Transplant & CAR T For Older Adults

Transcript:

Welcome

Hello, and welcome back to Thrive! — a BMT InfoNet podcast about navigating life before, during, and after stem cell transplant and CAR T-cell therapy. I’m Eric.

In today’s episode, our Deep Dive focuses on stem cell transplant and CAR T-cell therapy in older adults — and how care teams think about age, risk, and readiness when these treatments are being considered. We’ll explore what actually matters in those decisions, why age alone is rarely the deciding factor, and how patients and families can better understand the evaluation process.

But before we get there, we’re going to take a quick look at a recent headline that speaks to something refreshingly simple — and surprisingly powerful: how small amounts of daily movement can support long-term health.

Let’s get started.

A Few Updates

SMALL MOVEMENTS, MEANINGFUL IMPACT

For this week’s news update, we’re looking at new research that puts real data behind something many people intuitively feel — that even small amounts of movement can matter.

The piece, published by The Washington Post, draws on new research from a large analysis published in The Lancet, one of the world’s leading medical journals. Researchers analyzed data from more than 135,000 adults across the U.S. and Europe who wore activity trackers over an average follow-up of about eight years — so this wasn’t based on people guessing how much they moved. It was measured.

What they found was striking.

Adding just five minutes a day of moderate movement — something like a brisk walk — was associated with up to a 10 percent reduction in the risk of early death across the broader population. For the least active people, that same five minutes was linked to about a 6 percent reduction. And here's something that may matter even more for some of our listeners: simply reducing sedentary time — sitting less — by 30 minutes a day was associated with about a 7 percent reduction in mortality risk.

The lead researcher emphasized that every movement counts — that as soon as you start doing any activity, physiological changes begin. Your immune system responds, inflammation decreases, and over time those small shifts add up to real reductions in the risk of chronic disease.

What stands out about this research isn't intensity or performance. It's accessibility.

This wasn't about training harder or pushing limits. It was about what happens when people start where they are and add just a little more movement than they were doing before.

For transplant and CAR T survivors, that framing matters. Recovery, fatigue, and other health considerations can make traditional exercise advice feel overwhelming or out of reach. But this research reinforces that meaningful benefit doesn't require dramatic change — it can begin with small, manageable steps. Even getting up from the couch a little more often counts.

As always, any changes in activity should be discussed with your care team, particularly during recovery or if you're managing ongoing side effects. But this study supports something many clinicians emphasize: when appropriate, gentle and gradual movement can be part of supporting long-term health.

We'll include links to both the Washington Post article and the original Lancet research in the show notes if you'd like to learn more.

A Quick Note

Before we move on, just a quick note.

We’ve been hearing from listeners over the past few weeks — people reaching out with questions, suggestions, and notes about what they’re navigating after transplant or CAR T.

Some have asked about specific resources mentioned in earlier episodes. Others have shared topics they’d like us to explore — from AML in older adults, to transplant for non-cancer diagnoses, to long-term issues like kidney health. And some have simply written to say the conversations have been helpful, or that an episode arrived at the right moment for them.

As we move closer to the end of this first season of Thrive!, we’ve been spending some time reflecting on those messages — and on these conversations more broadly. And we wanted to open the door to hearing from you as well.

If something in the podcast has helped you — by answering a question, offering clarity, or helping you feel more prepared or supported — you’re welcome to share that with us.

We may include a few reflections in the final episodes as a way of acknowledging this community and the experiences you bring with you.

So, if you’d like to reach out — with a reflection, a question, or a topic you’d like us to explore — you can email us anytime at thrive@bmtinfonet.org

Something That May Help

You know, when someone is facing transplant or CAR T, one of the biggest questions can simply be: where does this care happen, and how do you even begin to compare options.

I want to share something that may help.

BMT InfoNet offers a Directory of Transplant Centers — a searchable resource designed to help patients, survivors, and care partners explore transplant and cellular therapy centers across the country.

The directory allows you to search by state, by adult or pediatric programs, and by specific transplant center. You can also search across more than 100 different diseases and conditions, which can be especially helpful when care decisions are tied to a particular diagnosis.

