Autologous Hematopoietic Cell Transplantation Survivors Research Articles

Late Kidney Morbidity and Mortality in Hematopoietic Cell Transplant Survivors

Increasing numbers of patients are undergoing hematopoietic cell transplantation (HCT); however, further characterization of late kidney outcomes in HCT recipients is needed. This study investigated long-term kidney outcomes in HCT survivors and compared the risk of late kidney morbidity/mortality in these survivors with that in non-HCT cancer survivors and the general population. A cohort of long-term (≥2 years) allogeneic and autologous HCT survivors treated for cancer at our institution between 1992 and 2009 (n=1792) was compared with a non-HCT cancer cohort selected from the state cancer registry (n=5455) matched on diagnosis, sex, and age at year of cancer diagnosis/HCT (index date). Additional comparisons were made with a matched general population sample drawn from state driver's licensing files (DOL; n=16,340). Statewide hospital discharge codes and death registry codes (International Classification of Diseases 9/10) were used to identify cases of acute kidney failure (AKF) and chronic kidney disease (CKD) occurring ≥2 years after the index date. Cumulative incidence rates and hazard ratios (HRs; according to multivariable proportional hazard models) estimated the absolute and relative risks of AKF and CKD. Among HCT survivors, we examined the influence of additional characteristics including estimated glomerular filtration rate (eGFR) at 1-year post-HCT. The cumulative incidence rates of late kidney complications were slightly greater in the HCT survivors versus the non-HCT cancer survivors at 10 years after the index date. Both groups were more likely to experience late AKF or CKD morbidity/mortality compared with the general population (AKF: HCT, 9.4%; non-HCT, 7.7%; DOL, 1.8%; CKD: HCT, 5.7%; non-HCT, 5.0%; DOL, 1.2%). Differences between HCT survivors and non-HCT survivors were seen primarily starting 5 years after the index date, with increased hazards for late AKF (HR, 1.4; 95% confidence interval [CI], 1.1 to 1.9) and CKD (HR, 1.9; 95% CI, 1.3 to 2.8). Among allogeneic HCT survivors, the presence of hypertension at <2 years post-HCT was significantly associated with subsequent AKF (HR, 2.9; 95% CI, 1.7 to 5.0) and CKD (HR, 5.2; 95% CI, 2.7 to 10.0) at 2 to 10 years post-HCT, with similar associations seen for autologous HCT survivors. Low eGFR (<60 mL/min/1.73 m2) at 1 year post-HCT was associated with late AKF morbidity/mortality for both allogeneic (HR, 5.3; 95% CI, 2.1 to 13.2) and autologous HCT (HR, 2.7; 95% CI, 1.2 to 6.3) compared with survivors with normal eGFR (>90 mL/min/1.73 m2). Overall, the risk for hospitalization or death from AKF or CKD continued to increase with time from HCT and exceeded that of non-HCT cancer survivors at >5 years after treatment. Appropriate screening and early intervention with medication adjustments or lifestyle modifications in those with hypertension or evidence of abnormal eGFR post-HCT could potentially mitigate this risk.

Predictors of Loss to Follow-Up Among Pediatric and Adult Hematopoietic Cell Transplantation Survivors: A Report from the Center for International Blood and Marrow Transplant Research.

Follow-up is integral for hematopoietic cell transplantation (HCT) care to ensure surveillance and intervention for complications. We characterized the incidence of and predictors for being lost to follow-up. Two-year survivors of first allogeneic HCT (10,367 adults and 3865 children) or autologous HCT (7291 adults and 467 children) for malignant/nonmalignant disorders between 2002 and 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. The 10-year cumulative incidence of being lost to follow-up was 13% (95% confidence interval [CI], 12% to 14%) in adult allogeneic HCT survivors, 15% (95% CI, 14% to 16%) in adult autologous HCT survivors, 25% (95% CI, 24% to 27%) in pediatric allogeneic HCT survivors, and 24% (95% CI, 20% to 29%) in pediatric autologous HCT survivors. Factors associated with being lost to follow-up include younger age, nonmalignant disease, public/no insurance (reference: private), residence farther from the tranplantation center, and being unmarried in adult allogeneic HCT survivors; older age and testicular/germ cell tumor (reference: non-Hodgkin lymphoma) in adult autologous HCT survivors; older age, public/no insurance (reference: private), and nonmalignant disease in pediatric allogeneic HCT survivors; and older age in pediatric autologous HCT survivors. Follow-up focusing on minimizing attrition in high-risk groups is needed to ensure surveillance for late effects.

