late effects of transplants: lessons …cmesyllabus.com/.../2018/03/updated-slides-armenian... ·...
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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
CITY OF HOPE COMPREHENSIVE CANCER CENTER
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I have no relevant disclosures
Disclosures
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2009 2015 2020 2025 2030
Year
600
500
400
300
200
100
All Survivors
Nu
mb
er
of
Surv
ivo
rs, x
10
3
109
164
242
354
502
2009 2015 2020 2025 2030
Year
600
500
400
300
200
100
Autologous
Allogeneic Related Donor
Allogeneic unrelated Donor
Survivors by Transplant Type
Nu
mb
er
of
Surv
ivo
rs, x
10
3
94
137
202
294
67
125
25 17
38 31
56
49
85
75
109
Growing Number of HCT Survivors
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25
20
15
10
5
0 20 25 30 35 40 45 50 55 60
Reduction in Life Expectancy (Years)
Attained Age (Years)
50
40
30
20
10
0 20 25 30 35 40 45 50 55 60
Reduction in Life Expectancy (%)
Attained Age (Years)
30% lower life expectancy than that of the U.S. population
Life Expectancy: 5-Year Survivors
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GvHD
Infection
Secondary Cancer Cardiovascular
Respiratory
Other
Unknown
Relapse
Chronic health conditions account for 75% of late deaths
Late Mortality: 5-year Survivors
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Late complications after HCT
Early complication
0 3 months 2 years 10 years
Delayed events Late events Very late events
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
Expert Rev Hematol. 2(5), 2009
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Cancer Survivorship Research to Improve Outcomes
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0%
20%
40%
60%
80%
100%
0 2 5 10 15 20
Years Since HCT
Cu
mu
lati
ve In
cid
en
ce (
%)
Blood, 2010, 116: 3129-39
59%
35%
Severe/life-threatening Condition
Chronic Health Condition
HCT Survivors: 3.5-fold risk of Severe/ life-threatening conditions compared to siblings
Burden of Chronic Health Conditions Over Time
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Ph
ysio
logi
c R
eser
ve C
apac
ity
Age→
FUNCTION
FRAILTY
Acute insult: Cancer & Associated
Treatment
Lifestyle choices: inactivity, smoking,
sub-optimal diet
Barriers or access to tailored interventions
Adapted from:
Accelerated Aging in Survivors
Frailty: State of increased vulnerability resulting from aging-related decline in reserve and function
across multiple physiologic systems, compromising the ability to cope with everyday or acute stressors .
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0.0
5.0
10.0
15.0
20.0
25.0
1 2
Series1
Series2
Series3
Perc
ent
7.9 7.2
0.0
22.2
15.0
6.2
Pre-frail Frail
Cancer Survivors (18-50y)
CHS (65-101y)
Controls
Five components of fitness
Cardiovascular Health Study (65-101 years of age)
Muscle wasting
Muscle weakness
Self-reported exhaustion
Slow walking speed
Low energy expenditure
Frail = 3 components (prevalence: 7.2%)
Pre-frail = 2 components (prevalence: 15%)
Frailty Phenotype and Cancer
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GvHD Post-HCT relapse of Ca
Post-HCT Therapeutic Exposures
HCT
HCT-related exposures
Diagnosis of Primary Ca
Pre-HCT Therapeutic Exposures
Pre-HCT relapse of Ca
Young HCT survivors vulnerable to frailty
Substantial Stressors
High cumulative therapeutic exposures
+/- Sequelae of chronic GvHD
+/- Chronic health conditions
post-HCT
Frailty Phenotype and HCT
Slide courtesy of M. Arora
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8.40% 8.30% 8.55%
0.70% 0.94% 0.52%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
10%
Entire cohort Males Females
Survivors Siblings
Predictor Odds Ratio (95% CI) P-value
Siblings 1.0
Survivors 8.4 (2.0-34.5) 0.003
Adjusted for age at study, income, chronic health conditions
PREVALENCE OF FRAILTY (<65Y) – HCT SURVIVORS AND SIBLINGS
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Hazards Ratio (95% CI) P-value
No frailty 1.0
Frailty 2.76 (1.7-4.4) <0.0001
Frailty and Impact on Long-Term Survival
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Autologous HCT Allogeneic HCT
Beyond the Frailty Phenotype: “Aging Mimicry”?
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Beyond the Frailty Phenotype: “Aging Mimicry”?
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Cancer and Aging
Cancer and its treatment -Chemotherapy
-Radiation -Surgery
-Bio/Immunotherapy
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Premature Aging in Cancer Survivors
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JAMA. July 7 2010;304(1):69-75
Biomarkers of Premature Aging in Cancer Survivors
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Bone Marrow Transplant. 2017 Apr;52(4):600-605
Biomarkers of Premature Aging in Cancer Survivors
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Biomarkers of Premature Aging in Cancer Survivors
Overall: 30%
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V02peak
Product of cardiac output and A-V oxygen difference
Inversely correlated with death from CV disease and all-cause mortality
Sedentary adult women
Patients with breast cancer
J Clin Oncol, 2012, 30: 2530-37
Biol Blood Marrow Transplant. 2017 Apr;23(4):700-705
Physiologic Measures of Premature Aging
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Non-Relapse Mortality
Characteristics of both patients at HCT: Hispanic Male, 25 y.o.; BMI 28 kg/m2; Diagnosis: ALL; Pre-HCT relapse risk: high risk; HCT-CI Score: 3; Myeloablative conditioning.
