|Measure ||Desired Direction ||As of this Report |
|Percentage of cases with death date within 100 days after |
stem cell transplant
| || |
|Percentage of patients receiving stem cell transplant within 21-day target following apheresis || || |
| See Methodology and Approach to find out how the ratings are calculated. |
The mortality rate up to 100 days after stem cell transplant was calculated in FY 2014/2015. Results indicate that mortality is low and within acceptable limits. Among patients receiving an allogeneic stem cell transplant from unrelated donors, 15% died within 100 days; 8% of patients with related donors died within 100 days of the transplant. Three percent (3%) of patients died within 100 days of an autologous stem cell transplant.
In Fiscal Year (FY) 2014/2015, 36% of multiple myeloma patients had an autologous stem cell transplant within the wait time target of 21 days from last apheresis, while 47% of relapsed lymphoma patients had an autologous stem cell transplant within 21 days of the last apheresis. More work is required to ensure a larger portion of patients have their transplant within the target of 21 days, an interval agreed upon by transplant experts.
What is stem cell transplantation?
- Stem cell transplantation is an essential treatment component for selected patients with hematological malignancies (including lymphoma, leukemia, myeloma and other disorders)1.
- The process involves administering high doses of chemotherapy, with or without radiation, to destroy a patient’s diseased cancer cells—a treatment that also destroys the patient’s own bone marrow.
- Following the chemotherapy, the patient receives an infusion of blood or marrow stem cells, with the intention that the cells will regenerate the patient’s bone marrow in a timely manner.
- Cancer Care Ontario funds 6 centres to perform stem cell transplants: Hamilton Health Sciences Corporation, Health Sciences North/Horizon Santé Nord, Kingston General Hospital, London Health Sciences Centre, the Ottawa Hospital and University Health Network (please see Figure 1).
What are autologous and allogeneic transplants?
- Autologous (auto) transplants use the patient’s own stem cells.
- Autologous-relapsed (auto-relapsed) patients are those who have relapsed following previous chemotherapy.
- Allogeneic (allo) is a type of transplant where stem cells from a similar donor—who can be a relative or an unrelated donor—are used.
- Stem cell similarity for allogeneic transplant is determined by a blood test called human leukocyte antigen (HLA) testing or typing. This is used to find the best matched donor.
- Transplants from unrelated donors are riskier, and complication rates tend to be higher since the stem cells are not as closely compatible1.
What is apheresis?
- Apheresis is an umbrella term for removing a blood component2.
- Apheresis includes plasmapheresis (removing plasma), cytapheresis (removing blood cells) and leukapheresis (removing white bloods cells that would contain the stem cells)3.
What is myeloma?
- Myeloma and multiple myeloma both refer to a cancer of the plasma cells.
- Plasma cells are found in the bone marrow. This is why myeloma is referred to as hematologic, blood or bone marrow cancer.
- The term multiple myeloma is used because the malignant cells tend to affect multiple areas of the bone marrow4.
What is lymphoma?
- Lymphoma is the most common form of blood cancer that affects the immune or lymphatic system. The lymphatic system carries lymph fluid, which contains lymphocytes and other white blood cells, across the entire body and helps fight infections5.
- There are 2 types of lymphoma:
- Hodgkin lymphoma
- non-Hodgkin lymphoma.
- More information on integrated wait times for lymphoma can be found on the Wait times from Diagnosis to Chemotherapy page.
What do the results show?
Majority of stem cell transplants are auto (Figure 2).
- The majority of stem cell transplants are auto (including auto-relapsed).
- Allo-related accounted for 12% of stem cell transplants and 16% were allo-unrelated.
Mortality is low and within acceptable limits. Among patients receiving allogeneic transplant from unrelated donors, 15% died within 100 days; 8% of patients with related donors died within 100 days of the transplant. Three percent (3%) of patients died within 100 days of an autologous stem cell transplant (Figure 3).
- Due to the aggressive nature of the treatment—and often of the underlying disease itself—some patients are not expected to survive. This is related to patient selection, the transplant procedure itself, and the monitoring or prevention of complications.
- One hundred (100) days was chosen as an appropriate measure because the first 3 months after the stem cell transplant is when a patient is most likely to die from a direct complication, and 100-day mortality is commonly measured in transplant literature.
- Potential complications could include bacterial, fungal and viral infections, organ dysfunction, and graft versus host disease6.
Thirty-six percent (36%) of multiple myeloma patients in FY2014/2015 had an autologous stem cell transplant within the wait time target of 21 days from the last apheresis (Figures 4 and 5).
- The wait time target of 21 days was agreed upon by clinical experts. That is the estimated number of days it would take for a patient to go through the next steps of the cancer journey, and experts estimate that 80% of patients should have received a transplant within 21 days of their last apheresis.
- Approximately one third (36%) of multiple myeloma patients received a transplant within 21 days, which shows that there still is work to be done (Figure 4).
- Figure 5 shows the median number of days that multiple myeloma patients were waiting, which is close to the target of 21 days. In the first quarter of FY2014/2015, 9 out of 10 patients were treated within approximately 67 days.
- The sharp reduction in wait times seen in Figure 5 is not related to data quality issues.
- It was found that there is no statistical difference between patient age and the number of days multiple myeloma patients had to wait to have an autologous stem cell transplant from last apheresis. Therefore, different age groups are not disadvantaged in relation to treatment (data not shown).
