASCTs, the total hospitalization days were 65 (median:1, range 0-9), while for the 14 admissions the median hospitalization days were 5 (1-9), which favorably compares with the average of 14 hospitalization days for a single “conventional” ASCT. No other toxicities (WHO > 3) were observed. All pts are alive, 7 (2-33) months post AHSCT. Our data indicate that the outpatient-ASCT is a feasible and safe approach provided a caregiver availability, close pts evaluation and adequate supportive care. Keeping in mind the nosocomial complications and the potential high cost of the prolonged hospitalization, it seems that the outpatient ASCT offers lower risk of infections and significant cost saving compared to the “convetional” inpatient ASCT approach.