Cardiovascular Function in Long-Term Hematopoietic Cell Transplantation Survivors

Peak oxygen consumption (VO2peak), as measured by cardiopulmonary exercise testing (CPET), is a powerful independent predictor of cardiovascular disease (CVD) and all-cause mortality in a broad range of populations. We assessed the safety and feasibility of CPET in aging long-term hematopoietic cell transplantation (HCT) survivors, a population at high risk for premature onset of CVD. Next, we examined how organ-specific impairments (eg, cardiac, pulmonary, hematologic) impact VO2peak after HCT. Twenty consecutive HCT survivors underwent a comprehensive assessment of cardiopulmonary health that included CPET, echocardiography with strain, pulmonary function testing, 6-minute walk test, and timed up and go. Median age at assessment was 67.4 years (range, 42 to 75), and median time from HCT was 9.8 years (range, 3 to 20). No adverse events were observed during CPET procedures, and 95% of studies were considered to be at “peak” effort (respiratory exchange ratio ≥ 1.10). VO2peak was on average 22% less than predicted, and allogeneic HCT survivors had markedly lower VO2peak when compared with autologous HCT survivors (18.2 mL/kg/min versus 22.2 mL/kg/min; P = .05). Six participants (30%) had VO2peak ≤ 16 mL/kg/min, a threshold associated with a 9-foldrisk of death in patients undergoing HCT. Despite the presence of normal (>50%) resting left ventricular ejection fraction in all participants, 25% had markedly abnormal left ventricular longitudinal strain, an advanced echocardiographic measure of myocardial dysfunction. These findings highlight the role of stress-based measures and advanced myocardial imaging to characterize CVD risk in HCT survivors, setting the stage for tailored interventions to prevent CVD with its attendant morbidity and mortality.

Genomic instability after allogeneic hematopoietic cell transplantation is frequent in oral mucosa, particularly in patients with a history of chronic graft-versus-host disease, and rare in nasal mucosa

AbstractGenomic instability (GI) of cells may lead to their malignant transformation. Carcinoma after hematopoietic cell transplantation (HCT) frequently involves some (eg, oral) but not other (eg, nasal) epithelia. We examined GI in oral and nasal mucosal specimens from 105 subjects, including short-term (7-98 days, n = 32) and long-term (4-22 yrs, n = 25) allogeneic HCT survivors. Controls included autologous HCT survivors (n = 11), patients treated with chemotherapy without HCT (n = 9) and healthy controls (n = 27). GI was detected in 60% oral versus only 4% nasal specimens in long-term allogeneic HCT survivors (P < .001). None of the controls showed GI. In oral specimens, GI was significantly associated with history of oral chronic graft-versus-host disease (cGVHD). We conclude that GI after HCT is frequent in some (oral) but rare in other (nasal) epithelia. This may explain why some epithelia (especially those involved with cGVHD) are prone to develop cancer.

Late Hospitalizations in Long-Term Survivors of Hematopoietic Cell Transplantation (HCT): Report From the Bone Marrow Transplant Study (BMTSS).

