Assessment of Late Mortality Risk After Allogeneic Blood or Marrow Transplantation Performed in Childhood
Authors: Anna Sällfors Holmqvist, Yanjun Chen, Jessica Wu, Kevin Battles, Ravi Bhatia, Liton Francisco, Lindsey Hageman, Michelle Kung, Emily Ness, Mariel Parman, Donna Salzman, Aman Wadhwa, Jeanette Falck Winther, Joseph Rosenthal, Stephen J. Forman, Daniel J. Weisdorf, Saro H. Armenian, Mukta Arora, Smita Bhatia
Journal: JAMA Oncology (2018)

<h3>Importance</h3> Allogeneic blood or marrow transplantation (BMT) is a curative option for malignant and nonmalignant diseases of childhood. However, little is known about trends in cause-specific late mortality in this population during the past 3 decades. <h3>Objectives</h3> To examine cause-specific late mortality among individuals who have lived 2 years or more after allogeneic BMT performed in childhood and whether rates of late mortality have changed over time. <h3>Design, Setting, and Participants</h3> A retrospective cohort study was conducted of individuals who lived 2 years or more after undergoing allogeneic BMT performed in childhood between January 1, 1974, and December 31, 2010. The end of follow-up was December 31, 2016. <h3>Exposure</h3> Allogeneic BMT performed in childhood. <h3>Main Outcomes and Measures</h3> All-cause mortality, relapse-related mortality, and non–relapse-related mortality. Data on vital status and causes of death were collected using medical records, the National Death Index Plus Program, and Accurint databases. <h3>Results</h3> Among 1388 individuals (559 females and 829 males) who lived 2 years or more after allogeneic BMT performed in childhood, the median age at transplantation was 14.6 years (range, 0-21 years). In this cohort, there was a total of 295 deaths, yielding an overall survival rate of 79.3% at 20 years after BMT. The leading causes of death were infection and/or chronic graft-vs-host disease (121 of 244 [49.6%]), primary disease (60 of 244 [24.6%]), and subsequent malignant neoplasms (45 of 244 [18.4%]). Overall, the cohort had a 14.4-fold increased risk for death (95% CI, 12.8-16.1) compared with the general population (292 deaths observed; 20.3 deaths expected). Relative mortality remained elevated at 25 years or more after BMT (standardized mortality ratio, 2.9; 95% CI, 2.0-4.1). The absolute excess risk for death from any cause was 12.0 per 1000 person-years (95% CI, 10.5-13.5). The cumulative incidence of non–relapse-related mortality exceeded that of relapse-related mortality throughout follow-up. The 10-year cumulative incidence of late mortality decreased over time (before 1990, 18.9%; 1990-1999, 12.8%; 2000-2010, 10.9%;<i>P</i> = .002); this decrease remained statistically significant after adjusting for demographic and clinical factors (referent group: &lt;1990; 1990-1999: hazard ratio, 0.64; 95% CI, 0.47-0.89;<i>P</i> = .007; 2000-2010: hazard ratio, 0.49; 95% CI, 0.31-0.76;<i>P</i> = .002;<i>P</i> &lt; .001 for trend). <h3>Conclusions and Relevance</h3> Late mortality among children undergoing allogeneic BMT has decreased during the past 3 decades. However, these patients remain at an elevated risk of late mortality even 25 years or more after transplantation when compared with the general population, necessitating lifelong follow-up.