Blood cancers

ASCT is as safe and effective in private sector as elsewhere


Outcomes following autologous stem cell transplantation (ASCT) performed in the private sector are reassuring with high 10-year overall survival and low transplant-related mortality (TRM) when benchmarked against ANZ data.

Findings from a retrospective study of 1,676 ASCTs performed in 1,454 patients at Icon Cancer Centre Brisbane between 1996 and 2018 reflect a safe and effective clinical and laboratory ASCT program.

The most common indications for ASCT were multiple myeloma (45%), DLBCL (15%) and follicular lymphoma (8%).

“Of the total population, 57% of patients received melphalan conditioning and 39% received BEAM (carmustine/etoposide/cytarabine/melphalan) conditioning. Almost all patients underwent chemotherapy-based mobilisation using either cyclophosphamide (66%) or other chemotherapy (32%) and mobilising cytokines (granulocyte-colony stimulating factor, G-CSF alone in 94% of patients).”

The study, published in the Internal Medicine Journal, found the 10-year overall survival for first transplants performed during 2001–2018 compared favourably with outcomes from the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR).

It found myeloma transplant survival was 59% at Icon Cancer Care compared to the ANZ benchmark of 36%; DLBCL survival was 68% compared to 46% and follicular lymphoma was 76% compared to 53%.

“Though speculative, possible reasons for the favourable survival outcomes of Icon transplant recipients could relate to differences in private cancer care delivery models, with improved service accessibility and early referral leading to gains in quality and efficiency of care,” the study said.

It also noted that differences in patient characteristics between the cohorts such as private patients having a higher social economic background, better access to healthcare and fewer comorbidities may be factors.

The 100-day and 1-year TRM in the entire cohort was 1.1% and 1.7% respectively.

“For ASCTs performed at Icon between 2014–2018, 100-day and 1-year TRM were 0.8% and 1.4% which is approximately half of the published ABMTRR rates of 1.6% and 2.7%.”

“Together with the favourable OS, the lower TRM at Icon serves to assure stakeholders regarding the safety and high quality of this highly specialised therapy in the private sector.”

The most common cause of death was relapse of primary disease (82%) followed by second primary malignancies (7%), organ failure (5%) and infection (3%). A third (35%) of the second primary malignancies were therapy-related myeloid neoplasms.

The study noted an increasing proportion of older patients ≥ 70 years over the 23-year study period. As well, during the most recent period 2014–2018, older patients represented a larger proportion of ASCTs at Icon than in the ABMTRR (21% v 5%).

The study, led by Dr Karthik Nath who is now pursuing a fellowship at Memorial Sloan Kettering Cancer Center in New York, said Icon provided about 40% of all southeast Queensland ASCTs during 2014–2018.

“In an era where cost containment is increasingly important and access to the public hospital system can be challenging, using the private sector to perform complex procedures such as ASCT reduces the reliance on the public sector and could potentially reduce government costs per patient.”

“Benchmarking outcomes from Icon’s transplant program compared with ABMTRR data provides assurance as to the clinical performance, quality, and safety of the ASCT program at Icon,” the study said.

The investigators said the outcomes support the expansion of other highly specialised therapies such as CAR T within the private sector.

Complexity

Dr John Bashford, Director of Research at Icon Cancer Care and founding director of the ASCT program, told the limbic that the quality of the program had been under continuous review from the outset as a unique private program in a new space.

“I think while it was to a degree unspoken, there was a sense that this was a public sector complex medical procedure and there was uncertainty as to how well that would translate to the private sector.”

“I think now in 2022 you can say that there are many things — complex neurosurgery, complex cardiac procedures are two examples — that have stepped over to routine private sector use as well.”

He said the results demonstrate that clinicians, health funds and government can be confident cellular therapies programs can be safely and effectively run in the private sector.

“And another reason for publishing this is that we are seeing a great growth internationally in the genetically modified cell programs such as CAR T and similar approaches that are probably going to have a very large impact on cancer care over the next 10 years.”

“I think the evidence in lymphoma and leukaemia suggests it will become routine therapy so there will be a need for an increased number of units…we have demonstrable outcomes which I think can be reproduced across the sector and provide confidence that the new cellular therapies can be introduced across both sectors into the future.”

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