Risk of All-Cause Mortality HR: 1.4, p=0.002*
*Adjusted for: Age, race/eth, risk of relapse, KPS, HCT source, aGVHD
Pre-HCT Assessment of Aging and “Fitness”
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Cancer Survivorship Research to Improve Outcomes
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Cancer/HCT Survivorship Screening Recommendations
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Utility of screening/surveillance
High Value Low Value Low Value
Low High Optimal Screening intensity
Harms plus costs
Costs
Harms
Benefits
Ann Intern Med. 2015;
162(10):712-717.
Screening value
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Stage A At high risk for CHF,
without heart disease
Stage B Asymptomatic LV dysfunction
Stage C Symptomatic heart disease
Stage D Symptomatic,
advanced heart disease requiring interventions
ACC/AHA Classification
At risk for heart failure
Clinical heart failure
Anthracycline
Life Cycle Model AC-exposed CCS
No heart abnormality
Death
Asymptomatic LV dysfunction
Symptomatic heart disease
10 million simulations
Transition probabilities
2014; 160: 672-683
Measuring cost-effectiveness of screening/surveillance
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0
100
200
300
400
500
600
700
800
45% of cases with CHF exposed to <250 mg/m2
Anthracycline dose (mg/m2)
0
100
200
300
400
500
600
Controls
(No Heart Failure)
Cases
(Heart Failure)
J Clin Oncol, 2008, 26: 5537-43; Blood, 2011, 118: 6023-9
Improving accuracy of late effects risk prediction in HCT survivors
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For a given exposure, there is marked variation in prevalence and severity of heart failure that is not explained exclusively by clinical risk factors
Clinical risk factors Genetic risk factors
Therapy-Related Heart Failure
Age at exposure
Female gender
Anthracycline dose
Comorbidities
Drug metabolism and Transport
Generation of reactive oxygen species
Anti-oxidant defense
DNA repair pathways
Renin-angiotensin system
Improving accuracy of late effects risk prediction in HCT survivors
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Anthracycline
Myocyte apoptosis
ROS
Mitochondrial dysfunction
Aconitase/IRP1
Loss of Fe Homeostasis
Energy/Redox Impairment
Maladaptive LV Remodeling
Asymptomatic ↓LVEF/FS
ABCC1, ABCC2
CBR1, CBR3
SOD2, APOE,
NQO1 RAC2 NCF4 CYBA
HFE
ADRB1, ADRB2 AGT, AGTR1, ACE
Heart Failure
Dox-semiquinone*
NAD(P)H
NAD(P)+
NAD(P)H oxidase multi-enzyme complex
O2*/H202
Prescribed dose
Internal dose
Dox-ol Dox-quinone
2013 Oct;163(2):205-13
OR 95% CI
Female 2.9 1.4-6.0
Chest XRT 4.7 1.0-16.5
HFE (rs1799945), GC/GG 2.5 1.0-6.3
RAC2 (rs13058338), TA/AA 2.8 1.4-5.6
ABCC2 (rs818710), GA/AA 4.3 1.5-12.5
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Improving accuracy of late effects risk prediction in HCT survivors
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TRANSLATING OBSERVATIONAL STUDIES INTO PREVENTION
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Subsequent Malignancy: Breast Cancer
Radiation exposed Survivors of
Childhood and AYA Cancer N=230
RANDOMI ZE
Tamoxifen 5mg x 2 yr (N=115)
Placebo x 2 years
N=115
Stratified by: Age at dx (<18/18-40)
Menopausal status Chest radiation
(12-26Gy, >26Gy)
Low Dose Tamoxifen for Radiation-Induced Breast Cancer Risk Reduction (R01 CA140245 [Palomares])
Endpoints: Mammographic Density, Histologic & Circulating Markers
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Cardiovascular Disease: Heart Failure
Phase IIb randomized placebo-controlled clinical trial
Childhood CA survivors treated
with high dose anthracycline (≥250 mg/m²)
RANDOMI ZE N= 250
6.25mg/day x 1 month Carvedilol If tolerating, escalate
Carvedilol 12.5mg/day total 2 yrs
N=125
2wk run-in 3.125mg/day
Placebo x 2 years
N=125
Equivalent evaluation and
dose mod.
Age at dx Time from tx
Chest radiation
NIH/NCI: R01CA196854 (Armenian) Leukemia & Lymphoma Society St. Baldrick’s Foundation
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Subsequent Malignancy: HPV Vaccination
R01 CA166559 (Landier, Klosky)
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Bridging the Gap in Follow-up Through Innovation
GPE
50%
60%
70%
80%
90%
100%
2-5 years 6-10 years 11+ years
Years since transplant
% Utilization Medical contact
Cancer Epidemiol Biomarkers Prev 2007; 16(4): 834
Cancer/HCT related visit
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Bridging the Gap in Follow-up Through Innovation
Traditional paternalistic model of care
Empowered Physician
Empowered Patient
• Patient completely reliant on HCP to receive information, diagnosis and referral
• Difficult for patients to navigate within and between health and social care
• Interventions usually in response to physical evidence from patient Empowered patient sharing ownership
Empowered Physician
Empowered Patient
• Patient informed whenever and wherever, using their interoperable medical record
• Co-creation of care packages, proactive prevention, rapid access to services
• Technology enabled support and self-management
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Bridging the Gap in Follow-up Through Innovation
Caltech-COH Biomedical Research Initiative (Armenian [COH], Gharib [Cal Tech]) R21 CA178344 (Armenian)
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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 •Psychosocial assessment • Counseling & answering questions
Follow-up • Assemble and summarize information • Multidisciplinary discussion of probs. • Recommendations for follow-up
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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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