Late Effects of Transplants: Lessons learned and strategies to improve the health of the HCT survivor

Transcription

1 Late Effects of Transplants: Lessons learned and strategies to improve the health of the HCT survivor Saro Armenian, DO, MPH Associate Professor, Departments of Pediatrics and Population Sciences Director, Division of Outcomes Research Director, HCT Long-term Follow-up Program City of Hope Comprehensive Cancer Center

2 Disclosures I have no relevant disclosures

3 The aim for this presentation At the end of the presentation you should know What are the late effects of HCT Why long-term surveillance is of importance What can we do to prevent and to treat late effects

4 Increasing number of transplants Annual Number of Transplant Recipients in the US by Transplant type 11, ,000

5 Long-term Survival after HCT % 68.8% Male Female Female Male Allogeneic HCT Autologous HCT Growing Years since HCTnumber of long-term Years since HCT survivors Blood, 2007, 110: Blood, 2005, 105:

6 HCT Survivors: Projections Number of Survivors, x All Survivors Year Number of Survivors, x Survivors by Transplant Type Autologous Allogeneic Related Donor Allogeneic unrelated Donor Year

7 Life Expectancy: 5-Year Survivors Reduction in Life Expectancy (Years) Reduction in Life Expectancy (%) % lower life expectancy than that of the U.S. population Attained Age (Years) Attained Age (Years)

8 Late Mortality: 5-year Survivors Relapse GvHD Unknown Infection Chronic Other health conditions account for 75% of late deaths Respiratory Cardiovascular Secondary Cancer

9 Chronic Health Conditions after HCT 100% Cumulative Incidence (%) 80% 60% 40% 59% Chronic Health Condition Severe/lifethreatening Condition 20% 35% 0% Years Since HCT Blood, 2010, 116:

10 Cancer Epidemiol Biomarkers Prev 2007; 16(4): 834 Healthcare Utilization 100% Medical contact 90% % Utilization 80% 70% 60% 50% 2-5 years 6-10 years 11+ years Years since transplant GPE Cancer/HCT related visit Primary care physicians increasingly provide care for survivors of HCT

11 Modifiers of late complications Age, Gender Comorbidity Primary disease Conditioning regimen Communication Access to care Pre-HCT treatment GvHD Lifestyle/ Health behaviors Genetics

12 Risk of Chronic Health Conditions after HCT Conventionally Treated Autologous HCT Allogeneic - Related Allogeneic - Unrelated 6.8 Risk Any Chronic Condition* *P<0.01 (Trend) Blood, 2011, 118: Severe or Lifethreatening* Multiple ( 2) Conditions*

13 Late complications after HCT Expert Rev Hematol. 2(5), 2009 Early complication Delayed events Late events Very late events 0 3 months 2 years 10 years Respiratory complications Chronic GvHD and infections Ocular complications Keratoconjunctivitis Thyroid dysfunction Growth failure Gonadal failure Chronic kidney disease Avascular necrosis Osteoporosis Infertility Sexual dysfunction Metabolic disorders Cardiovascular disease Liver cirrhosis Malignant complications Physical and psychological performance, QoL and social integration

14 Late Effects of Transplants: Chronic Health Conditions and Prevention

15 Ocular complications after HCT Subjective complaints Blurred vision Light sensitivity Dry eyes Pain Keratoconjunctivitis (Sicca) Risk factors Chronic GvHD TBI Cataract Risk factors TBI (Total dose, Fractionation) Corticosteroids

16 Ocular complications after HCT Keratoconjunctivitis Treatment goal Prevent corneal lesions Maintain visual acuity Treatment Local - Artificial tears - Immunosuppression Systemic (GvHD) Superinfection Cataract Significance?Increased risk of accidents Prevention Conditioning strategies Reduction/ decreased treatment with steroids Treatment Surgical - Timing of the surgery

17 BMT.2010;45(Suppl2):S4,92 Reproductive Health: Males Infertility: an asymptomatic late effect of HCT Risk factors for infertility in males TBI Pre-HCT alkylating agent/xrt Chronic GvHD Azoospermic Normospermic ( 20x10x6/ml) Oligospermic (5 to 20x10x6/ml) Severely oligospermic (< 5x10x6/ml) Cryptospermic (only microscopic obs)

