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Safety and Access to Hematopoietic Cell Transplant

Key findings

Measure:  Percentage of cases with death date within 100 days after hematopoietic cell transplant

 

Desired Direction:

 

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As of this Report:

 

An image of an arrow pointing straight in a yellow box. This indicates that there has been no increase or decrease in performance, as desired, over the previous periods identified and this action is below but approaching target or has notable regional variation.

The 100-day mortality rate after hematopoietic cell transplantation (HCT) in 2016 was low and within published standards. Among patients receiving an allogeneic HCT from unrelated donors, 12% died within 100 days, while 6% of patients with related donors died during the same time period. Three percent (3%) of patients died within 100 days of an autologous HCT. Furthermore, among patients receiving an autologous transplant for multiple myeloma, 100-day mortality was extremely low (approximately 0.6%). These results are the similar to those reported by large international registries.

In fiscal year 2016/2017, 56% of multiple myeloma patients had an autologous HCT within the wait time target of 21 days from 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 provincial transplant experts.

What is hematopoietic cell transplantation?

  • HCT is an essential treatment for select patients with hematologic malignancies (including lymphoma, leukemia, myeloma and other disorders) [1]. HCT replaces a patient’s blood or marrow cells.
  • HCTs are commonly referred to as blood or marrow transplants or stem cell transplants, although many different types of stem cells exist.
  • The 2 main types of HCT are autologous and allogeneic. Whether a patient requires an autologous versus an allogeneic transplant is based on the type of blood cancer or illness for which the patient is being treated.

Measure:  Percentage of patients receiving hematopoietic cell transplant within 21 day target following apheresis

 

Desired Direction:

 

An image of an arrow pointing upwards. This indicates that desired direction for this action is upwards.

 

As of this Report:

 

An image of an arrow pointing straight in a red box. This indicates that there has been no increase or decrease in performance over the previous periods identified and this action is well below targets.

  • For autologous (or auto) transplants, patients are administered high doses of chemotherapy, with or without radiation, to destroy the patient’s diseased cancer cells – a treatment that also destroys the patient’s own bone marrow. Reinfusion of the patient's own previously collected and stored hematopoietic cells allows the bone marrow to regrow, resulting in recovery of blood counts.
  • Autologous transplants are most commonly used to treat non-Hodgkin and Hodgkin lymphoma, multiple myeloma and germ cell tumours.
  • For allogeneic (or allo) transplants, the patient also receives chemotherapy, with or without radiation, but the intent is to prepare the patient's body to accept cells from a tissue-matched donor (related or un-related). The donated hematopoietic cells again regrow the bone marrow and a new immune system.
  • Allogeneic transplants are most commonly used to treat acute leukemia and related bone marrow failure syndromes, such as the myelodysplastic syndromes.
  • Cancer Care Ontario funds 6 centres to perform HCTs: Hamilton Health Sciences Centre, Health Sciences North/Horizon Santé Nord, Kingston General Hospital, London Health Sciences Centre, The Ottawa Hospital and University Health Network (see Figure 1).

Figure 1. Hematopoietic cell transplant centres

 

    Figure 2. Distribution of hematopoietic cell transplant by transplant type, 2012 to 2016

    More information regarding the methodology is available.

    Report date: Dec-16-2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. This includes 48 out-of-country (OOC) transplants in 2015 and 2016.
    2. January 1st, 2012 to December 31st, 2016. Data from SCT, SSO IS, SCT-OOC.

    Figure 3. Volume of hematopoietic cell transplant by transplant type, 2012 to 2016

    More information regarding the methodology is available.

    Report date: Dec-16-2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. This includes 48 out-of-country (OOC) transplants in 2015 and 2016.
    2. Data from calendar year 2012 to 2016 from SCT, SSO IS, SCT-OOC.

    Figure 4. Percentage of patients who had a hematopoietic cell transplant who died within 100 days after first transplant, 2012 to 2016

    More information regarding the methodology is available.

