Safety and Access to Hematopoietic Cell Transplant
Measure: Percentage of cases with death date within 100 days after hematopoietic cell transplant
As of this Report:
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) . 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
As of this Report:
- 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).
What is apheresis?
- Apheresis is an umbrella term for removing a blood component .
- 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 .
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 .
- 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 .
- 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) .
- Ontario’s mortality rate 100 days after HCT is comparable with other jurisdictions in Canada and internationally . 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
- For more information about the progress made HCT services in Ontario, please see the Complex Malignant Hematology Services in Ontario report .
- For more information on stem cell guidelines, please visit the CCO Program in Evidence-Based Care Transplantation Guidelines website.
- For more information on hematopoietic cell transplants in Ontario, please visit the Cancer Care Ontario website.