In FY2014/2015, 47% of relapsed lymphoma patients had an autologous stem cell transplant within 21 days of last apheresis (Figures 4 and 6).
- The wait time target of 21 days was agreed upon by clinical experts. That is the estimated number of days it would take for a patient to go through the next steps of the cancer journey. As in myeloma, 80% of patients should be within this target of 21 days.
- Almost half of the relapsed lymphoma patients (47%) were treated within 21 days in FY2014/2015, which shows that there is still work to be done (Figure 4).
- Figure 6 indicates that the median number of days that relapsed lymphoma patients were waiting is close to the target of 21 days. In the first quarter of FY2014/2015, 9 out of 10 patients were treated within approximately 67 days. In the third quarter of FY2014/2015, 9 out of 10 patients were treated within approximately 44 days, which is an improvement.
- There is no statistical difference across the patient age groups for the number of days relapsed lymphoma patients had to wait to have an autologous stem cell transplant (data not shown). Therefore, different age groups are not disadvantaged in relation to treatment.
Why is this important to Ontarians?
- Wait times and their impact are important to consider because the uncertainty and fear associated with cancer treatment often result in patient distress and anxiety7.
- One study looking at allo unrelated transplants in Canada and the United States found survival at 100 days in 2005 at 78% (22% mortality) for myeloid leukemias, acute lymphoblastic leukemia, myelodysplastic syndrome and chronic myeloid leukemia8.
- Another study looking at auto stem cell transplants found the overall survival at 100 days to be 96% (4% mortality) for patients with chemotherapy-sensitive relapsed non-Hodgkin lymphoma and 98% (2% mortality) for patients with chemotherapy-sensitive multiple myeloma9.
- One study identified that re-admission after allo stem cell transplant impacted overall survival. Infection during transplantation was a significant risk factor for re-admission, and re-admission was significantly associated with decreased overall survival10.
- Results from the Patient Survival Report for Blood Cell Transplant from the US Department of Health Resources and Services estimates 100-day survival rates of auto transplants at 98.6% from 2008 to 2012 for patients with multiple myeloma. The same report estimates allo transplant survival rates over the same period for patients with non-Hodgkin lymphoma (diffuse large cell) at 71.8% for allo related transplants (28.2% mortality), and at 69.9% for allo unrelated transplants (30.1% mortality)11.
- Ontario’s data are not broken down by disease site, but the above diseases were selected because they comprise the majority of patients for the different types of transplant.
- These comparisons demonstrate that Ontario’s mortality rate after 100 days of stem cell transplant has favourable risk compared with other jurisdictions.
Find out more
- Cancer Care Ontario [Internet]. Toronto: Ontario Ministry of Health and Long-term Care; c2009–2010. Ensuring access to high quality bone marrow and stem cell transplantation services in Ontario. Report of the Advisory Panel, 2007/2008; [cited 2015 Mar 7]. Available from: http://www.health.gov.on.ca/en/common/ministry/publications/reports/bm_stemcell_transplant/bm_stemcell_transplant.aspx.
- Canadian Cancer Society [Internet]. Toronto: the Canadian Cancer Society; c2016. Types of stem cell transplants; [cited 2015 Mar 11]. Available from: http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/stem-cell-transplant/types-of-stem-cell-transplants/?region=nl&sc_prof=1.
- Canadian Cancer Society [Internet]. Toronto: the Canadian Cancer Society; c2016. Lymphoplasmacytic lymphoma; [cited 2015 Mar 11]. Available from: http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/lymphoplasmacytic-lymphoma/?region=on.
- Myeloma Canada [Internet]. Myeloma Canada; c2016. What is myeloma?; [cited 2015 Feb 28). Available from: http://www.myelomacanada.ca/en/whatismyeloma.htm.
- National Cancer Institute [Internet]. Bethesda (MD): National Institutes of Health; 2007. Overview: non-Hodgkin Lymphoma; [cited 2015 Jan 12]. Available from: http://www.cancer.gov/cancertopics/types/non-hodgkin.
- Pallera A, Schwartzberg L. Managing the toxicity of hematopoietic stem cell transplant. Support Oncol. 2004; 2(3):223–37.
- Cancer Care Ontario. Current state of diagnostic assessment programs: ESRS Phase II report. Toronto: Cancer Care Ontario, 2013.
- Hahn T, McCarthy P, Hassebroek A, Bredeson C, Gajewski J, Hale G, et al. Significant improvement in survival after allogeneic hematopoietic cell transplantation during a period of significantly increased use, older recipient age, and use of unrelated donors. J Clin Oncol. 2013; 31(19):2437–49 .
- McCarthy P, Hahn T, Hassebroek A, Bredeson C, Gajweski J, Hale G, et al. Trends in use of and survival after autologous hematopoietic cell transplantation in North America, 1995–2005: significant improvement in survival for lymphoma and myeloma during a period of increasing recipient age. Biol Blood Marrow Transpl. 2013; 19:1116-1123.
- Spring L, Li S, Soiffer RJ, Antin JH, Alyea EP, Glotzbecker B. Risk factors for readmission after allogeneic hematopoietic stem cell transplantation and impact on overall survival. Bio Blood Marrow Transpl. 2015; 21(3):509–516.
- United States Department of Health Resources and Services Administration. Blood cell transplant: patient survival report [Internet]; [cited 2014 Feb 20] Available from: http://bloodcell.transplant.hrsa.gov/research/transplant_data/us_tx_data/survival_data/survival.aspx.