    Report date: Dec-16-2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database, Ontario Cancer Registry database (OCR)

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. January 1st, 2012 to December 31st, 2016 data from SCT, SSO IS, and OCR data used for mortality status

    Figure 5. Percentage of auto transplant patients who died within 100 days after the first transplant, by disease type, 2012 to 2016

    More information regarding the methodology is available.

    Report date: January 2018

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database, Ontario Cancer Registry database (OCR)

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. January 1st, 2012 to December 31st, 2016 data from SCT, SSO IS, and OCR data used for mortality status

    Figure 6. Percentage of auto transplant patients with multiple myeloma who were treated within 21 days from the last apheresis to transplant, for the first transplant, fiscal year 2012/2013 to fiscal year 2016/2017

    More information regarding the methodology is available.

    Report date: December 2017

    Data source: Stem Cell Transplant (SCT) database, Registered Persons Database (RPDB)

    Prepared by: Analytics and Informatics, Cancer Care Ontario

    Note:

    1. See technical notes for detailed methodology and inclusions/exclusions

    Figure 7. Wait time for auto transplant patients with multiple myeloma, from last apheresis to transplant by fiscal year and quarter, fiscal year 2013/2014 to fiscal year 2016/2017

    More information regarding the methodology is available.

    Report date: December 2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database, Registered Persons Database (PRDB)

    Prepared by: Analytics and Informatics, Cancer Care Ontario

    Note:

    1. See technical notes for detailed methodology and inclusions/exclusions
    2. † Values have been suppressed due to small cell counts

    Data Table 1. Hematopoietic cell transplant centres

    LHIN South West Hamilton Niagara Haldimand Brant Toronto Central South East Champlain North East
    Centre London Health Sciences Centre - Victoria Hospital Hamilton Health Sciences Centre - Juravinski Hospital University Health Network - Princess Margaret Hospital Kingston General Hospital The Ottawa Hospital General Campus Health Science North/ Horizon Sante Nord
    Address 800 Commissioners Road East London N6A 5W9 711 Concession St Hamilton L8V 1C3 610 University Ave Toronto M5G 2M9 76 Stuart St Kingston K7L 2V7 501 Smyth Road Ottawa K1H 8L6 41 Ramsey Lake Rd Sudbury P3E 5J1

     

    Data Table 2. Distribution of hematopoietic cell transplant by transplant type, 2012 to 2016

    Type of transplant Cases Total Percentage of Cases
    Auto 2695 3834 70.3
    Allo-related 486 3834 12.7
    Allo-unrelated 653 3834 17.0

    Report date: Dec-16-2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. This includes 48 out-of-country (OOC) transplants in 2015 and 2016.
    2. January 1st, 2012 to December 31st, 2016. Data from SCT, SSO IS, SCT-OOC.

    Data Table 3. Volume of hematopoietic cell transplant by transplant type, 2012 to 2016

    Type of transplant Volume from January 1, 2012 to December 31, 2012 Volume from January 1, 2013 to December 31, 2013 Volume from January 1, 2014 to December 31, 2014 Volume from January 1, 2015 to December 31, 2015 Volume from January 1, 2016 to December 31, 2016
    Auto 463 512 517 573 630
    Allo-related 66 73 91 103 153
    Allo-unrelated 111 113 123 140 166

    Report date: Dec-16-2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. This includes 48 out-of-country (OOC) transplants in 2015 and 2016.
    2. Data from calendar year 2012 to 2016 from SCT, SSO IS, SCT-OOC.