For many people, this resource serves as a starting point — a way to understand what options exist, identify centers with experience in a specific condition, and prepare more informed questions for conversations with referring physicians and transplant teams. It can also help when weighing practical considerations like distance from home, available support systems, and what follow-up care might look like after treatment.

As always, BMT InfoNet encourages patients to discuss transplant decisions with their care team, who can help interpret this information in the context of an individual’s health, diagnosis, and goals of care.

If this sounds like something that could be helpful for you or someone you care about, you’ll find a direct link in the show notes — or you can visit bmtinfonet.org and look under “Find a Provider” to access the Transplant Center Directory.

And for those exploring CAR T-cell therapy specifically, BMT InfoNet also offers a CAR T-cell Center Directory — a resource designed to help patients identify programs that provide CAR T-cell therapy. It’s something we’ll take a closer look at in a future episode.

Deep Dive - Transplant And CAR T In Older Adults: Benefits vs Risks

Seventy-five-year-old Martin didn’t think he was a candidate for a stem cell transplant. After all, he was “too old,” he joked—someone who still preferred reading the morning newspaper and using a landline phone he didn’t have to remember to keep charged.

But when his acute leukemia relapsed, his care team offered him something he didn’t expect: a real chance at long-term survival.

Before anyone talked about chemotherapy or donors, they talked about resilience. Could he walk for a few minutes without stopping? Was he eating well enough to hold his weight? How was his memory—especially under stress? And when he went home, who would be there to help him through the first hard stretch after discharge?

Taken together, those answers gave his team confidence that he could tolerate the treatment—not because of his age, but because he was fit, supported, and motivated.

His daughter puts it simply: “We went in thinking age would decide everything. Turns out, it didn’t.”

HOST INTRODUCTION 

Welcome to today’s Deep Dive. We’re exploring one of the most important—and most misunderstood—questions in transplant medicine: what makes an older adult a good candidate for stem cell transplant or CAR T-cell therapy, and just as important, what doesn’t?

This conversation is guided by the work and clinical experience of Dr. Amelia Langston — a transplant physician at the Winship Cancer Institute at Emory University, whose research and patient care focus on stem cell transplant and cellular therapies in adults of all ages.

Drawing from her BMT InfoNet 2025 Survivorship Symposium presentation, we’ll take some time together to walk through how transplant teams think about age, risk, and resilience—what they look at before treatment begins, how they weigh benefit against risk, and why age alone is rarely the deciding factor.

This isn’t about telling anyone what choice to make. It’s about helping patients and families better understand the questions being asked behind the scenes, so those conversations with care teams feel a little clearer—and a little less overwhelming.

Let’s begin with why this discussion matters.

SEGMENT 1: WHY AGE MATTERS— AND WHY IT DOESN’T

How do we approach someone who is an older adult and may benefit from a stem cell transplant or CAR T-cell therapy? It’s a question that matters not only to transplant teams, but to patients, families, and care partners who are trying to understand what’s possible—and what’s safe.

To begin answering that question, Dr. Langston starts by looking at how transplant physicians themselves are thinking about age and risk. She points to a recently published national survey focused on geriatric assessments in patients being considered for transplant or CAR T-cell therapy.

Dr. Langston
“It was a survey sent to transplant physicians around the country, and I think the bottom line was that transplant physicians have a lot of interest in geriatric assessment, but very limited knowledge and limited use of formal geriatric assessments in practice. But there was almost universal agreement that age is just a number, so it's really important that we think more deeply about how we approach our older patients.”

That shift in thinking matters because people are living longer. As a result, more people are reaching the age when blood cancers are more common—and more treatable than ever before. Many of these patients could benefit from a stem cell transplant or CAR T-cell therapy.

At the same time, there have been many advances that make stem cell transplants safer. Improvements in antibiotics and infection control, reduced-intensity chemotherapy regimens, and more effective immunosuppressive medicines have all changed what’s possible for older adults. Together, these advances mean that age alone is no longer the deciding factor it once was when considering advanced cancer treatments.

But look—progress doesn’t erase risk.

