Navneet Majhail MD MS Director Blood and Marrow Transplant Program Cleveland Clinic Professor Cleveland Clinic Lerner College of Medicine BldCancerDoc Number of HCT Survivors Is Increasing ID: 912900
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The Challenge Of Survivorship After BMT Navneet Majhail, MD, MSDirector, Blood and Marrow Transplant Program, Cleveland ClinicProfessor, Cleveland Clinic Lerner College of Medicine @BldCancerDoc
Slide2Number of HCT Survivors Is Increasing
NS Majhail et al,
Biol
Blood Marrow Transplant 2013
~500,000 BMT survivors by 2030
Estimated Number of HCT Survivors in the United States, 2009-2030
CIBMTR Analysis
Slide3Long-term Survival After HCT10,632 allo HCT recipients surviving ≥ 2 years in remission
Overall survival
Non-relapse mortality
J Wingard et al, J
Clin
Oncol
2011
~10% NRM @ 15 years
Slide4Late ComplicationsComplications that occur late (months to years) after HCTHCT exposures contribute to their riskLate complicationsOrgan toxicityInfectionsSecondary cancers
Growth and development issues
Sexual and fertility issues
Psychosocial and QOL issues
Slide5Challenges: Lost in TransitionPatientsDistance from transplant centerSocio-demographic and economic barriersComplex medical issues, not aware of risksProvidersCompeting priorities, knowledge, comfort level, limited resourcesTransplant centersLimited resources, competing priorities Healthcare systemCoverage for survivor care
Care coordination
Slide6Survivorship Care is ComplexSurveillance for disease recurrenceSurveillance, prevention and treatment of late complicationsScreening and prevention of second cancersRoutine health maintenanceHealth promotion and educationPsychosocial supportRehabilitationFinancial counselingReintegration into society (return to work/school)
Slide7Opportunities For Survivorship Care In BMT
Slide8Opportunities For Survivorship In BMTProvision of individualized survivorship care
Slide9Exposures Mediate Late Organ ToxicityChronic GVHDDry eye, caries, xerostomia, bronchiolitis obliterans, GU issuesSquamous cell cancers (skin, oral cavity, tongue, oro-pharynx)Exposure to corticosteroidsOsteoporosis, HTN, kidney disease, myopathyTBI
Coronary artery disease, caries, dry eye, cataracts, endocrine dysfunction
Non-squamous cell cancers (breast)
Slide10Risk Factor Based Approach To Survivorship CarePre-BMT BMT Post-BMT
Genetic predisposition
Age and sex
Lifestyle factors
DIAGNOSIS
Pre-BMT medical issues
Pre-BMT chemo/ radiation
BMT chemo/ radiation
GVHD
Other exposures (infections, drugs)
NS Majhail et al, Bone Marrow Transplant 2013
Slide11Opportunities For Survivorship In BMTProvision of individualized survivorship careSurvivorship care based on best practices (that are evidence-based, where possible)
Slide12Co-published in:
Biology of Blood and Marrow Transplantation, 2012; 18: 348
Bone Marrow Transplantation, 2012; 47: 337
Hematology Oncology and Stem Cell Therapy, 2012; 5: 1
Revista Brasileira de Hematologia e Hemoterapia, 2012; 34: 109
Slide13Organ Systems/Issues ConsideredImmune systemOcularOralRespiratoryCardiac and vascularLiver
Renal and genitourinary
Muscle and connective tissue
Skeletal
Nervous systemEndocrineMucocutaneousSecond cancersPsychosocial and sexualFertilityGeneral health issuesHealthy lifestyle
Slide14Resources Based on Guidelines
Physicians:
www.bethmatchclinical.org
Patients:
www.bethmatch.org
Slide15Slide16Opportunities For Survivorship In BMTProvision of individualized survivorship careSurvivorship care based on best practices (that are evidence-based, if possible)Organize care at transplant centers (LTFU clinics)
Slide17Demonstrate Value of LTFU ProgramsIncreasing recognition of importance of LTFU programsPart of FACT/JACIE standardsFacilitates timely recognition of late effects and their management*May be associated with transplant outcomes (unpublished data)Center characteristics survey through CIBMTR83 centers, 11,537 allogeneic HCT recipients
28 (35%) reported some form of LTFU program
Associated with 1-year survival (OR 1.23 [1.05-1.43]; P<0.01)
*VE Shanklin et al,
Eur
J Cancer Care 2016
Slide18Patient-Centered LTFU ModelsIntegrated careConsultative Shared careTransitional care
Slide19Opportunities For Survivorship In BMTProvision of individualized survivorship careSurvivorship care based on best practices (that are evidence-based, if possible)Organize care at transplant centers (LTFU clinics)Provide centers tools to facilitate survivorship care (Treatment summary and survivorship care plans)
Slide20Individualized Care Plans For BMT SurvivorsMajhail et al, ASH Oral Presentation 2017 (Sunday 7:30 AM)*Paper TS/SCP based on exposures reported to CIBMTR and 2012 LTFU guidelines1-5 year auto and allo HCT survivors randomized to TS/SCP or routine care PRO assessments at baseline and 6 months
495 patients enrolled at 17 centers
Significant decrease in cancer/transplant related distress and increase in MCS domain of SF12
No association with PCS QOL domain, confidence in survivorship information, health care utilization
Funded by Patient Centered Outcomes Research Institute
Slide21Opportunities For Survivorship In BMTProvision of individualized survivorship careSurvivorship care based on best practices (that are evidence-based, if possible)Organize care at transplant centers (LTFU clinics)Provide centers tools to facilitate survivorship care (Treatment summary and survivorship care plans)
Empower patients (self-management)
Slide22Technology Facilitated Self-management INternet
and
S
ocial-media
Program with Information and ResourcesTwo multicenter projects (funded as R01 grants from NCI)INSPIRE (PI Syrjala): efficacy of internet based intervention for depression/distress and increasing health care adherence (INSPIRE intervention vs. routine care)INSPIRE 2.0 (PI’s Syrjala, Majhail, Baker): efficacy of internet based stepped care self-management program for depression/ distress, cardiometabolic late effects, second cancer screening (INSPIRE intervention + TS/SCP vs. TS/SCP alone)
Slide23Opportunities For Survivorship In BMTProvision of individualized survivorship careSurvivorship care based on best practices (that are evidence-based, if possible)Organize care at transplant centers (LTFU clinics)Provide centers tools to facilitate survivorship care (Treatment summary and survivorship care plans)
Empower patients (self-management)
Research priorities
Slide24Research methodology and study designSubsequent neoplasmsPatient centered outcomesImmune dysregulation and pathobiologyCardiovascular disease and associated risk factorsHealth care delivery
Slide25Slide26Opportunities For Survivorship In BMTProvision of individualized survivorship careSurvivorship care based on best practices (that are evidence-based, if possible)Organize care at transplant centers (LTFU clinics)Provide centers tools to facilitate survivorship care (Treatment summary and survivorship care plans)
Empower patients (self-management)
Research priorities
Care coordination
Slide27Collaborative Coordinated Survivorship CarePatients are most comfortable with transplant centersSurvey of 441 adult allo HCT survivors 74% preferred care through or in collaboration with BMT program (
G Dyer et al,
Biol
Blood Marrow Transplant, 2016)
Primary care physicians are not comfortable in handling transplant specific issues (S Mani et al, Unpublished data)Survey of 256 PCPs in Cleveland Clinic health systemComfort level in handling (heme malignancy/BMT survivors) General medical issues – 77%Psychosocial issues – 39%Second cancer screening – 7% Cancer related medical issues – 5%
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