18 Reproductive Health: Females Follicle Count HCT Acute ovarian Failure Premature menopause Risk factors: High-dose Cy, TBI, Bu Older age (>30y) at HCT Abdominal radiation 25,000 1,000 (16) (25) (30) (37) (51)

19 Reproductive Health Infertility does not produce symptoms Symptoms due to gonadal failure Infertility may result in significant psychological distress for patient and partner No association with sexuality High probability of infertility Does not exclude: unwanted pregnancy, STDs Factors determining pregnancy/fatherhood rate Health status Age at HCT Family situation pre-hct Personality

20 Reproductive Health: action items

21 Reproductive Health: action items

22 Reproductive Health: action items After HCT Screening (females) FSH, LH; AMH, antral follicles on ultrasound Presence of menstruation not necessarily indicative of oocyte reserve and quality Control of hormone imbalance Hormone replacement (libido, sexual funct, bone density) Referral to specialists Reproductive assistance Cryopreservation Counseling Contraception, Prevention of STDs

23 Reproductive Health: resources

24 Osteopenia and osteoporosis Reduced bone density Increased risk for bone fractures No symptoms as long as no fractures

25 Osteopenia and osteoporosis: action items Screening Bone density (DEXA, CT) Vitamin D, Calcium Prevention Hormone replacement Reduce steroids Treatment Calcium/ Vitamin D Bisphosphonate What can a patient do? Regular physical activity Stop smoking Limit alcohol intake Moderate light exposure

26 Cardiovascular Disease and Risk Factors Cardiovascular Death Cardiomyopathy or Heart Failure Ischemic Heart Disease Stroke

27 Cardiovascular Disease and Risk Factors Hypertension Renal Disease Dyslipidemia Diabetes Mellitus

28 Cardiovascular Disease and Risk Factors Screening Risk-based surveillance - History & Physical - Echocardiography - ECG Aggressive management Hypertension Diabetes Dyslipidemia What can a patient do? Heart-healthy lifestyle -Heart-healthy diet -Smoking cessation -Physical activity Compliance in treatment of CV risk factors Prevention as the long-term goal

29 Risk Factors for Secondary Solid Cancers Blood, 2009, 113:

30 Second Cancers: action items Education Risk-based screening Breast (TBI) Oral Cavity & Skin (GvHD) Thyroid (TBI) Lung (Busulfan/cigarettes) What can a patient do? Self-examination Stop smoking Limit alcohol intake Comply with screening recs Consider pre-hct therapeutic risk factors Early therapeutic intervention

31 Quality of Life Most frequent subjective complaints in long-term HCT survivors Fatigue, Depression Musculoskeletal complaints Difficulties with concentration, forgetfulness Less frequently mentioned, but as important Problems with sexuality Financial hardship

32 Management of Fatigue Modifiable/treatable factors Pain Depression Sleep disorders Anemia Nutrition Hormonal imbalance Social integration Comorbidity Multi-disciplinary care

33 Long-term Follow-up Care Opportunities to optimize care

34 Organization of the LTFU visit Survivorship care plan History and treatment summary Comorbidities HCT-specific information - Type of HCT - Conditioning - GvHD Risk profile for late complications Present Possible Preparation Review all relevant documents Organize visit according to risk profile Team meeting (roles) Clinic visit Medical consultation Specialized investigations Consultative services Psychosocial assessment Counseling & answering questions Follow-up Assemble and summarize information Multidisciplinary discussion of probs. Recommendations for follow-up

35 Take home messages Late effects of HCT a reality, but not a fatality Cardiovascular complications, Osteopenia, infertility The occurrence of late effects and well-being not a contradiction Regular systematic screening allows prevention and early treatment of late complications Counseling re: healthy lifestyle part of long-term care Long-term survivorship care should also include Training and education of healthcare providers Healthcare agencies/resources of need for lifelong care Research opportunities to address gaps in knowledge

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