Highlights from BMT Tandem Nursing Meeting: Transplant for Older Adults
In 2017, nearly 1200 allogeneic transplant recipients facilitated by the National Marrow Donor Program/Be The Match were 65 or older.  The number of BMT recipients 70 years of age or older is also rising, and they represented nearly 5% of allogeneic transplants for blood cancers in 2016.  During the 2018 BMT Tandem Nursing Meeting, several sessions identified special considerations, assessments and interventions for older adult transplant patients.
Ethical considerations when there is no age limit for BMT
Patty Mayer, M.D., M.S., and September Mitchell, RN, BSN, MHI, OCN, CHTC, presented ethical frameworks to help analyze “non-traditional” cases.  According to Dr. Mayer, older adults have historically been “non-traditional” BMT patients. As more older adults are referred to transplant, there may be more ethical questions to consider.
Research continues to show that chronological age doesn’t affect BMT outcomes. [4,5] A case example encouraged attendees to consider an ethical analysis for an otherwise healthy 87-year-old with acute myeloid leukemia. The presenters recommended beginning with an assessment of clinically relevant facts, the patient’s values, and the ethical principles at stake. Then, by anticipating all possible outcomes in advance, you can reach a justification for action. The presenters recommended considering the ethical principles and not relying on chronological age alone to justify denying BMT as a treatment option.
Pre-habilitation aims to improve functional capacity
A concept that began in cardiology, pre-habilitation aims to improve pre-transplant functional capacity for patients of any age in order to boost outcomes afterwards.  Pamela Hansen, M.D., and Darren Walker, an exercise physiologist, outlined a model for BMT pre-habilitation that includes geriatric/frailty assessment, tailored exercise prescriptions, and group and individual training.  They emphasized the need for continued research to identify how best to implement pre-habilitation programs and measure the impact on transplant morbidity and mortality.
Tailored program assesses and prepares older patients for transplant
Finally, Jean Ridgeway, DNP, APN, AOCN, and Andrew Artz, M.D., M.S., co-presented on transplant in older adults and strategies to boost resiliency. For 5 years, the Transplant Optimization Program (TOP) at the University of Chicago has been providing holistic, standardized pre-transplant assessments for patients 50 years old and older.  Through this program, patients complete a day-long geriatric assessment. Based on the results, patients may have their transplant delayed in order to implement personalized interventions with the intent to boost resiliency for transplant. The two researchers credit the success of TOP to their interdisciplinary team approach, which results in a holistic view of a patient’s health for everyone involved in their care.
Future of BMT for older adults
The number of allogeneic transplants for treatment of malignant diseases in people 60 years of age and older continues to increase. Reduced-intensity preparative regimens and better supportive care continue to make the treatment less taxing with better outcomes for older adults.  Assessments of frailty and resiliency support improved treatment decision-making and transplant preparation for older adults.  Strategies to boost resiliency and fitness are an important aspect of holistic care that can improve quality of life and make a curative therapy accessible for older adults.
Resources for your older BMT patients
The Be The Match Patient Support Center offers your older patients and their caregivers free support programs:
- Through our Counseling Services, a licensed social worker provides one-on-one telephone counseling support to help older transplant patients and caregivers cope with transplant and recovery. Learn more at BeTheMatch.org/Counseling
- The Peer Connect program connects patients and caregivers by phone and email with a trained volunteer who is a transplant recipient or caregiver. Your patients and caregivers can request a connection at BeTheMatch.org/PeerConnect
- NMDP/Be The Match 2017 fiscal year reports.
- D’Souza A, Fretham C. Current Uses and Outcomes of Hematopoietic Cell Transplantation (HCT): CIBMTR Summary Slides, 2017. Available at: http://www.cibmtr.org
- Mayer P, Mitchell S. The Non-Traditional Transplant Patient: A Practical Ethical Analysis. BMT Nursing Meeting, Salt Lake City. 2018 BMT Tandem Meetings. Access
- Shah N, Ahn KW, Litovich C, et al. Outcomes of Patients 65 Years and Older with Non-Hodgkin Lymphoma Receiving Reduced-Intensity Conditioning Allogeneic Hematopoietic Stem Cell Transplantation Compared to Patients 55-64 Years of Age: A CIBMTR Analysis. Biol Blood Marrow Transplant. 2018; 24(3): S77-S78. Access
- Devine SM, Owzar K, Blum W, et al. Phase II study of allogeneic transplantation for older patients with acute myeloid leukemia in first complete remission using a reduced-intensity conditioning regimen: Results from Cancer and Leukemia Group B 100103 (Alliance for Clinical Trials in Oncology)/Blood and Marrow Transplant Clinical Trial Network 0502. J Clin Oncol. 2015; 33(35), 4167-4175. Access
- Hansen P, Walker D. Integrative Pre-Habilitation Programs and their Role in HSCT Populations. BMT Nursing Meeting, Salt Lake City. 2018 BMT Tandem Meetings. Access
- Artz A, Ridgeway J. Using Resiliency to Inform and Optimize Allogeneic Transplant in Older Adults. BMT Nursing Meeting, Salt Lake City. 2018 BMT Tandem Meetings. Access
- Federmann B, Faul C, Meisner C, et al. Influence of age on outcome after allogeneic hematopoietic cell transplantation: A single center study in patients aged ≥60. Bone Marrow Transplant. 2015; 50(3): 427-431. Access
- Abel GA, Klepin HD. Frailty and the management of hematologic malignancies. Blood. 2018; 131(5), 515-524. Access