Omidubicel (Expanded Cord Blood) for use in Allogeneic Transplant

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Introduction

Umbilical Cord Blood (UCB) has been used as a source of stem cells in allogeneic (donor) transplants since the late 1980s. When doing a transplant using bone marrow (BM) or peripheral blood (PB), it is necessary to have a close Human Leukocyte Antigen (HL) type match to reduce the chance of the transplant being rejected and the risk of Graft-Versus-Host Disease (GVHD). Since UCB contains more naïve cells, it does not need to match nearly as well to be used as a source of stem cells in a transplant. This is important for people who do not have good unrelated donor matches in the registries, in particular minorities who tend to be underrepresented in the registries and people of mixed race.

Since a single UCB unit contains significantly fewer stem cells than a PB or BM graft, it takes longer for a patient’s white blood (neutrophil) count and platelet count to recover when getting a UCB transplant. This is a fundamental problem of using UCB for transplants. This means that patients are at risk of infections for a longer time. There have been a number of attempts to expand the number of cells in a cord blood unit, dating back at least 20 years, but none have managed to be approved by the U.S. Food and Drug Administration (FDA).

FDA Approval

The FDA approved omidubicel to reduce time to neutrophil recovery in April, 2023. This was based on a Phase 3 randomized study (reported in Omidubicel vs standard myeloablative umbilical cord blood transplantation: results of a phase 3 randomized study) that compared the outcome of patients who received omidubicel versus those who underwent conventional cord blood transplants.

Comparison of Omidubicel and standard Cord Blood transplants

The trial enrolled 125 patients who were randomly assigned to receive omidubicel (62 patients) or a standard UCB transplant (63). Patients in the standard transplant arm received a double cord transplant if the initial CB unit was not well matched or contained a smaller number of cells. 67% of those patients received a double cord transplant, 33% a single cord transplant. Three alternative myeloablative conditioning regimens were allowed and different regimens to prevent GVHD.

The time to white blood cell recovery (a neutrophils count of at least 500) and platelet recovery (a count of at least 20) was much faster in patients who received omidubicel. Patients who received omidubicel had neutrophil recovery a median of 10 days faster than patients who received a standard UCB. Platelet recovery was a median of 13 days faster for those receiving omidubicel. Patients who received omidubicel spent a median of 11 fewer days in the hospital in the first 100 days post-transplant and experienced fewer serious infections..

There are a couple of drawbacks to omidubicel. About 10% of the CB units had manufacturing or production failure. In addition, it takes about 21 days to manufacture omidubicel. These issues resulted 14% of patients not being able to receive the therapy.

Discussion

Omidubicel is a significant advance in the use of cord blood for transplants. There was a big reduction in hospital stays and infections. There may be a survival benefit with omidubicel., the study was too small to determine if there was a statistically significant increase in survival, although there seemed to be a trend toward better survival. The authors of the paper in Blood , state: “The results suggest that omidubicel may be considered as a new standard of care for adult patients eligible for UCBT”. I think this probably is an understatement and centers that use cord blood in adults and older children will rapidly start using omidubicel. No doubt there will be a high price for omidubicel, but this is likely to be balanced out by reduced number of days in the hospital.

A major question that remains unanswered is how omidubicel will now compare to transplants using an unrelated donor or a half-matched family member (haploidentical). My guess is that most centers that do not do cord blood transplants in adults will continue to use unrelated or haploidentical donors. Probably, in a few years there will be a comparison done, at least using data from transplant registries.

I asked Karen Ballen, M.D. Chief, Hematology/Oncology, University of Virginia Cancer Center for comment on omidubicel (I would also like to thank her for graciously providing comments on this article):

Omidubicel is the first product approved by the FDA for expansion of a stem cell transplant graft, in this case cord blood. The randomized clinical trial showed an advantage in neutrophil and platelet engraftment and days in the hospital. There was no survival benefit, which could potentially limit use. The cost of the product is unknown. Another drawback is the 2.5 to 3 weeks needed to manufacture. Nonetheless, this represents a major advance in the cell therapy field.

Further Reading

Rezafungin for the Treatment of Candidemia and Invasive Candidiasis in Adults

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Introduction 

I was the patient representative on the FDA Advisory Antimicrobial Drugs Advisory Committee (AMDAC) that met on January 24, 2023, to consider whether to recommend the approval of a new anti-fungal drug Rezafungin. The indication was the treatment of candidemia (an infection of a fungus, Candida in the blood) and invasive candidiasis (a systemic infection with Candida). This is a summary of my thoughts on the meeting and Rezafungin.

