Journal
BIOLOGY OF BLOOD AND MARROW TRANSPLANTATION
Volume 17, Issue 10, Pages 1528-1536Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.bbmt.2011.03.006
Keywords
Immune suppression; Practice variation; Physician survey; Graft-versus-host disease
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Funding
- NCI NIH HHS [P30 CA076292] Funding Source: Medline
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Practice variation in transplant physician management of immune suppression (IS) after allogeneic hematopoietic cell transplantation (HCT) is anticipated to have important consequences, but has not been characterized to date. We conducted a national survey of transplant physician members of the American Society for Blood and Marrow Transplantation to discern variation in IS management, characterize the burden of graft-versus-host disease (GVHD) emerging in the setting of IS taper, and describe the proportion of HCT recipients who successfully discontinue IS by 2 and 5 years post-HCT. There was marked heterogeneity in IS discontinuation practice, with variation in initiation of taper, sequence of agents tapered, frequency of changes, and strategy utilized. Twenty-five percent reported no consistent strategy in their usual practice. Confidence in therapeutic decision making was limited. The majority indicated that they could not predict who would develop GVHD on taper of IS, and reported a resultant burden of both acute and chronic GVHD (aGVHD, cGVHD) emerging or recurring in the setting of IS taper. HCT physicians projected rates of IS discontinuation that increased from 2 to 5 years post-HCT, and differed significantly according to donor relation and stem cell source utilized. The marked variation in practice, burden of GVHD emerging in the setting of IS taper, and limited confidence in therapeutic decision making all highlight shortcomings in an essential component of HCT physicians' scope of practice. These data argue for more rigorous study of IS management post-HCT so that evidence-based practice guidelines can be developed. Biol Blood Marrow Transplant 17: 1528-7536 (2011) (C) 2011 American Society for Blood and Marrow Transplantation
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