Abstract 807Long-term survival is now an expected outcome after HCT. However, high intensity chemo-radiotherapy for conditioning, coupled with prolonged immune suppression after HCT are associated with the risk of developing endocrinopathies (diabetes), musculoskeletal disorders (osteonecrosis, osteoporotic fractures), and cardiopulmonary complications (congestive heart failure, pulmonary fibrosis), which could necessitate hospitalization for their management. Although hospitalization needs in the immediate post-HCT period are well-described, details for long-term survivors are lacking. An in-depth study of hospitalization patterns among long-term HCT survivors would help healthcare providers and patients/caregivers in developing resources for the long-term care of survivors. This study describes the prevalence and patterns of late hospitalization among long-term HCT survivors; compares this outcome with siblings; and identifies subpopulations at increased risk. Data are derived from the BMTSS, and include 1022 individuals, who had undergone HCT between 1974 and 1998, and survived at least two years, and 309 unaffected siblings. Primary diagnoses included AML, CML, ALL, HL, NHL, and SAA. Median age at HCT was 35 years (range 0.4-69); median time since HCT 7.3 years (2-28); 55% had received an allogeneic HCT. A total of 436 (43%) survivors required one or more hospitalizations in the two years prior to study participation, compared with 29% of the siblings (p<0.001). Age-, sex-, race/ethnicity-, SES-, education-, and insurance-adjusted analysis revealed that HCT survivors were at a 1.7-fold (95%CI=1.3-2.3) increased risk of hospitalizations compared with their siblings. Among HCT survivors, the prevalence of hospitalizations declined with time since HCT (2-5 years: 49%; 6-10 years 39%; and 11+ years 37%, p for trend<0.001). Multivariate analysis adjusted for sociodemographic factors including health insurance showed that compared with autologous HCT survivors, allogeneic HCT survivors were more likely to report late hospitalizations (related donor: odds ratio [OR]=3.2, 95%CI, 1.1-9.4; unrelated donor: OR=4.1, 95%CI=1.3-13.5); age at HCT >45 years was associated with a higher risk of late hospitalizations (OR=2.3, 95% CI=1.3-4.0); and, patients with chronic graft vs. host disease (cGvHD) were more likely to report late hospitalizations (OR=1.5, 95%CI=1.0-2.1). The major reasons for hospitalization included gastrointestinal (GI) problems (n=93), ocular complications (n=58), infection (n=51), endocrine dysfunction (n=41), musculoskeletal complications (n=40), cardiac (n=37), and pulmonary (n=33) events. After adjusting for SES and insurance status, older age at HCT was associated with hospitalization for musculoskeletal (OR=9.9, 95%CI, 1.1-88.2) and GI problems (OR=3.9, 95%CI, 1.5-10.1); survivors of allogeneic HCT were more likely to be hospitalized for endocrinopathies (related HCT: OR=7.4, 95%CI, 1.4-38.9; unrelated HCT: OR=3.8, 95% CI, 0.4-37.6) and GI problems (related HCT: OR=7.57, 95%CI, 1.8-31.5; unrelated HCT: OR=9.67, 95% CI=1.9-49.6); and patients with cGvHD were more likely to be hospitalized for infection (OR=2.7, 95%CI, 1.2-6.0), ocular (OR=2.8, 95%CI, 1.2-6.4) and pulmonary problems (OR=2.7, 95%CI, 1.0-7.4). This study demonstrates that over 40% of long-term HCT survivors require late hospitalizations; that older individuals, those who underwent allogeneic HCT and those who developed cGvHD continue to be at an increased risk for late hospitalizations; and that attention needs to focus on instituting targeted follow-up to proactively minimize the need for these hospitalizations. Furthermore, ongoing healthcare issues emphasize the requirement for comprehensive health insurance coverage, even many years after HCT. Disclosures:No relevant conflicts of interest to declare.