    Data Table 4. Percentage of patients who had a hematopoietic cell transplant who died within 100 days after first transplant, 2012 to 2016

    Type of transplant Mortality from January 1, 2012 to December 31, 2012 Numerator from January 1, 2012 to December 31, 2012 Denominator from January 1, 2012 to December 31, 2012 Upper confidence interval from January 1, 2012 to December 31, 2012 Lower confidence interval from January 1, 2012 to December 31, 2012 Mortality from January 1, 2013 to December 31, 2013 Numerator from January 1, 2013 to December 31, 2013 Denominator from January 1, 2013 to December 31, 2013 Upper confidence interval from January 1, 2013 to December 31, 2013 Lower confidence interval from January 1, 2013 to December 31, 2013 Mortality from January 1, 2014 to December 31, 2014 Numerator from January 1, 2014 to December 31, 2014 Denominator from January 1, 2014 to December 31, 2014 Upper confidence interval from January 1, 2014 to December 31, 2014 Lower confidence interval from January 1, 2014 to December 31, 2014 Mortality from January 1, 2015 to December 31, 2015 Numerator from January 1, 2015 to December 31, 2015 Denominator from January 1, 2015 to December 31, 2015 Upper confidence interval from January 1, 2015 to December 31, 2015 Lower confidence interval from January 1, 2015 to December 31, 2015 Mortality from January 1, 2016 to December 31, 2016 Numerator from January 1, 2016 to December 31, 2016 Denominator from January 1, 2016 to December 31, 2016 Upper confidence interval from January 1, 2016 to December 31, 2016 Lower confidence interval from January 1, 2016 to December 31, 2016
    Auto 4.11 18 438 6.08 2.14 3.38 16 474 5.11 1.64 3.32 16 482 5.02 1.62 2.10 11 525 3.42 0.77 3.00 17 567 4.49 1.51
    Allo-related 12.70 8 63 21.71 3.68 5.71 4 70 11.87 0.00 8.54 7 82 15.19 1.88 8.42 8 95 14.53 2.31 5.67 8 141 9.85 1.50
    Allo-unrelated 13.89 15 108 20.87 6.90 13.64 15 110 20.50 6.77 13.64 15 110 20.50 6.77 15.38 20 130 21.97 8.80 12.18 19 156 17.63 6.73

    Report date: Dec-16-2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database, Ontario Cancer Registry database (OCR)

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. January 1st, 2012 to December 31st, 2016 data from SCT, SSO IS, and OCR data used for mortality status

    Data Table 5. Percentage of auto transplant patients who died within 100 days after the first transplant, by disease type, 2012 to 2016

    Disease Mortality from January 1, 2012 to December 31, 2012 Numerator from January 1, 2012 to December 31, 2012 Denominator from January 1, 2012 to December 31, 2012 Upper confidence interval from January 1, 2012 to December 31, 2012 Lower confidence interval from January 1, 2012 to December 31, 2012 Mortality from January 1, 2013 to December 31, 2013 Numerator from January 1, 2013 to December 31, 2013 Denominator from January 1, 2013 to December 31, 2013 Upper confidence interval from January 1, 2013 to December 31, 2013 Lower confidence interval from January 1, 2013 to December 31, 2013 Mortality from January 1, 2014 to December 31, 2014 Numerator from January 1, 2014 to December 31, 2014 Denominator from January 1, 2014 to December 31, 2014 Upper confidence interval from January 1, 2014 to December 31, 2014 Lower confidence interval from January 1, 2014 to December 31, 2014 Mortality from January 1, 2015 to December 31, 2015 Numerator from January 1, 2015 to December 31, 2015 Denominator from January 1, 2015 to December 31, 2015 Upper confidence interval from January 1, 2015 to December 31, 2015 Lower confidence interval from January 1, 2015 to December 31, 2015 Mortality from January 1, 2016 to December 31, 2016 Numerator from January 1, 2016 to December 31, 2016 Denominator from January 1, 2016 to December 31, 2016 Upper confidence interval from January 1, 2016 to December 31, 2016 Lower confidence interval from January 1, 2016 to December 31, 2016
    Lymphoma 5.9 8 135 10.3 1.6 6.6 10 152 10.9 2.3 4.8 8 168 8.3 1.2 4.2 7 165 7.6 0.9 7.9 15 190 12.0 3.8
    Mulitple myeloma 3.3 9 274 5.6 1.0 1.7 5 292 3.4 0.1 2.1 6 290 3.9 0.3 1.2 4 322 2.6 0.0 0.6 2 338 1.6 0.0

