General MM

Evidence for favourable outcomes following outpatient auto-HCT treatment in MM

Autologous hematopoietic stem cell transplantation (auto-HCT) is common in patients with Multiple Myeloma (MM). Nina Shah, from the Hematology-Oncology Department, University of California San Francisco, and colleagues, performed a retrospective analysis of hospital charts for patients with MM undergoing auto-HCT. The aim of the study was to evaluate the differences in clinical characteristics and outcomes of inpatient versus outpatient treatment. The analysis considered patients with auto-HCT therapy between January 2008 and December 2012.

Key Findings
  • Patients enrolled in the study: n = 1046; inpatients = 669 vs outpatients = 377
  • Average patient age: inpatients vs outpatients = 58 (34–78) vs 62 (31–82)
  • Out-pts were significantly younger than inpatients: P < 0.001
  • Primary endpoints: unscheduled admissions, Treatment-Related Mortality (TRM), Grade 2–4 Adverse Events (AEs) and average cost of auto-HCT
  • Secondary endpoints: Overall Response Rates (ORR), Progression-Free Survival (PFS) and Overall Survival (OS)
  • Treatment-related mortality: inpatients vs outpatients = 10 patients (1.5%) vs 1 patient (0.3%), P = 0.10
  • Complete Response (CR): inpatients vs outpatients = 89.5% vs 5%, P < 0.001
  • Two-year PFS: inpatients vs outpatients = 50% vs 60%, HR = 0.7, 95% CI (0.6–0.9), P = 0.005
  • Two-year OS: inpatients vs outpatients = 77% vs 83%, HR = 0.6, 95% CI (0.4–0.9), P = 0.01
  • Average cost of transplant: inpatients vs outpatients = US$416,154 vs US$292,572
Safety
  • Non-hematologic Adverse Events (AEs):
    • Grade 2–5: inpatients vs outpatients = 552 (83%) vs 277 (73%)
  • 55% outpatients required hospital admission within 30 days of stem cell infusion; 42% due to neutropenic fever
  • Neutropenic fever: inpatients vs outpatients = 381 vs 154, P < 0.001

 

Conclusion

The outpatient group had a lower incidence of AEs and better PFS and OS. The authors suggested that these findings can be attributed to the more favorable baseline characteristics of the outpatient group, as they were younger, had a less advanced disease and fewer co-morbidities. Although a high number of outpatients required hospital admission (80%), they had fewer AEs and there was no significant difference between the two groups for treatment-related mortality.

This, therefore, suggests that the outpatient setting for auto-HCT can be carried out safely, with further study required to fully evaluate symptoms and quality of life for patients in this group. It must also be noted that this study was limited to some extent by patient bias, and future comparisons would need to be carried out using patients with more closely related baseline characteristics. However, this provides positive news for patients, for whom outpatient experiences are often viewed more favorably, and hospital trusts, as they would benefit from reduced overall treatment costs. However, patients need to be assessed on an individual basis.

References
  1. Shah N. et al. In-patient versus out-patient autologous hematopoietic stem cell transplantation for multiple myeloma. European Journal of Haematology. 2017 Sep 12. DOI: 10.1111/ejh.12970. [Epub ahead of print]
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