Jason Mendler, MD, and William Blum, MD
2010-12-05
King Pyrrhus of Epirus’ army suffered irreplaceable casualties in defeating the Romans at Heraclea in 280 B.C. and Asculum in 279 B.C. during the Pyrrhic War. Although victory was won, it came at a devastating cost and implied that another such victory would ultimately cause defeat. Unfortunately, this type of “Pyrrhic victory” is not uncommon in allogeneic transplant patients in whom the joy of a cure is often tempered by the devastating costs of transplant-related complications. Improving pre-transplant prediction of complications and post-transplant ability to recognize and treat them is sure to improve outcomes for our patients.
In yesterday’s Education Session on “Issues of Toxicity in Allogeneic Bone Marrow Transplantation,” which will also occur today at 9:30 a.m. in Room 224 of the Orange County Convention Center, Dr. Mohamed Sorror of the Fred Hutchinson Cancer Research Center discussed the general lack of standardization in how transplant physicians use pre-transplant comorbidities to predict risk of toxicity following allogeneic stem cell transplantation (allo-SCT). He showed compelling evidence that the use of a hematopoietic cell transplantation comorbidity index (HCT-CI), which summates objective organ co-morbidities into a single risk factor, is a more standard and effective way to predict transplant-related toxicity. He gave examples of how this index might be used, including the consideration of reduced-intensity conditioning regimens in patients with higher scores and myeloablative conditioning regimens in older patients with lower scores. His talk raised several important questions among attendees, including how best to mitigate co-morbidities pre-transplant, whether mitigation affects outcome, and whether allo-SCT should even be offered to patients with HCT-CIs above a certain score.
Dr. Mohamad Mohty of the CHU de Nantes in France noted that although a higher percentage of allo-SCT recipients are surviving the early transplant period, they experience a high incidence of long-term medical complications and increased risk of mortality. He addressed several of these complications, including endocrin disorders, secondary malignancies, and chronic graft-versus-host disease. He emphasized the need for awareness of these issues and appropriate management strategies requiring a close partnership between transplant centers, organ-specific specialities, and local primary-care providers.
Emphasizing the importance of quality of life after allo-SCT, Dr. Margaret Bevans of NIH concluded the session by bringing to light the multiple dimensions affecting health-related quality of life (HRQOL) in allo-SCT patients. She discussed not only how physical symptoms affect patient HRQOL, but also how psychosocial, emotional, and caregiver distress impact this variable. She suggested that the true impact of these multiple dimensions on QOL is often under-recognized and that more widespread and systematic assessment of patient-reported outcomes would facilitate recognition. Her group is working on developing formal guidelines to assist transplant centers in making these assessments.
As evidenced by today’s session, cure is no longer enough in allo-SCT. We must also ensure that life is worth living after the cure. What could be better than replacing Pyrrhic victories with overwhelming ones?
Drs. Mendler and Blum indicated no relevant conflicts of interest.