    Report date: January 2018

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database, Ontario Cancer Registry database (OCR)

    Prepared by: Cancer Analytics, Informatics, Cancer Care Ontario

    Note:

    1. January 1st, 2012 to December 31st, 2016 data from SCT, SSO IS, and OCR data used for mortality status

    Data Table 6. Percentage of auto transplant patients with multiple myeloma who were treated within 21 days from the last apheresis to transplant, for the first transplant, fiscal year 2012/2013 to fiscal year 2016/2017

    Category Percentage met wait time target in fiscal year 2012/2013 Number of cases met target in fiscal year 2012/2013 Number of total cases in fiscal year 2012/2013 Lower confidence interval in fiscal year 2012/2013 Upper confidence interval in fiscal year 2012/2013 Percentage met wait time target in fiscal year 2013/2014 Number of cases met target in fiscal year 2013/2014 Number of total cases in fiscal year 2013/2014 Lower confidence interval in fiscal year 2013/2014 Upper confidence interval in fiscal year 2013/2014 Percentage met wait time target in fiscal year 2014/2015 Number of cases met target in fiscal year 2014/2015 Number of total cases in fiscal year 2014/2015 Lower confidence interval in fiscal year 2014/2015 Upper confidence interval in fiscal year 2014/2015 Percentage met wait time target in fiscal year 2015/2016 Number of cases met target in fiscal year 2015/2016 Number of total cases in fiscal year 2015/2016 Lower confidence interval in fiscal year 2015/2016 Upper confidence interval in fiscal year 2015/2016 Percentage met wait time target in fiscal year 2016/2017 Number of cases met target in fiscal year 2016/2017 Number of total cases in fiscal year 2016/2017 Lower confidence interval in fiscal year 2016/2017 Upper confidence interval in fiscal year 2016/2017
    Ontario 40.1 81 202 33.1 47.1 36.4 91 250 30.2 42.6 38.5 110 286 32.7 44.3 49.2 160 325 43.6 54.8 55.5 176 317 49.9 61.2

    Report date: December 2017

    Data source: Stem Cell Transplant (SCT) database, Registered Persons Database (RPDB)

    Prepared by: Analytics and Informatics, Cancer Care Ontario

    Note:

    1. See technical notes for detailed methodology and inclusions/exclusions

    Data Table 7. Wait time for auto transplant patients with multiple myeloma, from last apheresis to transplant by fiscal year and quarter, fiscal year 2013/2014 to fiscal year 2016/2017

