Outcomes of Allogeneic Hematopoietic Stem Cell Transplantation in Community Cancer Centers: Single Institution Experience

Abstract

Variability in outcomes after hematopoietic stem cell transplantation (HCT) due to differences in health care delivery is traditionally referred to as “center effect”. Data analysis by CIBMTR demonstrated improved day 100 survival after related donor (RD) HCT with greater physician involvement in patient's care regardless of medical school affiliation. We hypothesized that the greater physician involvement in patient's care at our community transplant center would compensate for the lack of infrastructure available to academic centers and result in comparable outcomes. We retrospectively reviewed the medical records of 50 consecutive patients who underwent matched unrelated (MUD) HCT (n = 26) or RD HCT (n = 24) for hematological malignancies between August 2007 and April 2010. GVHD prophylaxis used was Tacrolimus/Methotrexate or Tacrolimus/Mycophenolate. MUD HCT recipients recieved ATG in addition. Twenty one (42%) and twenty eight patients (56%) of cohort had progressive/persistent disease and high risk cytogenetics at time of transplant respectively. Thirty three patients (66%) had Charlson Co-morbidity index of 3 or more. Patients characteristic is shown in the table below. OS at 100 days and 1 year were 86% and 67% respectively. There was no statistical difference in OS between RD and MUD; (83% vs. 88% at day 100 and 74% vs. 64% at 1 year for RD and MUD recipients respectively, P = 0.85). DFS was 55% at 1year. Again, there was no statistical significance difference in DFS between RD and MUD at 1 year (P = 0.48). The cumulative incidence of relapse was 16% at 1 year (21% for RD and12% for MUD). We found no difference in the cumulative incidence of NRM between RD and MUD recipients at day 100 (12%). In contrast, NRM was higher at 1 year in MUD recipients of 34% vs. 25% for the RD recipients. The overall cumulative incidence of acute GVHD grade II-IV was 47.8% with incidence of severe GVHD grade III/IV of 16%. The cumulative incidence of chronic GVHD was 67.6%. Allogeneic HCT outcomes in the community seem to be comparable to outcomes reported in literature. In this single institution experience, despite the absence of direct cause and effect relationship, the greater involvement of physicians in the patient's care may have contributed to the improved outcomes in this high risk cohort of patients. Community transplant centers may contribute in the future to meet the increased demands for allogeneic HCT with reasonable outcomes.Table 1Patients characteristicNumber of patients50 (100%)AgeMedian 56 (Range 23-71)Patients above the age of 5527 (54%)Patients below the age of 5523 ( 46%)Match related (RD)23 (46%)Mismatched related 5/61 (2%)Matched unrelated (MUD)22 (44%)Mismatched unrelated4 (8%)Male30 (60%)Female20 (40%)DiagnosisAML/MDS26 (52%)ALL8 (16%)Myelofibrosis2 (4%)CLL2 (4%)T-cell prolymphocytic leukemia2 (4%)CML (accelarated phase)1 (2%)HD2 (4%)Severe aplastic anemia1 (2%)Non Hodgkins lymphoma3 (6%)Multiple myeloma3 (6%)Stem cell sourcePeripheral stem cells 50 (100%)Status at transplantComplete remission -120 (40%)Complete remission-29 (18%)Progressive disease7 (14%)Persistent disease14 (28%)Prior TransplantsAutologous7; non tandem (14%)Allogeneic related5 (10%)CytogeneticsHigh Risk28 (56%)Normal19 (38%)Not available3 (6%)Charlson Comorbidity IndexScore 07 (14%)Score 1-210 (20%)Score 3-420(40%)Score 5 and above13 (26%)Conditioning RegimensFull Intensity (FIC)20 (40%)Reduced Intensity(RIC)21(42%)Non Myeloablative (NMA)9 (18%)GVHD, graft versus host disease; OS, overall survival; DFS, disease free survival; NRM, non relapse mortality; NMA, Flu/TBI, RIC, FluBU-2/FluMel, FIC FluBU-4/BUCY/CYTBI Open table in a new tab