I have to say that I was a little bit out of my element at this meeting. I originally thought that the topic of the meeting was going to be fungal infections after a transplant or chemotherapy or preventing fungal infections. However, patients with quite a few underlying conditions (including having had chemo and/or a transplant) who had Candidemia or Invasive Candidiasis were included in this indication. There is a separate, ongoing trial looking at preventing fungal infections in transplant patients using Rezafungin. 

Overview of the Rezafungin Trials 

The first-line treatment for Candida is with antifungal drugs in the echinocandin class. The existing echinocandins are Micafungin (Mycamine), Eraxis (Anidulafungin) and Canicidas (Caspofungin). Rezafungin is an addition to that class, derived from Anidulafungin, but modified so it can be given weekly instead of daily. 

There were two clinical trials that formed the basis of the evidence for Rezafungin. The trials compared Rezfungin to Caspofungin. The first trial called STRIVE (which I think stands for something, although I am not sure what) was a Phase II (smaller) trial that compared two dosages of Rezafungin (both had a 400 mg initial dose, followed by weekly doses of either 400 mg or 200 mg) against Casofungin. After the first part of the trial, it was determined that 400/400mg dosing was no more effective than the 400/200 dosing, so the latter was used for the rest of the trial.  The trial enrolled 76 patients in the 400/400 Rezafungin group, 46 in the 400/200 group and 61in the caspofungin group.

The second trial was a larger Phaee III mutli-center, randomized double blind trial, called ReSTORE (I am also not sure what this stands for). It was designed to show that Rezafungin was non-inferior (i.e. at least as good as) Caspofingin. This trial used the 400/200 mg dosing. This trial enrolled 93 patients in the Rezafungin arm and 94 in the Caspofungin arm. 

In both trials, patients in the Rezafungin arm received daily infusions, giving Rezafungin on the first day and a placebo (saline alone) infusion on the next 6 days. Patients in the Capofungin arm who responded well after 3 or more days from the start of the trial could be switched to oral fluconazole “stepdown” therapy (fluconazole is an antifungal in a different class that is available orally). Patients in the Rezafungin arm would receive a placebo pill if they were deemed to be appropriate for stepdown therapy.  

FDA generally requires 2 well done Phase III trials. Given that there is an “unmet need” for better antifungal drugs, FDA used a “flexible development program” that requires less evidence for an approval. In this case, the approval requested was for a “limited use indication”.  Although there were some questions about the quality of the data in some cases, overall, the committee agreed that there did not seem to be any significant safety concerns (at least compared to Caspofungin) and Rezafungin seemed to have similar efficacy. 

Interesting Notes from the Meeting 

If you are interested in the details of trials, you can dive into the briefing materials. I will point out some interesting bits in this section. 

One area of concern for echinocandins is infusion reactions. In the ReSTORE trial there were no infusion reactions in the Caspofungin arm while there were 4 patients who had reactions in the Rezafungin arm. However, 2 of the patients who had reactions, had them on Day 3, a day on which they would have been getting a placebo. Overall, while medical personnel who are prescribing and giving Rezafungin should be on the lookout for infusion reactions, I don’t think it is a major concern. 

There is some hope that Rezafungin would be useful for deep tissue (intraabdominal and peritoneal) invasive candidiasis. This is based in part on the fairly large initial (loading dose) as well as the long-lasting effects of the drug. However, there is little data to back that up as only a few patients have gotten the drug for deep tissue infections. 

The FDA noted that in the STRIVE study, the patients who were in the Rezafungin 400/200 dose arm had a higher chance of mycological eradication (that is cultures for Candida were negative) at day 5 (82.6%) compared to the patients in the 400/400 dose arm (71.7%). However, at day 5, patients in both arms had received the exact same amount of the drug (400 mg, in the first dose). I am not sure what to make of this anomaly. 

Conclusion 

We recommended 14-1 for approval. My opinion is that Rezafungin is a useful drug, comparable to the existing drugs in the echinocandins class, with a modest benefit – weekly dosing instead of daily. In the discussion, it was felt that the best candidates initially for this drug are patients who would likely have difficulty coming in for daily infusions, which was generally not a population treated in the trial, as all patients received daily infusions of one of the drugs or an infusion of a placebo. It will be interesting to see if Rezafungin does work better than the other drugs for deep tissue infections. 

