Identifying and evaluating patients who may benefit from hematopoietic cell transplantation (HCT) is complex and involves many factors. Some considerations are specific to whether an autologous or allogeneic transplant is being considered. In autologous transplantation, for example, patients should have no active disease in the bone marrow, and collection of hematopoietic cells is attempted as soon as a remission is achieved.
The patient's overall health, age, and disease stage are also extremely important considerations in evaluating adult patients. Patients under consideration for HCT require an extensive evaluation performed by a transplant physician. A comprehensive pre-transplant evaluation should:
- Determine the patient's health and performance status
- Determine the patient's disease status
- Guide the informed consent process
- Identify any psychosocial issues that would interfere with the transplant procedure/recovery [1]
For a comprehensive discussion on evaluating candidates for HCT, the NMDP recommends a review article published in 2010 in Bone Marrow Transplantation. [2]
Health and performance status
Determining the patient's health and performance status involves a history and physical examination along with an evaluation of major organ function to identify any decrease in organ reserve.
The chemotherapy and/or radiation that a transplant recipient receives as part of the pre-transplant conditioning regimen can result in damage to various organ systems. A decrease in organ function prior to transplant may not necessarily make a patient ineligible for the procedure, but the increased risk for complications needs to be addressed in the informed consent process.
Many transplant physicians use the HCT comorbidity index (HCT-CI) to evaluate HCT candidates. The HCT-CI measures the prevalence and severity of comorbidities in 17 organs. It is useful in assessing the suitability of HCT for patients, and it can also provide valuable prognostic information after HCT. [3,4]
Access the HCT-CI online calculator: http://www.hctci.org/
Other scoring systems in use by transplant physicians are the Karnofsky performance score, the ECOG score, and the Lansky performance score for children.
Disease status
The status of the patient's disease is an important factor in determining eligibility for hematopoietic cell transplantation. In addition, this information allows the transplant physician to outline recommendations for additional treatment that may be needed prior to transplant. The extent of underlying disease and response to previous treatment influence the decision to proceed with transplant and the selection of the conditioning regimen.
The specific disease will determine the testing necessary to evaluate the current extent of the disease. Appropriate diagnostic procedures include X-rays, scans, biopsies, bone marrow aspiration and biopsy, and cytogenetic and molecular studies. It is also important for the transplant physician to review previous diagnostic information so a comparison can be made.
Other considerations
Infectious disease history
The pre-transplant evaluation should include a search for any signs of active infection. Patients with active infections at the time of hematopoietic cell transplant have a very high mortality rate. Patients with a significant infection history are at also greater risk of reactivating infections.
A complete history of previous infections provides important information to the transplant physician. Transplant physicians should be informed of previous fungal infections, especially with Aspergillus, so that active infection can be ruled out. Systemic aspergillosis has an extremely high mortality rate in transplant recipients.
Previous chemotherapy/radiation
Many patients under consideration for hematopoietic cell transplantation have a history of previous treatment. Multiple cycles of cytotoxic drugs and previous radiation, especially to the chest or mediastinum, are known to affect post-transplant complications. The transplant physician needs to know the lifetime dose of anthracyclines a patient has received.
While previous treatment is not a reason to exclude a patient, it is important to identify the increased risk to organ systems. Knowledge of the toxicity resulting from previous treatment helps to determine if there is a risk for overlapping toxicity from the transplant conditioning regimen.
Psychosocial evaluation
A thorough psychosocial evaluation is important in assessing the patient's ability to undergo the transplant procedure. This evaluation provides information about the ability of the patient and family or caregiver to comply and cope with the treatment plan.
A diagnosis of a psychiatric disorder may not be a contraindication to transplant, but it requires thorough psychiatric evaluation and follow-up. A history of substance abuse is also an indication for psychiatric evaluation and can have a serious negative impact on the transplant procedure.
Transfusion history
The patient's transfusion history can provide important information to the transplant physician. Detailed information about red blood cell and platelet transfusion — particularly any adverse reactions and the response to the transfusion — can assist the physician in post-transplant care.
References
- Blume KG, Krance RA. The evaluation and counseling of candidates for hematopoietic cell transplantation. In: Appelbaum FR, Thomas ED, eds. Thomas' Hematopoietic Cell Transplantation. 4th ed. Hoboken, NJ: Wiley-Blackwell; 2009: 445-460.
- Hamadani M, Craig M, Awan FT, Devine SM. How we approach patient evaluation for hematopoietic stem cell transplantation. Bone Marrow Transplant. 2010; 45(8): 1259-1268.
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- Sorror ML. How I assess comorbidities before hematopoietic cell transplantation. Blood. 2013; 121(15): 2854-2863.
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- Sorror ML, Maris MB, Storb R, et al. Hematopoietic cell transplantation (HCT)-specific comorbidity index: a new tool for risk assessment before allogeneic HCT. Blood. 2005; 106(8): 2912-2919.
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