Hematopoietic Cell Transplant (HCT) in the Elderly: Myths, Controversies and Unknowns

The incidence of most hematological malignancies increases with age. Despite the higher incidence of hematological malignancies in the elderly, the geriatric population is poorly represented in the early oncology clinical trials that established the current standards of care. Hematopoietic cell transplant (HCT), either upfront or at relapse, provides a potentially life-prolonging, often curative option for many patients with hematological malignancies and is considered the standard of care, at least for younger patients. Historically, the concern that older adults undergoing HCT may experience higher morbidity and transplant-related complications has limited the use of this potentially curative option to younger adults, particularly in allogeneic (allo-) HCT. There is growing evidence to support the feasibility, tolerability, and relatively similar effectiveness of both autologous and allo-HCT in the geriatric population. In the allo-HCT setting, nonmyeloablative/reduced-intensity conditioning (NMA/RIC) has expanded the spectrum of patients that can be considered for this approach. Overall survival is largely affected by disease stage, performance status, and comorbidities rather than by chronological age per se. Comprehensive geriatric assessment (CGA) is a promising tool that can uncover frequently undocumented vulnerabilities in an elderly transplant-eligible patient. Serial study of CGA throughout the peri-HCT period may help predict the short- and long-term impact of HCT on an older adult's functional status and quality of life. Further research is needed to evaluate whether early intervention to improve such vulnerabilities can improve survival and quality of life of these older patients.