Further Reading 

Note: The FDA documents (including the ones from the Cidara) seem to go away after a while (perhaps a year, I am not sure). 

Cidara Briefing Document for AMDAC meeting January, 24, 2023, the briefing document from Cidara on Rezafungin.(accessed March 12, 2023) 

FDA Briefing Document for AMDAC meeting, January 24, 2023, the FDA’s briefing on Rezafungin, there is a minor errata to the document. 

January 24, 2023: Antimicrobial Drugs Advisory Committee Meeting Announcement, more information about the meeting, as well as other documents (the FDA slides, the committee members, the above briefing documents). 

Echinocandins, a listing of the existing Echinocandins from drugs.com 

Cidara Therapeutics and Melinta Therapeutics Announce FDA Advisory Committee Recommends Approval of Rezafungin for the Treatment of Candidemia and Invasive Candidiasis, a press release from Cidara on the recommendation to approve Rezafungin or treatment of candidemia and invasive candidiasis 

30-Year Acute Myeloid Leukemia Survivor Shares His Journey

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30-Year Acute Myeloid Leukemia Survivor Shares His Journey from Patient Empowerment Network on Vimeo.

What might acute myeloid leukemia (AML) patients experience for symptoms, treatment, and coping with AML? AML patient and Empowerment Lead Art Flatau shares the experience of his AML journey from diagnosis, through treatment and AML survival, and advancements in AML treatments.

Art also shares his empowerment advice for patients and care partners to ensure optimal care and how he has found a sense of purpose in patient advocacy efforts.

See More from [ACT]IVATED AML

Related Resources:

Empowered AML Patient: Ask the AML Expert

Empowered AML Patient: Ask the AML Expert 

 How an AML Survivor’s Resilience Saved Her Life

How an AML Survivor’s Resilience Saved Her Life 

 Advice for Acute Myeloid Leukemia Patients Seeking a Clinical Trial

Advice for Acute Myeloid Leukemia Patients Seeking a Clinical Trial 

Transcript:

My name is Art, and I live in Austin, Texas. In 1992, I was 31 and married with two young children. I was in graduate school and working full-time. For a couple weeks, I had been feeling tired and had been running a low-grade fever. I also had a lot of bruises, probably because I was playing rugby at the time. I thought the fatigue was because I was overworked and getting  too little sleep.

On Saturday, I had a rugby game but was too tired to play more than a few minutes. The next day, I was too tired to do much. My wife and I decided that I would go to the doctor on Monday. 

Monday morning, I woke, and there was blood on my pillow as my gums were bleeding. My wife wanted to take me to the ER, but I convinced her to just call our doctor. I went to the doctor later that morning. She noted my symptoms, did a quick exam, and sent me for blood work. After lunch, she called and said I needed to go to the hospital and see a hematologist. I knew I was in trouble.

We talked to the doctor and he said, “We have to see what kind of leukemia you have.” What a shock.  I knew that I was sick with something I had not had before. The fact that it was cancer was a shock. I didn’t know that there were different types of leukemia but soon found out that I had acute myeloid leukemia (AML).

That evening, I received platelets and red blood transfusions. The next morning, I had a bone marrow biopsy, more platelets, and surgery to put in a central line. That afternoon, less than 24 hours after hearing the word leukemia in reference to me, I started chemotherapy. This was all overwhelming. We had no way to understand what our options were or to get a second opinion.

Three-and-a-half weeks later, I got out of the hospital with no hair, 25 pounds lighter, a lot weaker but alive. I had more chemotherapy in the next few weeks and more hospitalizations. A few months later, I was finished with chemo. I regained some strength, regrew my hair, and tried to get my life back to normal.

In early 1993, about 9 months after being diagnosed, we got another shock, I had relapsed. I needed to have a bone marrow transplant. Although we had a little time, a few days to figure out where to go for a transplant, we were again struggling to understand the process. We were also struggling to figure out how to move to Dallas for three more months for the transplant. The transplant was a long grind, a month or so in the hospital, a couple of months of going to the outpatient clinic two to three times a week, but we made it through. 

Now, 30 years later, I’m still around. My children graduated from high school, college, and graduate school and have successful careers. My wife and I are empty-nesters.  I am still working but hoping to retire in a few years. Although I consider myself very lucky to have survived and have had relatively few side effects, I do have some side effects to deal with, including low testosterone.