Stem cell transplant and cellular therapies remain the most powerful tools we have for treating blood cancers—and among the most complex and high-risk treatments used in care today.

Infections. Sepsis. Chemotherapy toxicities. Graft-versus-host disease. CAR T-cell complications like cytokine release syndrome and neurotoxicity. Steroid-related side effects. And the physical toll of long hospital stays. These risks are real, and they tend to affect older adults differently.

So the question becomes this: what separates an older adult who can come through treatment successfully from someone for whom the risks may outweigh the benefits?

According to Dr. Langston, the answer isn’t age itself—it’s resilience.

SEGMENT 2: THE REAL DECIDING FACTOR – RESILIENCE

Dr. Langston
“The name of the game here is resilience. The Oxford Dictionary defines resilience as the capacity to withstand or to recover quickly from difficulties. And it's this concept of resilience … is what separates the patient that is a good candidate for transplant or cell therapy from one where it may not be such a great idea.”

So what does resilience actually mean in a medical setting?

According to Dr. Langston, it isn’t a single test or score. It’s a combination of factors—each one offering insight into how well a person may tolerate treatment and recover afterward.

One of the first things transplant teams look at is comorbidities—other medical conditions that exist alongside the blood cancer itself. Heart disease, lung disease, diabetes, and similar conditions can all affect how much stress the body can safely handle.

Then there’s frailty, which goes beyond age or appearance. Frailty reflects strength, mobility, and physical reserve. During a long hospital stay—especially one involving intensive therapy—frail patients are at greater risk of muscle loss and physical decline.

Nutrition is another key piece. Patients going into transplant or cell therapy almost always experience a period of nutritional deficit. Starting treatment in a stronger nutritional state can make a meaningful difference in how well the body weathers that stress.

Dr. Langston also emphasizes cognitive status. Patients who enter treatment with cognitive impairment tend to have poorer outcomes than those with intact cognition. This affects everything from managing medications to recognizing complications early.

Then there’s care partner support—a factor that’s especially important for older adults. When both patient and spouse are aging, the care partner’s ability to provide physical help, manage medications, and respond quickly to problems becomes a critical part of the equation.

And finally, there’s financial stability, which is often underestimated. Transplant and cell therapy can require extended time away from home. Travel. Temporary housing. Out-of-pocket costs that add up quickly. Financial stress can directly affect recovery and a patient’s ability to stay on track with care.

Taken together, these factors form the foundation of the decision-making process. Not a single yes or no—but a careful assessment of whether the potential benefits of treatment outweigh the risks for that individual patient.

SEGMENT 3: HOW PROVIDERS MEASURE FITNESS IN OLDER ADULTS

To make the most informed decision possible, transplant teams don’t rely on a single test or threshold. Instead, they use a set of tools that help them understand how a patient’s body—and support system—may respond to treatment.

One of those tools is the Comorbidity Index. This is a well-established scoring system that assigns points for medical conditions unrelated to the blood cancer itself—things like heart disease, lung disease, or kidney problems. The higher the score, the greater the risk of complications after treatments like transplant or CAR T-cell therapy.

Another commonly used measure is the Karnofsky Performance Status, a 0-100 scale that rates how well someone is functioning in everyday life—whether they’re able to carry out normal activities independently, or whether illness is beginning to limit them. Older adults often fall somewhere in the middle of this scale, and even small differences can be meaningful when it comes to treatment planning.

Transplant teams also look more closely at fitness and frailty using simple, practical assessments.

One example is the three-minute walk test, which measures how far a person can walk in a short amount of time. It’s straightforward, but it provides valuable insight into mobility and physical reserve.

Another is the Instrumental Activities of Daily Living, or IADL. This assessment looks at how someone manages the practical tasks of daily life—using a phone, driving, emailing, cooking, shopping, and paying bills. These activities reflect both physical and cognitive function, and they can reveal challenges that aren’t always obvious in a standard medical appointment.

In many cases, patients undergo a formal geriatric assessment performed by a trained geriatrician, with a focus on cognition, mental health, and overall functional status. Nutrition assessments help determine whether a patient is entering treatment with enough reserve to handle periods of decreased intake. And caregiver assessments help teams understand who will be available to provide support after discharge—and how much help that person can realistically give.

