Can the relationship between a community hematology/oncology practice and a transplant center really impact patient access to hematopoietic cell transplantation (HCT)? The findings of two small studies indicate that the answer is likely “yes,” illustrating that strong communication and relationships are vital to both timely referral and improved patient outcomes.
The National Marrow Donor Program (NMDP)/Be The Match examined how community hematology/oncology physicians perceived their relationship with their closest transplant center and how that relationship was associated with physicians’ perceptions and attitudes regarding early treatment and post-HCT care. The group conducted an online survey from November 24, 2020, through January 3, 2021, with 131 board-certified U.S. hematologists/oncologists who had seen at least two patients with acute myeloid leukemia (AML) in the past year. The survey measured respondents’ agreement with the statement, “I/my practice has a strong relationship with the nearest transplant center.”
While the study could not prove a causal impact, it did show that those physicians who indicated the lack of a strong relationship with the transplant center also reported lower agreement with statements supporting early treatment behaviors such as discussing transplantation as a treatment option with patients newly diagnosed with AML (p<0.001), human leukocyte antigen typing at diagnosis (p<0.001), and HCT in early-stage disease leading to improved outcomes (p=0.0012; Figure1). Additionally, those who lacked a strong relationship with the transplant center had lower agreement with statements that indicated confidence in providing post-HCT care (Figure 1).1
Another study revealed that formal outreach by HCT physicians has the potential to increase allogeneic and autologous transplant referrals while also reducing health care disparities. Augusta University in Georgia started an aggressive outreach program in fiscal year (FY) 2018 that emphasized physician-to-physician communication as a way to improve transplant referrals, particularly when patients are ethnically diverse. They compared cohorts of patients who received allogeneic and autologous transplants between FY 2014 and FY 2017 (cohort A), which was before the outreach program began, to those who received transplants in FY 2019 to FY 2021 (cohort B), with the data collection starting one year after the outreach program began.
The researchers analyzed 389 total transplants and found a 116 percent increase in transplants in cohort B compared to cohort A. While transplant increased for both African American patients and white patients, there was a higher increase for African American patients compared to white patients (147% vs. 96%). The researchers concluded that academic outreach increases referrals, and that it may also be an effective model to reduce health care disparities.2
Additional research illustrates the importance of timely referrals and communication between community and transplant physicians as transplant eligibility constantly evolves, transplant outcomes improve, and transplantation becomes safer. For example, age alone is no longer a limiting factor for HCT. Many patients older than 70 years are good candidates for HCT, and the proportion of older adults who receive allogeneic HCT has steadily increased (Figure 2).3
In patients with high-risk myelodysplastic syndromes, recent research shows HCT provides a significant survival benefit for those aged 50 to 75 years compared to those who received DNA hypomethylating agents or best supportive care. In this multicenter biologic assignment trial, patients for whom an allogeneic donor was identified within 90 days of search initiation and who underwent HCT (donor arm) demonstrated a three-year overall survival (OS) of 47.9 percent, while those without a donor (no-donor arm) who received hypomethylating agents or best supportive care demonstrated a three-year OS of 26.6 percent (p=0.0001; Figure 3).4
Additionally, the likelihood of a patient having a suitable donor has also changed in recent years. The availability of cord blood, alternative graft sources, and advances in graft-versus-host disease prophylaxis that show good outcomes for patients who receive a mismatched unrelated donor or haploidentical donor have the potential to expand HCT access to nearly 100 percent, including among those who are racially and ethnically diverse.5, 6
Recent data have shown the importance of early referrals of high-risk patients with AML to transplant centers. In this study, the researchers used a disciplined, organized process for early human leukocyte antigen typing and cytogenetic testing, rapid donor identification, and early referral for HCT consultation. This resulted in a 65 percent transplant rate in CR1 and a 37 percent increase in two-year OS compared to patients who did not undergo HCT (48% vs. 35%, respectively; p=0.031).7
Shared care and communication are vitally important after transplantation, too. Research funded by the Patient-Centered Outcomes Research Institute is underway, comparing standard care post-transplant (receiving care only at the HCT clinic) to shared care where patients alternate visits between the community practice and the HCT clinic, with the clinicians sharing a plan and staying in regular communication. The study assesses 100-day nonrelapse mortality, transplant-related quality of life, and financial hardship. The results can help transplant centers and community practices provide care that best supports patients holistically after transplant. Analysis is expected in late 2022.8
What does this mean in practice for community hematologists/oncologists and transplant center physicians? Both groups must work to develop either formal programs for sharing care or informal methods of communicating. Doing so provides the best experience for the patient and helps clinicians stay abreast of the ever-changing advances and guidelines in HCT. Outdated perceptions of who is eligible for HCT, when a patient should be referred for consultation, and the likelihood a patient will have a donor, can limit or delay referral for patients who may be appropriate candidates for HCT, and this in turn can impact outcomes. Outreach from a transplant physician to a community hematologist/oncologist can help ensure research that has practice-changing implications gets into the hands of community physicians.
The road HCT patients and their families travel is not easy. The responsibility lies with the hematology/oncology community to create a more seamless experience. Community hematologists/oncologists and transplant center physicians must work together to improve communication and relationships. Doing so benefits everyone, especially patients and their families, and improves outcomes for patients undergoing HCT.
Dr. Stefanski and Dr. Bellomo indicated no relevant conflicts of interest.