Some things that I’ve learned during my AML journey include: 

  • AML is a rare disease: The good news is that over the last several years a lot of new treatments have been discovered for AML. These new treatments are leading to more people surviving AML. However, these new treatments are evolving rapidly. It is important to find a cancer center and doctors who treat a lot of patients with leukemia. 
  • Consider volunteering: Advocacy work is an excellent way to help yourself and to support other patients and continued research efforts.
  • If something doesn’t feel right with your health, advocate for yourself and ask for further testing.

These actions (for me) are key to staying on my path to empowerment.

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Ivosidenib and Azacitidine for IDH1-Mutated AML

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There has been another significant advance in the treatment of Acute Myeloid Leukemia (AML) at least for the small subset of patients (6-10%) who have a mutation in one of their genes called IDH1 (isocitrate dehydrogenase 1).   

Until 5-7 years ago, the typical initial treatment (called induction) for patients with AML consisted of relatively high doses of cytarabine (Ara-C) and another chemotherapy called an anthracycline (usually either daunorubicin or idarubicin).  Cytarabine is given as a continuous infusion for seven days and a daunorubicin or idarubicin is given on the first 3 days (this is commonly referred to as “7 + 3“regimen). There are other regimens that are sometimes used although most contain cytarabine.  This regimen is effective, but quite toxic and usually reserved for healthier fitter patients (generally under 65 without comorbidities like diabetes, or certain heart conditions). 

In 2018, the Food and Drug Administration (FDA) approved venetoclax and azacitidine for use in older patients or those with comorbidities.  Earlier this year, FDA approved Iivosidenib (used in combination with azacytidine) for newly diagnosed AML patients an IDH1 mutation.  The approval was for “adults 75 years or older, or who have comorbidities that preclude use of intensive induction chemotherapy”.  This was based on a clinical trial reported in the New England Journal of Medicine (NEJM): Ivosidenib and Azacitidine in IDH1-Mutated Acute Myeloid Leukemia,.  Ivosidenib is not a brand new drug, it was approved in 2018 for relapsed or refractory AML. 

The current approval was based on a global, double-blind, randomized, placebo-controlled trial comparing AML patients with an IDH1 mutation treated with ivosidenib and azacytidine with patients treated with azacytidine alone.  The primary end point of the trial was event-free survival (EFS), defined as the time until treatment failure (i.e., the patient did not have complete remission by week 24), relapse or death.  The first group of patients, who received ivosidenib had an EFS at 12 months of about 37% versus 12% in the placebo group.  In addition, the median overall survival (that is half of the patients lived at least this long) was 24.0 months with ivosidenib and azacitidine versus 7.9 months with azacitidine alone.  This is a big difference, although there is still a lot of room for improvement.  In addition, there were fewer infections in the ivosidenib, group although there were more incidences of low white blood counts (neutropenia) and bleeding in that group. 

While this is good news, showing ivosidenib (Tibsovo) and azacitidine (Vidaza) is better than azacitidine alone, most patients with AML with an IDH1 mutation who are not good candidates for intensive induction chemotherapy during the time period of the trial would likely have been treated with azacitidine and venetoclax (Venclexta).  The combination has been shown to be much more effective than azacitidine alone.  My guess is that azacitidine alone was chosen as the comparison, since the ivosidenib trial started enrolling patients in March 2018 (presumably the protocol for the trial was completed several months before that) and venetoclax was not approved until November, 2018.  The question remains, which is better ivosidenib and azacitidine or azacitidine and venetoclax.  I believe we will probably never know.  Given that AML is already a rare disease and no more that 10% of AML patients have an IDH1 mutation, it is not likely such a trial would be done.  Instead, it seems more likely that trials will look at the 3-drug combination of ivosidenib, venetoclax and azacitidine.  Perhaps a trial with 3 arms may be done, comparing azacitidine with ivosidenib, or venetoclax or both.  I hope the 3-drug combination will be more effective than either ivosidenib or venetoclax combined with azacitidine.  If the side effects are not much worse, then standard therapy for AML patients with an IDH1 mutation who are not good candidates for intensive chemotherapy would become the 3-drug combination.  This would happen faster than first comparing ivosidenib to venetoclax and then comparing the better of those two to the 3-drug combination.   For younger healthier patients, ivosidenib is being combined with intensive chemotherapy in clinical trials.