Late Effects after Autologous Hematopoietic Cell Transplantation

Over 30,000 autologous hematopoietic cell transplants (HCT) have been performed yearly during the past decade. With improvement in supportive care, few patients succumb to early treatment complications; hence, more attention is being paid to causes of late complications and death. However, interpretation of the data that exist is difficult as the definition of ‘‘late’’ varies by study, as does the patient population, underlying diseases, HCT mobilization and conditioning regimens, stem cell sources, and duration of follow-up (Table 1). Most importantly, the methods used to estimate the incidence of late complications over time are different or are not explained in sufficient detail. Some studies report relative risk or standardized mortality compared with the general population. Other studies report an acturial estimate (which ignores competing risks and thus may overestimate the incidence), whereas others report cumulative incidence calculations.

Late Effects in Survivors of Hodgkin and Non-Hodgkin Lymphoma Treated with Autologous Hematopoietic Cell Transplantation: A Report from the Bone Marrow Transplant Survivor Study

We determined the prevalence of self-reported late-effects in survivors of autologous hematopoietic cell transplantation (HCT) for Hodgkin lymphoma (HL, n = 92) and non-Hodgkin lymphoma (NHL, n = 184) using a 255-item questionnaire and compared them to 319 sibling controls in the Bone Marrow Transplant Survivor Study. Median age at HCT was 39 years (range: 13-69) and median posttransplant follow-up was 6 years (range: 2-17). Median age at survey was 46 years (range: 21-73) for survivors and 44 years (range: 19-79) for siblings. Compared to siblings, HCT survivors reported a significantly higher frequency of cataracts, dry mouth, hypothyroidism, bone impairments (osteoporosis and avascular necrosis), congestive heart failure, exercise-induced shortness of breath, neurosensory impairments, inability to attend work or school, and poor overall health. Compared to those receiving no total-body irradiation (TBI), patients treated with TBI-based conditioning had higher risks of cataracts (odds-ratio [OR] 4.9, 95% confidence interval [CI] 1.5-15.5) and dry mouth (OR 3.4, 95% CI 1.1-10.4). Females had a greater likelihood of reporting osteoporosis (OR 8.7, 95% CI: 1.8-41.7), congestive heart failure (OR 4.3, 95% CI 1.1-17.2), and abnormal balance, tremor, or weakness (OR 2.4, 95% CI 1.0-5.5). HL and NHL survivors of autologous HCT have a high prevalence of long-term health-related complications and require continued monitoring for late effects of transplantation.

Health Care Utilization by Adult Long-term Survivors of Hematopoietic Cell Transplant: Report from the Bone Marrow Transplant Survivor Study

The high intensity of therapy and prolonged immune suppression after hematopoietic cell transplantation (HCT) increase the risk of long-term complications and health care needs among survivors. The aim of this study was to evaluate the current status of health care utilization by long-term HCT survivors and to identify factors associated with lack of utilization. A total of 845 individuals who had undergone HCT between 1974 and 1998 at age 21 years or older and survived 2 or more years after HCT participated in the study. Health care utilization was assessed through a mailed questionnaire in three domains: general contact with health care system, general physical examination, and cancer/HCT-related visit. The median age at HCT was 38.2 years, and the median length of follow-up was 6.4 years. Overall, 98% of allogeneic and 94% of autologous HCT survivors reported medical contact 11+ years after HCT. Cancer/HCT-related visits decreased with increasing time from HCT (allogeneic HCT, 98-57%; autologous HCT, 94-63%). The prevalence of general physical examination increased with time (allogeneic HCT, 56-74%; autologous HCT, 72-81%). Primary care physicians provide health care for an increasing number of adult long-term survivors of HCT, emphasizing the need for increased awareness of the long-term follow-up needs of the HCT survivors by the health care providers.

