The optimal healthcare model for follow-up of allogeneic stem cell transplant (allo-SCT) recipients after day-100 is not clear. Most centers reintegrate patients into primary hematology clinics, with a few centers having dedicated long term follow-up infrastructure. Long term transplant clinic (LTTC) was established at Vanderbilt University Medical Center in 2006. We have previously shown that LTTC longitudinal follow-up is associated with superior overall survival (OS) (Jagasia et al, BBMT, 289a, 2008). Recent data suggests that a long driving time to transplant center is associated with worse OS (Abou-Nassar et al, BBMT 2012). We hypothesized that geographic distance would not be associated with inferior outcome if patients are followed in a dedicated transplant clinic.
Since 2006 all patients beyond day-100, who were medically stable (n=381) for discharge from the transplant center, were transitioned to LTTC and followed in a systematic manner. Some patients who were transplanted at other institutes established care in LTTC for geographic, insurance or social support reasons, and transitioned at later time points. Patients who could not return to the center for follow-up as per protocol were contacted through telephone, and all patients were encouraged to use an electronic communication system (email@example.com). The LTTC team coordinated multidisciplinary care with dedicated consultants in endocrinology, lipid, dermatology, pulmonary, infectious disease, orthopedics, and ophthalmology. Only patients with more than 1 LTTC visit (n=375) were included in the study cohort.
Pre-transplant characteristics: age (median-48 y, range 18–70); recipient gender (male-207, 55.2%; female-168, 44.8%); regimen (ablative-212, 56.5%; other-163, 43.5%); donor (related-204, 54.4%; unrelated-170, 45.3%); diagnosis (acute leukemia-179, 47.8%; lymphoid malignancies-90, 23.9%; other-106, 28.3%); and CIBMTR disease risk (low-191, 50.9%; intermediate-97, 25.9%; high-84, 22.4%). The median distance from the transplant center was 113 miles (range, 0.6–562.5). The 75th percentile (163 miles) was used as the cut off to analyze the impact of distance from the center on outcome (279 patients ≤ 75th percentile; 96 patients > 75th percentile). The two cohorts were balanced for pre-transplant characteristics (data not shown). The median day post-SCT for transition to LTTC was 114 d (range, 83–5844), with 70% transitioning by day 130. OS was calculated from transition to LTTC until last follow-up or death. Of the 375 patients, 78 are dead (relapse-52, 66.7%; non-relapse-26, 33.3%). Two-year OS for the entire cohort was 79.9% (±0.024 SE). In univariate analyses, age, regimen, donor, and diagnosis did not impact survival. Two-year survival for patients ≤ 163 miles and > 163 miles was 78.5% (±0.028 SE) and 82.4% (±0.045 SE), respectively (P=0.127). In multivariate analyses, adjusted for donor type, CIBMTR disease risk, time of transition to LTTC (cut off day 130), distance from transplant center (cut off 75th percentile), did not impact outcome.
Contrary to previous reports, our study suggests that geographic distance from the transplant center is not associated with inferior outcome when follow-up care is delivered via a dedicated long-term transplant follow up clinic incorporating well orchestrated multidisciplinary care. Systematic care in LTTC to monitor, prevent, and treat chronic GVHD and late effects after allo-SCT will be increasingly important to optimize outcomes and should be considered an integral part of a transplant program.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.