Further reading: 

Ivosidenib and Azacitidine in IDH1-Mutated Acute Myeloid Leukemia, the original article from the New England Journal of Medicine (N Engl J Med 2022; 386:1519-1531). 

Ivosidenib and Azacitidine for IDH1-Mutated AML, mostly a repeat of the abstract of the above NEJM article, but also includes some commentary. 

Ivosidenib with Chemotherapy New Option for Some People with AML an article on Ivosidenib and Azacytidine from Cancer Currents: An NCI Cancer Research Blog. 

This AML Treatment Option is an Alternative to Induction Therapy an article on Ivosidenib and Azacytidine from PatientPower. 

FDA approves ivosidenib in combination with azacitidine for newly diagnosed acute myeloid leukemia an article about the drug approval, from Practice Update (registration may be required). 

Ivosidenib or enasidenib combined with intensive chemotherapy in patients with newly diagnosed AML: a phase 1 study, an article in Blood (Volume 137, Issue 13, April 1 2021) about a preliminary study of Ivosidenib and Enasidenib (for patients who have a mutation in IDH2) along with intensive chemotherapy (“7+3” induction, Ara-C consolidation). 

FDA grants regular approval to venetoclax in combination for untreated acute myeloid leukemia, an article from the FDA on the approval of Venetoclax for treating AML (October, 2020). 

FDA approves first targeted treatment for patients with relapsed or refractory acute myeloid leukemia who have a certain genetic mutation, an article from the FDA on the initial approval of Ivosidenib for treating AML (July, 2018).FDA approves first targeted treatment for patients with relapsed or refractory acute myeloid leukemia who have a certain genetic mutation, an article from the FDA on the initial approval of Ivosidenib for treating AML (July, 2018). 

Naïve T-cell Depletion in Donor Blood Stem Cell Transplant Patients 

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Introduction 

T-cell depletion is a strategy to remove T-cells from bone marrow or peripheral stem cells taken from a donor before they are given to a patient. T-cell depletion (TCD) has been around for quite some time, at least since the early 1980s. TCD decreases the risk of graft-versus-host disease (GVHD) and, in particular, deaths from GVHD. The goal is to also have similar survival to non-T-cell depleted transplants (sometimes referred to T-cell replete or T replete). This would be a significant advance. Removing only the naïve T-cells from the graft looks like a promising approach to achieve these goals. The recent article Naive T-Cell Depletion to Prevent Chronic Graft-Versus-Host Disease reports on a trial looking at the use of naïve T-cell depletion and comparing the results to historical controls.  

What are Naïve T-cells? 

I had not heard of naïve T-Cells before. According to an article from the National Cancer Institute (NCI) Can Chronic Graft-Versus-Host Disease Be Prevented? 

T cells are among the many types of immune cells that can attack cancer cells. But there are several subsets of T cells. Naive T cells have never encountered an antigen—a protein or other molecule that can provoke an immune response. For reasons that are not yet fully understood, they are more likely to react to healthy cells in the transplant recipient. 

I don’t know how naïve T-cells can be distinguished from other T-cells, but apparently this is possible. 

Problems with T-Cell Depletion 

TCD does significantly reduce the risk of GVHD and deaths from GVHD, however it is not without drawbacks.    There have been many attempts at T-cell depletion over the years, first removing all T-cells and more recently selectively removing some of the T-cells. However, most of the problems listed below have persisted to some degree: 

  1. Graft failure is generally higher in TCD transplants than in non TCD transplants  
  2. Epstein-Barr virus–associated lymphoproliferative disorders (LPD). This is a rare side effect of T-replete transplants, but is much more common in TCD transplants (as well as solid organ transplants) Generally, the decrease in deaths acute GVHD are about equivalent in the increase in deaths LPD  
  3. There is a much higher rate of disease recurrence after TCD transplants. It is well established that patients who experience GVHD have a lower rate of relapse (this was known at the time of my transplant, almost 30 years ago). This is because of what is known as a graft-versus-leukemia (GVL) effect (or more generally as a graft-versus-tumor, GVT effect). The T-cells are causing GVHD by attacking the host cells in the patients.  Since any residual cancer cells are also recognized as foreign by the T-cells, they are destroyed as well.

