Barriers to Autologous Stem Cell Transplantation As Consolidation for Primary Central Nervous System Lymphoma (PCNSL) in HIV Positive Patients in a Minority Rich Cohort in the Bronx, New York

Background HIV-infected individuals have a higher incidence of primary CNS lymphoma (PCSNL) than the general population although it is declining now with the use of highly active antiretroviral therapy. Autologous stem cell transplantation is a commonly used consolidative treatment for PCNSL and is widely recommended as it offers the longest sustained remission when compared to other modalities. Access to this treatment modality has been hampered by social, race, ethnic, demographic and socioeconomic determinants. The impact of HIV status on access to autologous stem transplantation for PCNSL has not been previously studied in our community in the Bronx which has been disproportionately affected by this condition experiencing one of the highest rates of HIV infection than any other county in the nation.

Methods

We performed a retrospective analysis of our database from 06/01/2000 to 04/05/2022 for single patient records with a diagnosis of Primary CNS lymphoma (Diffuse Large B-Cell subtype). Patient characteristics were compared by using χ2 statistics and Mann-Whitney test and independent sample t test. The Kaplan-Meier method was used to calculate OS. For survival analyses, when there was an interval between last date known alive and first date known dead, death was assumed at the end of the interval. Socioeconomic status (SES) was measured using area deprivation index (ADI), composed of 17 categories, and validated for a range of health outcomes and disease domains. (Kind et al NEJM 2018).

Results

Fifty-three unique records were identified. Further evaluation revealed that 10 patients had diagnosis of HIV/AIDS (18.9%). Baseline characteristics analysis revealed that the vast majority were minorities; 5 (50%) Hispanics and 4 (40%) were African-American. (Table 1) Most patients were male 6 (60%). Notably there was a very significant difference in age with the HIV cohort being significantly younger (45 vs 64 years, p=0.006). At the time of PCNSL diagnosis, 40 % of the patients had virologically controlled HIV infection. In the HIV positive cohort, 4 (40%) of patients were not eligible for treatment due to poor performance status. (Table 2) HIV positive patients were significantly less likely to receive induction treatment with methotrexate based regimen followed by consolidation with ASCT than the HIV negative patients. (p= 0.02) In a logistic regression model, factors like race/ethnicity and SES did not affect access to ASCT while HIV positive status was significantly associated with decreased access to ASCT (p=0.01) in a multivariate analysis. To evaluate if these patients were candidates for this treatment modality, we determined the HCT-CI score (Hematopoietic Stem Cell Transplant Comorbidity Index) and was equal or greater than 3 in 50 % of the HIV patients. Nevertheless, none of the HIV positive patients received an ASCT whereas in the non-HIV population 32% of patients received an autologous graft. The reasons for not proceeding to an ASCT were: 1) Poor performance status (60%); 2) Poor candidate due to non-compliance (20%) and 3) Patient refusal (20%). Overall survival (OS) of the entire cohort at one year was 80%, while in the HIV positive population it was 65.5% (p value= 0.5). HIV positive patients had a higher early mortality of 22% within three months of PCNSL diagnosis compared to only 10% in their HIV negative counterparts. (Table 1) Seventy percent (n=7; 7/10) of the HIV patients were alive at the last follow-up compared to the 83.3% (35/43) of the HIV negative cohort.

Conclusion We observed that PCNSL affects disproportionately HIV positive individuals with poorly controlled infection and this cohort did not receive ASCT as consolidative treatment. Poor performance status, noncompliance and patient refusal were the main reasons for this fact.Continuous improvement in HIV infection treatments, patient education and access to health care resources are likely to result in optimal utilization of ASCT to maximize survival in this cohort.

Bazarbachi:ASH: Research Funding. Shastri:NACE: Honoraria; Rigel Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy; Kymera Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding. Verma:Novartis: Consultancy; Jannsen: Consultancy, Research Funding; Throws Exception: Current holder of stock options in a privately-held company; BMS: Research Funding; Medpacto: Research Funding; Prelude: Research Funding; Bakx Therapeutics: Consultancy, Current equity holder in private company; Eli Lilly: Research Funding; Ionctura: Research Funding; Stelexis Therapeutics: Current equity holder in private company, Honoraria; Curis: Consultancy, Research Funding.