Homebound Autologous Hematopoietic Cell Transplantation for Plasma Cell Disorders in an Urban Setting Is Safe for Patients and Preferred By Patients and Caregivers
Authors: Landau Heather J. , Shah Gunjan L. , Reeds Morgan , Hilden Patrick , Andrejko Marci , Applebaum Alison , Batalha Jason , Cazeau Naomi , Chung David J. , Cortes Melissa , Gerber Jenkelowitz Juliet , Kiss Christina , Devlin Sean M , Lestrange Nicole , Lynch Kathleen , McElrath Courtney , Palumbo Dayna , Rodriguez Elizabeth Schmidt , Scordo Michael , Giralt Sergio 
Published: October 2019

Abstract
Background: Autologous hematopoietic stem cell transplantation (AHCT) is a mainstay of therapy for eligible patients with multiple myeloma (MM) and light chain (AL) amyloidosis and confers a progression free and overall survival benefit in most studies. Yet, AHCT requires specialized care at a transplant center and investment from patients and caregivers. To decrease the burden of therapy and increase access to AHCT, we studied the safety and feasibility of delivering transplant care in a homebound setting.
Methods: Eligible MM and AL patients undergoing AHCT resided in designated zip codes, had 24hr caregiver support, adequate Wi-Fi connection, Sorror Co-morbidity index ≤ 3 and Karnofsky performance status ≥ 80. Following high-dose melphalan (day -2) and stem cell reinfusion (day 0) in the outpatient clinic, protocol-specific homecare commenced (day +1) until engraftment. Care included daily assessments by advanced practice providers and interventions were delivered by registered nurses in the afternoons. Attending physicians communicated through telemedicine daily. Due to regulation, blood products required infusion in the outpatient clinic. Patient and caregiver quality-of-life (QOL) and satisfaction were assessed using patient/caregiver reported outcome instruments (Functional Assessment of Cancer Therapy (FACT)-General and FACT-Bone Marrow Transplant (FACT-BMT) questionnaires, MD Anderson Symptom Inventory (MDASI), Caregiver QOL Index--Cancer (CQOL-C) and satisfaction surveys). Video diaries and one-on-one interviews provided detailed qualitative evaluations. The primary objective was feasibility defined by readmission within 21 days of AHCT. Descriptive statistics were used to describe the population, toxicities and QOL measures.
Results: Between 2/2016 - 5/2018, 15 patients (60% MM; 40% AL) and caregivers met inclusion criteria. Patient median age was 62 years (range 40-71) with 80% male. AHCT was part of 1st line therapy in most patients (N=13); 2 with MM underwent 1st AHCT as part of salvage. Melphalan dose was 200mg/m2 (N=11) or less (N=4) in patients ≥70 or AL. All patients received pegfilgrastim 6mg on day +1; thereafter, intravenous fluids and electrolytes were the most common interventions administered at home. During homecare, a median of 2 (range 1-3) visits to clinic were required for platelet transfusions and only 1 patient required 1 red cell transfusion. Median time to neutrophil and platelet engraftment was 9 (range 8-10) and 18 (range 11-22) days, respectively. Overall 7/15 (47%) (95% CI; 0.21-0.73) of patients were admitted for a median of 4 (range 3-10) days. Admission occurred on day +7 (N=5), day +8 (N=1) and day +12(N=1). Reasons for admission included neutropenic fever (NF) (N=2), fever attributed to engraftment syndrome (N=2), diarrhea (N=2), and dehydration (N=1). Only 1 (7%) patient had a documented infection (C. difficile) and 1 admitted for NF required ICU care (2 days) for GI bleed. Overall, 47% of patients experienced grade ≥ 3 non-hematologic toxicities. There were no deaths on study.
Results of thematic content analysis of transcripts for patient-caregiver dyads demonstrate that while feeling challenged, caregivers derived satisfaction from assisting with the patient's recovery through maintaining hygiene of the home environment, managing dietary needs and responding to symptoms. Caregivers reported that living with the patient during AHCT strengthened their relationship by being able to provide for one another in unanticipated ways. Patients reported positive support from the medical team, connection to the world and the ability to engage in relaxing activities and physical exercise as important during AHCT. Caregivers and patients unanimously described the homebound program as preferable to a hypothesized experience in the hospital and satisfaction surveys indicated favorable responses (Figure). Symptom burden and QOL data are being analyzed.
Conclusion: Homebound AHCT is safe and feasible with less than half of patients requiring inpatient admission. Patients required an average of two outpatient visits while receiving homebound care for blood products. Qualitative evaluations of the program by patients and caregivers were overwhelmingly positive. Based on these results we intend to expand the homebound program and investigate other potential biologic (microbiota diversity preservation) and economic benefits.

Disclosures
No relevant conflicts of interest to declare.