132: Late effects in survivors of Hodgkin’s and non-Hodgkin’s lymphoma treated with autologous hematopoietic cell transplantation: A report from the bone marrow transplant survivor study

We conducted a retrospective cohort study to evaluate late effects of autologous hematopoietic cell transplantation (HCT) in Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL) survivors. Eligible subjects received HCT at either City of Hope or University of Minnesota between 1974 and 1998, were 18 years or older at the time of interview and had survived for 2 years or more after HCT. A random sample of siblings of study participants was recruited for comparison. All participants (n=92 HL, n=184 NHL, n=319 siblings) completed a 238 item questionnaire. Median age at HCT was 39 years (range, 13-69) and median followup was 6 years (range, 2-17) since HCT. Median age at completion of survey was 46 years (range, 21-73) for HCT survivors and 44 years (range, 19-79) for siblings. Patient characteristics were similar between HL and NHL groups except a higher proportion of NHL survivors received total body irradiation (TBI) as part of their conditioning (83% vs 40%). Compared to siblings (after adjusting for age at interview and sex), HCT survivors reported a significantly higher frequency of cataracts (14% vs 4%), dry mouth (14% vs 1%), hypothyroidism (19% vs 7%), bone impairments (osteoporosis and avascular necrosis) (7% vs 3%), congestive heart failure (4% vs 0.3%), exercise induced shortness of breath (10% vs 3%), neurosensory impairments (33% vs 20%), second cancers (8% vs 2%), and inability to attend work or school due to health impairments (16% vs 2%). 84% subjects rated their overall health as good, very good or excellent compared to 95% siblings (p<0.001). Multivariate models adjusted for age at HCT and time since HCT simultaneously considered the effects of sex, diagnosis (HL vs. NHL) and conditioning regimen (TBI vs. no TBI). Compared to those receiving no TBI, patients treated with TBI based conditioning had higher risks of cataracts (odds ratio (OR) 4.9, 95% CI: 1.5-15.5) and dry mouth (OR 3.4, 95% CI: 1.1-10.4). Females had a greater likelihood of reporting hypothyroidism (OR 2.5, 95% CI: 1.3-4.7), osteoporosis (OR 8.7, 95% CI: 1.8-41.7), congestive heart failure (OR 4.3, 95% CI: 1.1-17.2) and abnormal balance, tremor or weakness (OR 2.4, 95% CI: 1.0-5.5). In conclusion, HL and NHL survivors of autologous HCT have a high prevalence of long-term health-related complications and require continued monitoring for late effects with timely introduction of appropriate interventions.

Long-term outcomes of survivors of autologous hematopoietic-cell transplantation for refractory and relapsed Hodgkin’s Disease

6554 Background: With improvements in survival among refractory/relapsed Hodgkin’s Lymphoma (HL) patients after high-dose chemo-radiotherapy and autologous hematopoietic-cell transplant (AHCT), it is important to evaluate risk of late complications in this heavily treated population. Methods: From 1985–1998, 218 refractory/relapsed HL patients were treated on high dose chemo-radiotherapy and AHCT salvage protocols. 153 (70%) surviving ≥2 years after AHCT were analyzed. All received either radiotherapy with initial therapy or total lymphoid irradiation and involved field boost with the conditioning regimen (43%). Information from surviving patients was obtained through a self-administered questionnaire. The NDI was queried to determine vital status and cause of death. Primary endpoint was non-HL mortality, defined as mortality due to cardiac causes, infection or second malignancy (SM). Competing risk methods were used to calculate cause-specific mortality rates and examine its predictors. All events were calculated from 2 years post-AHCT to date of death/last follow-up. Results: Median follow-up time was 11 years. There have been 51 deaths, 32 due to HL and 19 due to other causes. Eleven deaths were due to SM: AML (3), MDS (2), NHL (2), NSCLC (2), gastric and colon cancer. There were 8 non-SM deaths: cardiac toxicity (4), infection, aplastic anemia, suicide, unknown causes (1 each). The 10 and 15-year overall survival (OS) rates are 64% and 57%, respectively. The 10-year cumulative incidence of death from HL and from non-HL causes were 22% and 13.5% ( table ). By univariate analysis, increased risk of death due to SM was associated only with higher age at AHCT (p=0.02). Conclusions: While HL initially accounts for the majority of deaths among patients surviving high-dose therapy, the HL mortality rate plateaus and risk of death from non-HL mortality increases after 5 years. Yet, even at 15-years, SM risk does not exceed that observed in patients treated with standard regimens. [Table: see text] No significant financial relationships to disclose.

