Patient Eligibility for HCT
Identifying and evaluating patients who may benefit from hematopoietic cell transplantation (HCT) involves many factors, including overall health, prior therapies, age, disease, and disease stage. If an allogeneic transplant is being considered, it is important to identify available HLA-matched related donors, unrelated donors, or cord blood units as soon as possible.
Patients under consideration for HCT require a thorough evaluation performed by a transplant physician. A comprehensive pre-transplant evaluation should:
- Determine the patient's health and performance status
- Assess the patient's disease status
- Guide the informed consent process
- Identify any psychosocial issues that would interfere with the transplant procedure/recovery 
Health and Performance Status
Well-established health and performance status criteria to assess patient eligibility for HCT include:
- Karnofsky performance score
- Left ventricular ejection fraction
- Pulmonary function test; forced vital capacity
- Diffusion capacity (DLCO)
- Kidney function
- Liver function
- Mental health [2,3]
Recent research has shown that age alone should not be a determinant for HCT eligibility. [4,5] Transplant physicians therefore generally do not set an upper age limit for transplant and instead assess HCT eligibility on other clinical factors such as presence of co-morbidities and geriatric/frailty assessments. [4,6]
HCT comorbidity index
For more than a decade, transplant physicians have been using the HCT comorbidity index (HCT-CI) to evaluate HCT candidates. The HCT-CI measures the prevalence and severity of comorbidities in 17 organs. It is useful in assessing the suitability of HCT for patients, and it can also provide valuable prognostic information after HCT. [7,8]
Assessing patient eligibility using an HCT-specific tool is important because research has shown that physical function and co-morbidities, and not chronological age alone, should be considered when determining eligibility for transplant.  Therefore, many older patients — once considered by many transplant centers to be ineligible due to chronologic age — may in fact now be candidates for HCT.
The Fred Hutchinson Cancer Research Center has made available an online HCT-CI calculator.
Disease stage, previous treatments (chemotherapy/radiation), infectious disease, and transfusion history can also have a significant impact on HCT outcomes. Research shows that early referral is an important step that can affect survival.
Three hematopoietic cell sources are used in HCT: bone marrow, peripheral blood stem cells (PBSC), and umbilical cord blood. Each source in an allogeneic transplant can come from a related or unrelated donor or cord blood unit. Most autologous transplants use PBSC for ease of collection of the cells and a more rapid hematopoietic recovery.
Recent outcome studies have demonstrated that related and unrelated donor transplant outcomes are comparable in many patient populations. Therefore, lack of a related donor should not preclude referral for a transplant consultation. 
If an unrelated donor is needed, between 66-93% of patients have an available and willing HLA-matched donor at ≥7 of 8 loci through the Be The Match Registry®, depending on race or ethnicity. Because appropriate planning and early donor identification are critical for optimal outcomes, early referral for a transplant consultation is appropriate, even for patients who ultimately may never need HCT.
Other (Non-Clinical) Factors
A psychosocial evaluation is important to assessing a patient's ability to undergo a transplant. The primary goal of the assessment is to manage any psychosocial issues that would interfere with the transplant procedure and the recovery phase. [1-3]
Due to the often lengthy recovery period, most transplant centers require a caregiver to advocate for the patient and to be available to assist the patient during and after transplant.
Transplant Center-Specific Requirements
Transplant centers in our Network each have criteria for the kinds of transplants performed, and diseases and ages treated. Access individual U.S. transplant center information and outcomes.
- Blume KG, Krance RA. The evaluation and counseling of candidates for hematopoietic cell transplantation. In: Appelbaum FR, Thomas ED, eds. Thomas' Hematopoietic Cell Transplantation. 4th ed. Hoboken, NJ: Wiley-Blackwell; 2009: 445-460.
- Scott BL, Sandmaier BM. The evaluation and counseling of candidates for hematopoietic cell transplantation. In: Forman SJ, Negrin RS, Antin JH, Appelbaum FR, eds. Thomas' Hematopoietic Cell Transplantation. 5th ed. Hoboken, NJ: Wiley-Blackwell; 2016: Chapter 29. Access
- Fedele R, Salooja N, Martino M. Recommended screening and preventive evaluation practices of adult candidates for hematopoietic stem cell transplantation. Expert Opin Biol Ther. 2016; 16(11): 1361-1372. Access
- Sorror ML, Storb RF, Sandmaier BM, et al. Comorbidity-age index: a clinical measure of biologic age before allogeneic hematopoietic cell transplantation. J Clin Oncol. 2014; 32(29): 3249-3256. Access
- Rashidi A, Ebadi E, Colditz GA, DiPersio JF. Outcomes of allogeneic stem cell transplantation in elderly patients with acute myeloid leukemia: A systematic review and meta-analysis. Biol Blood Marrow Transplant. 2016; 22(4): 651-657. Access
- Abel GA, Klepin HD. Frailty and the management of hematologic malignancies. Blood. 2018; 131(5): 515-524. Access
- Sorror ML. How I assess comorbidities before hematopoietic cell transplantation. Blood. 2013; 121(15): 2854-2863. Access
- Sorror ML, Maris MB, Storb R, et al. Hematopoietic cell transplantation (HCT)-specific comorbidity index: A new tool for risk assessment before allogeneic HCT. Blood. 2005; 106(8): 2912-2919. Access
- McClune BL, Weisdorf DJ, Pedersen TL, et al. Effect of age on outcome of reduced-intensity hematopoietic cell transplantation for older patients with acute myeloid leukemia in first complete remission or with myelodysplastic syndrome. J Clin Oncol. 2010; 28(11): 1878-1887. Access
- Saber W, Opie S, Rizzo JD, et al. Outcomes after matched unrelated donor versus identical sibling hematopoietic cell transplantation in adults with acute myelogenous leukemia. Blood. 2012; 119(17): 3908-3916. Access