Current Study 

For the most part the current study did not show the problems listed above. There were 138 patients with acute leukemia treated in this trial. There were 2 patients who experienced graft failure (< 2%). The incidence of Epstein-Barr virus (EBV) reactivation was rare, only 3 patients (2.3%) experiences this.  Only 1 required treatment with rituximab (Rituxan, which is one of the more effective therapies for EBV related LPD).  The overall incidence of relapse was 23%, which is in line with the expected relapse rate from T-replete transplants. The incidence of acute GVHD was low and most patients who experienced acute GVHD were treated successfully with steroids.  Only 7% of patients developed chronic GVHD (much lower than T-replete transplants), which also largely responded to steroids. 

Future Reading 

  1. Naive T-Cell Depletion to Prevent Chronic Graft-Versus-Host Disease, the full article from the Journal of Clinical Oncology, from April 2022 (registration may be required). 
  2. A blog article from the National Cancer Institute (NCI) Can Chronic Graft-Versus-Host Disease Be Prevented? This is quite interesting and not nearly as technical as the journal articles. 
  3. An older abstract (2020) from the same author, Marie Bleakley: Naive T-cell depletion in stem cell transplantation  
  4. Naive T Cell Depletion for Preventing Chronic Graft-versus-Host Disease in Children and Young Adults with Blood Cancers Undergoing Donor Stem Cell Transplant, the clinical trial description from the National Cancer Institute 
  5. The history and future of T-cell depletion as graft-versus-host disease prophylaxis for allogeneic hematopoietic stem cell transplantation  from the journal Blood.  A technical and older (2001) article but may be interesting to some. 
  6. Does GVHD Ever Resolve in Acute Myeloid Leukemia Patients?

References

Naive T-Cell Depletion to Prevent Chronic Graft-Versus-Host Disease Marie Bleakley, Alison Sehgal, Stuart Seropian, Melinda A. Biernacki, Elizabeth F. Krakow, Ann Dahlberg, Heather Persinger, Barbara Hilzinger, Paul J. Martin, Paul A. Carpenter, Mary E. Flowers, Jenna Voutsinas, Theodore A. Gooley, Keith Loeb, Brent L. Wood, Shelly Heimfeld, Stanley R. Riddell, and Warren D. ShlomchikJournal of Clinical Oncology 2022 40:11, 1174-1185

Low Testosterone in Cancer or Transplant Survivors

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I was one of the authors (out of more than 50) of a review article on male specific late effects in stem cell transplant patients [1]. The article looked at many late effects in male transplant survivor. This post is a summary on one late effect, hypogonadism (that is low testosterone) as well as my opinion about the recommendations on screening for low testosterone.

We do not know much about low testosterone in cancer survivors or transplant survivors. There is a significant increase in the incidence of low testosterone but the size of the increase in transplant survivors is not well understood. Symptoms related to low testosterone include: “loss of body hair, small testes, and ED (Erectile Dysfunction)”. Other symptoms that may be signs of low testosterone but may be signs of other problems include: “loss of libido, anemia, fatigue, lack of motivation, reduced muscle mass, and increased fat mass” (I don’t really know what “lack of motivation” means). The article recommends: “testing and consideration of hormone replacement therapy based on symptoms”. This is similar to what has been recommended in the past [2].

In 2016, some 23 years after my bone marrow transplant (BMT) I was diagnosed with low testosterone. I had finally asked one of my doctors to get tested and my testosterone level was 192 (my free testosterone was also low, and this is useful for the doctors, but I won’t mention it anymore). The normal level of testosterone is between 300 and 1000 nanograms per deciliter (ng/dL). [3] While I had symptoms, low libido, loss of muscle mass and fatigue primarily, no doctor had asked about those symptoms, and I had not thought about them as more than getting old.

I started on testosterone replacement, and it has made a huge difference. The biggest difference in my mind is less fatigue. One of the more common side effects of testosterone replacement is it can raise your red blood count (I like to call this an “effect”). Since a year or two after my transplant, my hemoglobin was on the low side (typically 12-13, normal for men is 13.2-16.6) and my hematocrit was generally between 37 and 40% (normal for men is 38.3-48.6%) [4]. A few years ago, at my annual exam my hematocrit was close to 35%. I went to see an oncologist (the oncologist who treated me is no longer seeing patients in the office). A whole bunch of tests were run, but not a testosterone test and nothing abnormal other than my red blood values was found. After starting testosterone replacement, my hematocrit is 43-45% and my hemoglobin is 14-15. The biggest change for me is that I have far less fatigue presumably because I have more red blood cells.

