Often patients ask in clinic, “What is the success rate of transplantation?” I commonly pause when posed this question. Often, I start off by trying to understand what they mean by “success.” And every answer I get takes me a step further in what we as transplant doctors and researchers know, should know, and should be working toward. Staying alive and getting disease control are the finite versions of these responses, but reality acquires a deeper and broader scope with every conversation I have with my patients. The Education Program session, “Survivorship After Allogeneic Hematopoietic Cell Transplant,” which included a live Q&A on Saturday, December 11, opened doors to these nuances, or rather realities, that surround transplant and that we all ought to be thinking about.
Session chair and panelist Dr. Nandita Khera, reviewed how hematopoietic cell transplantation (HCT) affects patients beyond disease control. Physical, psychological, and social sequalae are some of the overarching categories that will begin to inform us and carry our knowledge beyond immediate-HCT–related bedside care standards. Understanding these possible complications is our first step into recognizing, treating, and ideally preventing complications that lower patient quality of life. The financial toxicity related to cancer care is not a secret, but it remains easily ignored. Statistics from 2021 revealed that two-thirds of all personal bankruptcies are due to medical bills I’ll let that sink in!
Bankruptcy resulting from this toxicity is an under-recognized, sad reality, and one that deserves urgent attention lest this monstrosity continue to dampen the enthusiasm of the “success” that transplant researchers over the years have brought forth. After all, this is one of the many factors that builds up to the impassable and interminable barrier to pursuing intensive and expensive treatments such as HCT. The step after recognition is to develop objective metrics to quantify and grade “success” by incorporating patient-reported outcomes of HCT. Dr. Khera sheds light on some of these knowledge gaps and the research that is needed to address the very real challenges that haunt our patients, their loved ones, and us as clinicians. Also in this session, Dr. Per Ljungman covered infections occurring late after HCT and the role of immunizations to prevent infections in this immunosuppressed population. Dr. Kirsten Williams addressed non-infectious pulmonary complications which circles back to quality of life, pre-existing conditions that may increase the risk of developing this toxicity, and objective parameters for monitoring and intervention. In sum, this session explained what “giving a life” via an HCT really means.
While we are on the topic of “success” of HCT, I would be remiss not to mention access to HCT beyond finances, including biological age, donor availability, global access, and socioeconomic factors. These have long been issues to address in the world of HCT and the Education Program session “How Can We Ensure That Everyone Who Needs A Transplant Can Get One?” which also presented a live Q&A on Saturday, December 11, focused on access to care, diversity, and equity in the world of HCT. If biological age or other socioeconomic factors by themselves remained a barrier to offering HCT, any amount of HCT research would fall short. So, in this session thought leaders discussed how to make that access to all feasible. For instance, front-line work in the field is looking at objective metrics to eliminate “biological age-limit” as a barrier and instead use a prediction tool to offer this curative therapy to people who are expected to do well with HCT regardless of their age. Beyond age, donor availability, race, and socioeconomics are other areas of opportunities that the world of HCT has been working on. One of these efforts landed with the success of family mis-matched donors with post-transplantation cyclophosphamide and have since opened avenues for improvements and further research.
If you missed any of these sessions, please check the annual meeting platform to watch them on-demand. And to ensure you don’t miss any more HCT-related fun, I will point you in the direction of oral sessions presented on Saturday December 11, on graft-versus-host disease and immune reconstitution, chaired by Drs Shernan Holtan, Johns Koreth, and John Magenau; on infections, chaired by Drs Leslie Kean and Marcie Riches; and on novel approaches in HCT chaired by Drs Elizabeth Stenger and Luca Castanga. Prognostic biomarkers are the “in” thing, and why should HCT be far behind — you can review emerging data from the allogeneic transplantation oral abstract session held on Sunday December 12. Lastly, I’ll take the liberty to place a plug for the session Dr James LaBella and I chaired on Sunday, December 12 on novel conditioning approaches including combination with humanized chimeric antigen receptor T cells as well as maintenance strategies. It is always a joy to watch Dr. Uday Popat present with his poise and calm demeanor (and I got to tell that to him on stage this time). When asked about the challenges of using post-HCT maintenance strategies, both he and Dr Joanathan Brammer acknowledged that the drop-off between HCT and initiation of maintenance is real and an area where we need to strive to improve.
The most positive news here is that the HCT world has continued to move on at a regular pace despite the SARS-Cov-2 pandemic (well almost), and this speaks to the unwavering resolve of the organizations such as Center for International Blood and Marrow Transplant Research (CIBMTR), the National Marrow Donor Program (NMDP), and the American Society of Transplantation and Cellular Therapy (ASTCT). A huge shout out to these partner organizations that keep the world of transplant marching forward.
Dr. Jain indicated no relevant conflicts of interest.
