Several factors may drive recent improvements in allo-HCT outcomes
FROM ANNALS OF INTERNAL MEDICINE
Potential drivers of outcome
Dr. McDonald said this study’s design makes it difficult to determine the causes of improved outcomes in the 2013-2017 period. However, the researchers do have theories about which practice changes may have contributed to better allo-HCT outcomes.
Dr. McDonald said the decrease in GVHD over time was “likely owing to the introduction of newer preventive strategies and immune-suppressive drugs.”
The decrease in nonrelapse mortality may have been driven, in part, by a reduction in fatal infections. Dr. McDonald said these infections were less frequent in the 2013-2017 period because of “molecular methods of diagnosis (especially for herpesviruses) and newer treatments (especially for fungal infections).”
“Another reason for a lower frequency of serious infection was a change in practice for treating graft-versus-host disease,” Dr. McDonald added. “Based on a randomized trial comparing lower- versus higher-dose prednisone for less-severe GVHD … both initial doses of prednisone and total prednisone exposure were reduced.”
Another factor that may have improved allo-HCT outcomes is the center’s change in approach to conditioning therapy over time.
“The gradual shift from very-high-dose conditioning therapy to less-intense myeloablative therapy and to reduced-intensity conditioning was likely responsible for a reduction in damage to the liver, lungs, and kidneys over the last 10 years,” Dr. McDonald said. “We were able to identify patients who were at especially high risk for mortality during a screening process before transplant ... thus allowing patients at highest risk to receive less intense conditioning therapy.”
Dr. McDonald added that this study’s results are encouraging, particularly the reduction in nonrelapse mortality. However, there is still room for improvement when it comes to relapse and progression.
This research was funded by the National Institutes of Health, the American Cancer Society, and the Patient-Centered Outcomes Research Institute. Dr. McDonald reported relationships with Sangamo Therapeutics, Soligenix Therapeutics, and Lucent Medical Systems. His coauthors disclosed relationships with a range of companies.
SOURCE: McDonald GB et al. Ann Intern Med. 2020 Jan 20. doi: 10.7326/M19-2936.
