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Choosing Wisely encourages dialogue about reducing unnecessary procedures, tests, or treatments in healthcare. The American Society for Blood and Marrow Transplantation (ASBMT) and Canadian Blood and Marrow Transplant Group (CBMTG) established a Choosing Wisely BMT Task Force whose objective was to create a list of top 5 practices in blood and marrow transplantation to be questioned. The Task Force consisted of representatives from ASBMT's Quality Outcomes, Education, and Practice Guidelines committees; ASBMT's Pharmacy Special Interest Group; CBMTG Program Directors; and Center for International Blood and Marrow Transplant Research (CIBMTR). Suggestions for current transplantation practices to question were elicited from the CBMTG Program Directors; members of ASBMT's Quality Outcomes, Practice Guidelines, and Education committees; and chairs of the CIBMTR scientific working committees. We received 119 unique suggestions that were ranked based on their potential impact on harm reduction, cost reduction, necessity of the test or practice, and the strength of available evidence. Through a modified Delphi process, suggestions were narrowed down to 6, which were then subjected to systematic reviews. The final 5 recommendations focus on graft source for patients with aplastic anemia, corticosteroid dose for initial treatment of graft-versus-host-disease, optimal number of umbilical cord blood units for transplantation, graft source in matched unrelated donor transplantation, and use of prophylactic intravenous immunoglobulin in transplant recipients. These Choosing Wisely BMT recommendations are relevant to the current clinical practice of blood and marrow transplantation and focus on tests, treatments, or procedures that may be harmful, wasteful, or for which there is no apparent clinical benefit. [ABSTRACT FROM AUTHOR]

Hematopoietic cell transplantation (HCT) is a potentially curative treatment for children and adults with malignant and nonmalignant diseases. Despite increasing survival rates, long-term morbidity after HCT is substantial. Neurocognitive dysfunction is a serious cause of morbidity, yet little is known about neurocognitive dysfunction after HCT. To address this gap, collaborative efforts of the Center for International Blood and Marrow Transplant Research and the European Society for Blood and Marrow Transplantation undertook an expert review of neurocognitive dysfunction after HCT. In this review we define what constitutes neurocognitive dysfunction, characterize its risk factors and sequelae, describe tools and methods to assess neurocognitive function in HCT recipients, and discuss possible interventions for HCT patients with this condition. This review aims to help clinicians understand the scope of this health-related problem, highlight its impact on well-being of survivors, and help determine factors that may improve identification of patients at risk for declines in cognitive functioning after HCT. In particular, we review strategies for preventing and treating neurocognitive dysfunction in HCT patients. Finally, we highlight the need for well-designed studies to develop and test interventions aimed at preventing and improving neurocognitive dysfunction and its sequelae after HCT. [ABSTRACT FROM AUTHOR]

Busulfan (BU) has been used for approximatively four decades as a major component of chemotherapy-based conditioning before allo-HCT. At our center, IV-BU dose in MAC is 12.8 mg/kg (BU12.8) and in those not eligible for MAC, it is 9.6 mg/kg (BU9.6). The aim of this study was to compare the impact of BU9.6 to BU12.8 on outcomes in patients with acute leukemia (AL) or myelodysplastic syndromes (MDS) who received allo-HCT after BU-based conditioning from matched related or unrelated donors. This study included 181 patients: 134 AL [122 AML, 10 ALL and 2 biph. AL] and 47 (26%) MDS patients who received allo-HCT between Jan 2012 and Dec 2018 at the Ottawa Hospital. Median age at allo-HCT was 58 years (range: 18-73), 104 (57%) were males. At time of conditioning, among AL patients, 99 (74%) were in CR1, 19 (14%) in CR2 and 16 (12%) not in CR, and among MDS patients, 22 (47%) were not treated. All patients received PBSC from HLA matched related [N=68 (38%)] or unrelated [N=113 (62%)] donors. Patients were classified according to the refined Disease Risk Index (DRI): 94 (52%) intermediate, 81 (45%) high and 6 (3%) very high. GVHD prophylaxis consisted of tacrolimus and short course methotrexate for all patients. Rabbit antithymocyte globulin (rATG, Thymoglobulin) was used in all transplants from unrelated donors (n=113) and in BU12.8 transplants from related donors (n=28). Bu dose was 9.6 mg/kg for 74 (41%) patients and 12.8 mg/kg for 107 (59%). Ninety-eight % of the patients engrafted; GVHD requiring systemic immunosuppression was observed in 26/74 (35%) patients (4 acute, 22 chronic) after BU9.6, and in 45/107 (42%) patients (13 acute, 32 chronic) after BU12.8. With a median follow-up of 22 months (range: 5-74) for survivors, no significant difference in survival, relapse (REL) or NRM was observed between BU9.6 and BU12.8. Two-year OS, REL and NRM for the whole population were 65% (95%CI: 57-73), 29% (95%CI: 22-37) and 10.8% (95%CI: 6-16) respectively. When stratified according to DRI: intermediate, high and very high scores had 2-year OS of 76% (95%CI: 65-84), 53% (95%CI: 38-66) and 0% respectively, p=0.001; and 1-year REL rates of 12% (95%CI: 6-20), 31% (95%CI: 21-42) and 67% (95%CI: 12-92) respectively, p<0.001. In multivariable analysis adjusted for conditioning, DRI, the use of rATG and rATG dose, the only factors that significantly impacted OS were DRI [high-very high vs intermediate: HR=1.98 (95%CI: 1.15-3.4), p=0.013] and the use of ATG [No ATG vs ATG 4.5mg/kg: HR=2.2 (95% CI: 1.06-4.6), p=0.033], while only DRI [high-very high vs intermediate: HR=3.56 (95%CI: 1.86-6.8), p=0.0001] impacted on REL. Our results validate the efficacy of a reduced 9.6 mg/kg BU-based conditioning regimen for patients not suitable for traditional 12.8mg/kg dose. Relapse was not increased, in addition, we confirm the value of DRI in prognosticating both relapse and survival. [ABSTRACT FROM AUTHOR]