    Category Benchmark (days) Median in fiscal year 2013/2014 Q1 75th percentile in fiscal year 2013/2014 Q1 90th percentile in fiscal year 2013/2014 Q1 Median in fiscal year 2013/2014 Q2 75th percentile in fiscal year 2013/2014 Q2 90th percentile in fiscal year 2013/2014 Q2 Median in fiscal year 2013/2014 Q3 75th percentile in fiscal year 2013/2014 Q3 90th percentile in fiscal year 2013/2014 Q3 Median in fiscal year 2013/2014 Q4 75th percentile in fiscal year 2013/2014 Q4 90th percentile in fiscal year 2013/2014 Q4 Median in fiscal year 2014/2015 Q1 75th percentile in fiscal year 2014/2015 Q1 90th percentile in fiscal year 2014/2015 Q1 Median in fiscal year 2014/2015 Q2 75th percentile in fiscal year 2014/2015 Q2 90th percentile in fiscal year 2014/2015 Q2 Median in fiscal year 2014/2015 Q3 75th percentile in fiscal year 2014/2015 Q3 90th percentile in fiscal year 2014/2015 Q3 Median in fiscal year 2014/2015 Q4 75th percentile in fiscal year 2014/2015 Q4 90th percentile in fiscal year 2014/2015 Q4 Median in fiscal year 2015/2016 Q1 75th percentile in fiscal year 2015/2016 Q1 90th percentile in fiscal year 2015/2016 Q1 Median in fiscal year 2015/2016 Q2 75th percentile in fiscal year 2015/2016 Q2 90th percentile in fiscal year 2015/2016 Q2 Median in fiscal year 2015/2016 Q3 75th percentile in fiscal year 2015/2016 Q3 90th percentile in fiscal year 2015/2016 Q3 Median in fiscal year 2015/2016 Q4 75th percentile in fiscal year 2015/2016 Q4 90th percentile in fiscal year 2015/2016 Q4 Median in fiscal year 2016/2017 Q1 75th percentile in fiscal year 2016/2017 Q1 90th percentile in fiscal year 2016/2017 Q1 Median in fiscal year 2016/2017 Q2 75th percentile in fiscal year 2016/2017 Q2 90th percentile in fiscal year 2016/2017 Q2 Median in fiscal year 2016/2017 Q3 75th percentile in fiscal year 2016/2017 Q3 90th percentile in fiscal year 2016/2017 Q3 Median in fiscal year 2016/2017 Q4 75th percentile in fiscal year 2016/2017 Q4 90th percentile in fiscal year 2016/2017 Q4
    Ontario 21.0 26.0 51.0 65.0 31.0 59.0 66.0 32.0 60.0 93.0 27.0 49.0 60.0 30.0 37.0 67.0 28.0 59.0 75.5 31.0 55.5 72.0 28.0 47.0 63.0 20.0 35.0 73.0 22.0 32.0 65.0 22.0 49.0 66.0 21.0 28.0 40.5 22.0 36.0 64.0 20.5 28.0 62.0 19.0 26.0 44.0 20.0 29.0 37.0

    Report date: December 2017

    Data source: Hematopoietic Cell Transplant (HCT) database, Specialized Services Oversight Information System (SSO IS) database, Registered Persons Database (PRDB)

    Prepared by: Analytics and Informatics, Cancer Care Ontario

    Note:

    1. See technical notes for detailed methodology and inclusions/exclusions
    2. † Values have been suppressed due to small cell counts

    What is apheresis?

    • Apheresis is an umbrella term for removing a blood component [1].
    • Apheresis includes plasmapheresis (removing plasma), cytapheresis (removing blood cells) and leukapheresis (removing white bloods cells that contain the hematopoietic cells).

    What is myeloma?

    • Myeloma and multiple myeloma both refer to a cancer of the plasma cells.
    • Normal plasma cells are a cell in the immune system that make antibodies to protect against infections.
    • Plasma cells are found in the bone marrow, which is why myeloma is referred to as a hematologic, blood or bone marrow cancer.
    • The term “multiple myeloma” is used because the malignant cells tend to affect multiple areas of the bone marrow [2].

    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 infections [3].
    • Lymphomas are broadly classified into 2 types: Hodgkin lymphoma and non-Hodgkin lymphoma.

    What do the results show?

    The majority of hematopoietic cell transplants are autologous. The overall number of transplants performed each year is increasing (Figures 2 and 3).

    • Auto transplants account for approximately 70% of all HCTs.  
    • Allo-related donor procedures accounted for 13% of HCTs. Seventeen percent (17%) were allo-unrelated donor procedures.
    • The number of HCTs done has increased annually for auto, allo-related and auto-unrelated transplants, and this trend is expected to continue. Work is underway to build capacity in Ontario to meet this need.  

    Mortality is low and within acceptable limits (Figure 4 and 5).