Predictors of Avascular Necrosis (AVN) of Bone after Long-Term Follow-Up of Allogeneic and Autologous Hematopoietic Cell Transplantation (HCT) for Malignant and Non-Malignant Disorders.

Patients undergoing allogeneic HCT are known to be at an increased risk of AVN. Chronic steroid use, to treat chronic graft vs. host disease (cGVHD) has been identified as a risk factor. Previous studies reporting AVN after allogeneic HCT are limited either due to small cohort size or reliance on registry data for passive reporting on outcomes such as AVN. Furthermore, little is known about the risk of AVN after autologous HCT. We report a retrospective chart review of 1595 consecutive patients undergoing HCT at City of Hope Cancer Center between 1976 and 1998, and surviving one or more years after HCT. The median age at HCT was 35 years (range, 0.6–71.5) and the median length of follow-up was 7.0 years (1–25.3). The cohort included 940 males (59%). In this cohort, 78 patients developed AVN of 163 joints, resulting in a mean of 2.1 affected joints per patient (range, 1 to 8). Diagnosis of AVN was confirmed by review of radiologic evidence of necrosis in the presence of clinical symptoms. The hip joint was the most common joint affected (70.5% of patients), followed by the knee (35%) and shoulder (26%). Symptoms developed a median of 38.7 months from HCT (12 to 199 months). The overall cumulative incidence was 6.2% at 15 years from HCT for the first reported AVN developing one or more years after HCT. Nineteen of 741 autologous HCT survivors developed AVN (cumulative incidence: 3.5% at 10 years), while 46 of the 746 allogeneic sibling donor HCT survivors (cumulative incidence, 6.2% at 10 years), and 12 of the 108 unrelated donor HCT recipients developed AVN (cumulative incidence 13.9% at 10 years, p<0.001). A multivariate analysis of the entire cohort identified exposure to cyclosporine, both for GVHD prophylaxis (relative risk (RR), 3.03, 95% confidence interval (CI), 1.4–6.5), and treatment of cGVHD (RR=4.1, 95% CI, 2.2–7.9), male sex (RR=2.1, 95% CI, 1.3–3.6), primary diagnosis of multiple myeloma (RR=7.5, 95% CI, 1.4–40.7) and Hodgkin disease (RR=10.8, 95% CI, 2.2–53.6) when compared with aplastic anemia to be independently associated with an increased risk of AVN after HCT. Among survivors of allogeneic HCT, presence of cGVHD (RR=4.2, 95% CI, 1.7–10.0), and treatment of cGVHD with a combination of systemic steroids, Cyclosporin, and Tacrolimus (RR=3.6, 95% CI, 1.7–7.7), compared to a combination of systemic steroids and Cyclosporin, were independently associated with an increased risk of AVN. Finally, no risk factors were identified for the development of AVN among autologous HCT recipients. AVN is a frequent and significantly debilitating consequence of HCT, frequently requiring surgical intervention, and potentially impacting the overall HRQL of the HCT survivors. This study describes the magnitude of risk in autologous and allogeneic HCT recipients and identifies cGVHD and use of immunosuppressive agents such as systemic steroids, Cyclosporin and Tacrolimus as risk factors, indicating the possible pathogenic role of Cyclosporin- and Tacrolimus-induced microangiopathy in the development of AVN in this population. Identification of genetic susceptibility and the role of interaction between therapeutic exposures and genetic susceptibility in handling these therapeutic exposures would further assist in identification of the populations at risk and the mechanistic pathways involved in the development of AVN in this population.