Testosterone levels naturally decrease with age. The folklore is that the testosterone level decreases about 1% per year from age 30 or so. [5] Other sources say from age 20. I believe this means that if you level is 800 at age 30 (there seems to be little data for a “normal” level at different ages), it will go down about 8 units per year (1% of 800). So, at age 80, the level would be around 400 (if this actually means a decrease of 1% of the current level every year, it will go down to about 480 at age 80). If the level was 600 at age 30, then it would be about 300 at age 80 (or around the low end of the normal range, which I imagine is about the average level for 80-year-old men). What if a 30-year-old had a testosterone level of 800 and then was diagnosed with AML and had chemotherapy and a transplant? Perhaps 2 years post-transplant is now 500, which is normal. There seems to be no data on testosterone levels in long term transplant survivors. However, if this goes down 8 units a year (this seems to be as good a guess as any), then after 25 years the level would be 320 and after 30 years it would 280, which is less than the 80-year-old man without cancer. It is important to state that there appears is no data to support or refute this scenario. Still my belief is that this is essentially what happened to me. My guess is that quite a few male transplant survivors have a testosterone level in the normal range 1 or 2 years post-transplant (although most will not have it tested) but will eventually have hypogonadism and likely not realize it.

While there is a lot we do not know about testosterone levels in transplant survivors (or for that matter healthy men), there is one thing we do know. “The majority of health care professionals do not address [sexual dysfunction]” [1]. In my mind this calls into question the recommendation to test testosterone levels “based on symptoms”. Most doctors do not seem to ask about symptoms specific to low testosterone and the other symptoms are non-specific. It seems to me that not testing testosterone levels at say 1 or 2 years post-transplant is likely causing harm to some male long term survivors. A better guideline would be to routinely test 1 or 2 years post-transplant and then again if symptoms warrant.

The BMT Infonet as part of their Celebrating a Second Chance at Life Symposium had a really good workshop on Sexual Concerns in Men after Transplantation by John Mulhall MD, from Memorial Sloan Kettering Cancer Center. You will have to register before viewing the replay of this workshop. While it covered other topics, there was a lot of information about low testosterone 

Contact Art Flatau, flataua@acm.org

Bibliography

[1] Phelan, R et. al., “Male-Specific Late Effects in Adult Hematopoietic Cell Transplantation Recipients: A Systematic Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complica,” Transplantation and Cellular Therapy, 2021.

[2] Navneet, Majhail S.; et. al., “Recommended Screening and Preventive Practices for Long-Term Survivors after Hematopoietic Cell Transplantation,” Biology of Blood and Marrow Transplantation, vol. 18, no. 3, pp. 348 – 371, 2012.

[3] Icahn School of Medicine at Mount Sinai, “Testosterone,” [Online]. Available: https://www.mountsinai.org/health-library/tests/testosterone

[4] Mayo Clinic, “Complete Blood Count,” [Online]. Available: https://www.mayoclinic.org/tests-procedures/complete-blood-count/about/pac-20384919

[5] Mayo Clinic, “Testosterone therapy: Potential benefits and risks as you age,” [Online]. Available: https://www.mayoclinic.org/healthy-lifestyle/sexual-health/in-depth/testosterone-therapy/art-20045728

[6] WebMd, “Is Testosterone Replacement Therapy Right for You?,” [Online]. Available: https://www.webmd.com/men/guide/testosterone-replacement-therapy-is-it-right-for-you

Introducing Art Flatau, AML Empowerment Lead

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I have decided to try my hand at writing a regular blog.  I hope to write a post every month or so. This first post is something of an introduction.  You can read more of my background on my PEN Empowerment Lead page. I suppose I should mention that I am not a medical doctor and am not giving medical advice. I have in the past written a very occasional blog, largely summarizing conferences or meetings I have attended (Art Flatau’s Blog on Leukemia). My plan is to mostly write about new advances in AML treatment and stem cell transplants (including other cellular therapy like CAR T-cell).  However, I also want to write some about my own experience, particularly dealing with late effects. 

I am an AML and bone marrow transplant survivor. My interests are in new advances in AML treatment including stem cell transplants. As a long-term survivor (the 29th anniversary of my transplant was last month, February 2022) I am also interested in late effects. I have a few ideas currently on subjects I would like to explore further, including: 

Let me know if you have topics that you are interested in. I cannot promise to write about them there are lots of interesting topics in this area that I know little about.