    • Due to the aggressive nature of the treatment, and often of the underlying disease itself, some patients will die of complications from the transplant or from disease persistence or relapse.
    • In 2016, among patients receiving an allo-unrelated transplant, 12% died within 100 days. Six percent (6%) of patients with related donors died within 100 days of the transplant. Three percent (3%) of patients died within 100 days of an auto HCT (Figure 4).
    • Among auto transplant patients, the mortality for multiple myeloma patients in 2016 was less than 1% (Figure 5). Over half of the auto transplants done in Ontario in 2016 were for multiple myeloma patients.
    • One hundred (100) days was chosen as an appropriate measure because the first 3 months after HCT is when a patient is most likely to die from a direct complication, and 100-day mortality is commonly reported in transplant literature. Ultimately, moving towards reporting 1-year survival is desirable to align with evolving international reporting standards, as is separating out treatment-related mortality from death due to relapse or persistence of the disease for which the transplant was undertaken.

    There is potential to improve on the time it takes to get patients to transplant (Figures 6 and 7).

    • In fiscal year 2016/2017, 56% of multiple myeloma patients had an auto transplant within 21 days of last apheresis (Figure 6). This is below CCO’s target of 80%, indicating there is more work to be done.
    • The wait time target of 21 days was agreed upon by clinical experts as the estimated number of days it would take for a patient to go through the next steps of the cancer journey.
    • Figure 7 shows that the median number of days that multiple myeloma patients were waiting is close to the target of 21 days. In addition, the 75th percentile for multiple myeloma ranged from 26 to 36 days in fiscal year 2016/2017.

    Why is this important to Ontarians?

    • 100-day mortality is a standard metric reported by transplant programs that reflects the overall quality of care.
    • Wait times and their impact are important to consider because the diagnosis of cancer and uncertainty associated with cancer treatment often result in patient distress and anxiety [4].
    • Wait times are a useful tool to assess the healthcare system. If wait times are too long, work must be undertaken to determine whether appropriate resources are available and whether they are being efficiently utilized.
    • More importantly, long delays in treatment can negatively impact survival.

    How does Ontario compare to other jurisdictions?

    • A recent study found that the median wait time in Canada for last apheresis to transplant for aggressive lymphoma is 23 days, which is comparable to the median wait time in Ontario (Figures 6 and 7) [5].
    • Ontario’s mortality rate 100 days after HCT is comparable with other jurisdictions in Canada and internationally [6]. Studies from Canada and the United States have found 100-day survival ranging from 70% to 98%, depending on the years examined and the specific hematologic disease being considered [7–9].

    Find out more

    Notes

    1. Canadian Cancer Society [Internet]. Toronto: Canadian Cancer Society; c2016. Types of stem cell transplants [cited 2018 Feb 5]. Available from here.
    2. What is Myeloma? [Internet]. Myeloma Canada; c2019 [cited Feb 5, 2018]. Available from here.
    3. Overview: non-Hodgkin Lymphoma [Internet]. Bethesda (MD): National Institutes of Health; n.d. [cited Feb 5, 2018]. Available from here.
    4. Cancer Care Ontario. Current state of diagnostic assessment programs: ESRS Phase II report. Toronto: Cancer Care Ontario; 2013.
    5. Skamene T, Jiang W, Meyer R, Crump M, Kuruvilla J, Kouroukis T, et al. Impact of wait times for autologous stem cell transplantation in patients with aggressive non-Hodgkin lymphoma. Poster session presented at American Society of Hematology Annual Meeting; 2016 Dec 3–6; San Diego, California. 
    6. Pasquini MC, Zhu Z. Current uses and outcomes of hematopoietic stem cell transplantation: CIBMTR summary slides, 2015. Available at here.
    7. 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.
    8. 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.
    9. Blood Cell Transplant: Patient Survival Report [Internet]. Rockville (MD): United States Department of Health Resources and Services Administration; n.d. [cited 2014 Feb 20]. Available from here.