Late mortality in survivors of autologous hematopoietic-cell transplantation: report from the Bone Marrow Transplant Survivor Study

AbstractWe assessed late mortality in 854 individuals who had survived 2 or more years after autologous hematopoietic cell transplantation (HCT) for hematologic malignancies. Median age at HCT was 36.5 years, and median length of follow-up was 7.6 years. Overall survival was 68.8% ± 1.8% at 10 years, and the cohort was at a 13-fold increased risk for late death (standardized mortality ratio [SMR] = 13.0) when compared with the general population. Mortality rates approached those of the general population after 10 years among patients at standard risk for relapse at HCT (SMR = 1.1) and in patients undergoing transplantation for acute myeloid leukemia (AML; SMR = 0.9). Relapse of primary disease (56%) and subsequent malignancies (25%) were leading causes of late death. Relapse-related mortality was increased among patients with Hodgkin disease (HD; relative risk [RR] = 3.6), non-Hodgkin lymphoma (NHL; RR = 2.1), and acute lymphoblastic leukemia (ALL; RR = 6.5). Total body irradiation (RR = 0.6) provided a protective effect. Nonrelapse-related mortality was increased after carmustine (RR = 2.3) and with use of peripheral blood stem cells (RR = 2.4). Survivors were more likely to report difficulty in holding jobs (RR = 9.4) and in obtaining health (RR = 7.7) or life insurance (RR = 8.4) when compared with siblings. Although mortality rates approach that of the general population after 10 years in certain subgroups, long-term survivors of autologous HCT continue to face challenges affecting their health and well-being.

Health Care Utilization by Hematopoietic Cell Transplantation (HCT) Survivors: A Report from the Bone Marrow Transplant Survivor Study.

HCT is increasingly being used to successfully treat a variety of malignant and nonmalignant disorders with an attendant growing population of survivors. We determined the type of outpatient medical care reported by adult survivors of HCT and examined factors associated with limited medical care. Eligible subjects were individuals who had undergone HCT at either City of Hope Cancer Center or the University of Minnesota between 1974 and 1998, were age 21 years or older at time of transplant, and had survived two or more years after HCT. We analyzed data from 755 adult HCT survivors enrolled in this retrospective cohort study who had completed a 255-item health questionnaire (Allogeneic HCT: n=424; autologous HCT: n=331), representing over 70 percent participation among those successfully contacted. Because of the widely divergent health-related issues among the autologous and allogeneic HCT recipients, the results of the analysis for the two groups are presented separately. Median age at HCT for the allogeneic and autologous HCT survivors was 35.4 and 39.5 years respectively, and the median length of follow-up 7.3 and 6.2 years respectively. Four self-reported outcome measures were used to determine outpatient medical care in the most recent 2-year period: general contact with health care system, general physical examination, HCT-related medical visit, and medical visit at a cancer center, with the percentage of patients reporting such visits shown in the Table below. Among allogeneic HCT recipients, the risk of not reporting a general physical examination, HCT-related visit, or a cancer center visit was decreased among male survivors (OR=0.46, 95% CI, 0.29–0.73) when compared with females, and among patients who received cyclosporine as part of their GVH prophylaxis (OR=0.42, 95% CI, 0.24 to 0.74), when compared with those who had not. Among autologous HCT recipients, the risk of not reporting a medical visit was increased among patients who reported a lack of concern for future health (OR=6.3, 95% CI, 1.4–27.8) and decreased among older survivors (>45 yr. at HCT, OR=0.47, 95% CI, 0.3–0.8). The likelihood of reporting a general physical examination increased as the interval from HCT to questionnaire completion increased (p<0.001), while the likelihood of reporting an HCT-related or cancer center visit decreased (p<0.001). This study demonstrates that although 20% of the allogeneic survivors continued to report a cancer-center visit 18 years on average from HCT, primary care physicians provide health care for most of this growing high-risk population, necessitating effective and ongoing communication between cancer centers and primary care physicians.Health care Utilization by HCT SurvivorsHCT TypeGeneral Medical ContactGeneral Physical ExaminationHCT-related visitCancer center visitAllogeneic HCT98%67.8%81.5%54.3%Autologous HCT97%73.3%80.8%53.3%