Functional Status After Bone Marrow Transplantation

ABSTRACT & COMMENTARY

Synopsis: Among patients who survive five years or more after allogeneic bone marrow transplantation, 14% die by 15 years. Leading causes of late death are primary tumor recurrence, chronic graft-vs.-host disease, and secondary cancer.

Source: Duell T, et al. Ann Intern Med 1997;126: 184-192.

Quality-of-life studies of of bone marrow transplant (BMT) survivors have begun to appear. In view of the increasing number of conditions for which allogeneic BMT is curative therapy, and with advances in technology that may permit transplants to be done in patients without a sibling donor (e.g., with the use of cord blood as a source of allogeneic stem cells), more and more people should be long-term survivors. It is useful to know the expected clinical course.

Duell and colleagues carefully studied 798 patients treated by the European Group for Blood and Bone Marrow Transplantation who were five-year survivors. Overall, most patients (93%) were in good health and had returned to full time work or school (89%). However, mortality rates were greater than those seen in an age-matched population reaching 8% at 10 years and 14% at 15 years. Fifty-five patients died more than five years after transplant. The leading causes of death were recurrence of the primary tumor (21 cases), chronic graft-vs-host disease with infections and lung disease (11 cases), and secondary cancers (8 cases). Male sex of recipient and female sex of donor were also predictors of late toxicity, presumably related to the ability of these variables to predict chronic graft-vs-host disease. Women and older patients were less likely to resume complete social activity.

COMMENTARY

A variety of strategies could be pursued to further reduce the late toxicities associated with allogeneic BMT: the preparative regimens need to be improved to kill more tumor cells; methods of boosting graft-vs.-tumor effects (it is hoped without boosting graft-vs.-host disease) need to be tested to obtain better tumor control; methods of improving the prevention and treatment of chronic graft-vs.-host disease need to be developed. There are abundant ideas in these three areas that are undergoing clinical testing.

A more problematic area is the development of second tumors, nearly always related to the treatment rather than occurring as a natural consequence of the disease. Completely novel treatment approaches that do not employ carcinogenic drugs or radiation therapy have not been developed. Until such approaches are developed, long-term survivors of allogeneic BMTs would make a superb group for the testing of cancer prevention strategies.