Each of these tools captures a different piece of the picture. Taken together, they help clinicians understand not just whether treatment is possible—but how safely it can be pursued.

SEGMENT 4: WHAT OUTCOMES REALLY LOOK LIKE FOR OLDER ADULTS

Here’s where the discussion shifts from caution to optimism.

In data from the Center for International Blood and Marrow Transplant Research, looking at stem cell transplants for multiple myeloma, the message is striking: when older adults are carefully assessed and found to be fit, their outcomes closely mirror those of younger patients.

Dr. Langston
“… Across a range of ages, overall survival after transplant is no different for the younger patient versus the older patient across the spectrum of ages that encompass most myeloma patients. That's not to say that we aren't careful about assessing those older patients, but the fit older patient could certainly do very well with autologous transplantation.”

That same pattern shows up across other diseases.

In transplants using donor cells, called allogeneic transplants, among people with acute myeloid leukemia in first remission, there may be higher early risks—but over time, transplant can often offer better long-term survival than chemotherapy alone.

In CAR T-cell therapy for diffuse large B-cell lymphoma, patients over 65 can do just as well as younger patients when they’re thoughtfully selected.

The takeaway is clear: fit older adults can benefit just as much as younger ones—and in some cases, even more.

SEGMENT 5: WHAT PROVIDERS CAN DO TO IMPROVE OUTCOMES

Dr. Langston is clear that improving outcomes doesn’t begin on transplant day — it begins long before treatment ever starts.

For providers, that means taking responsibility for the full picture of a patient’s health and life circumstances. Managing existing medical conditions. Bringing in specialists when needed — including geriatrics, cardiology, and infectious disease. Making sure nutrition is addressed early, and that patients are supported by social workers who can help navigate transportation, lodging, and caregiver logistics.

But just as important as preparation is honesty.

Dr. Langston
“We as providers have an obligation to disclose what the risks are. If on balance, after evaluating the patient and looking at the whole situation, I think a transplant or the cell therapy is a bad idea or a particularly risky idea, I'm going to tell folks that rather than putting them through the paces because they came to the office.”

SEGMENT 6: WHAT PATIENTS AND FAMILIES CAN DO

So what can patients and families do to improve outcomes?

According to Dr. Langston, preparation matters — both physically and practically. If time allows, building strength before treatment begins can make a real difference. That may include focused physical or occupational therapy, often referred to as “prehab.” And once treatment starts, continuing to move — even in small ways — helps patients maintain strength and recover more effectively.

Support systems matter just as much.

Patients and families are encouraged to think carefully about their caregiver team. In many cases, that means involving more than one person — some younger, some physically able to help if mobility becomes an issue. It’s also helpful to designate one person as the organizer: someone who tracks medications, appointments, and changes along the way.

And finally, it’s important to set expectations.

There is rarely a straight line through stem cell transplant or CAR T-cell therapy. Plans may change. Setbacks can happen. Flexibility — and patience with the process — can make a significant difference for everyone involved.

SEGMENT 7: THE REAL QUESTION ISN’T “Who Should Get a Transplant”

Dr. Langston
“In my mind, it’s not a question of who should get a transplant or cell therapy, but who shouldn’t.”

The goal of the evaluation process isn’t to rule people out — it’s to make sure that anyone who moves forward has a realistic chance for treatment to go well.

And that determination is rarely made in a single visit.

Dr. Langston
“… At the time of that last meeting, I’ve got to be convinced that there’s a reasonable chance this can go well.”

For patients and families, this means the assessment is ongoing, thoughtful, and collaborative — shaped by medical insight, lived experience, and shared decision-making over time.

OUTRO
So, here’s what I hope you take with you.

If you’re an older adult — or caring for one — facing a stem cell transplant or CAR T-cell therapy, this conversation is meant to offer clarity, not pressure.

Age alone does not determine whether these treatments are possible. Resilience does.

And resilience is shaped by many things: careful medical assessment, physical preparation, cognitive and emotional health, strong caregiver support, and realistic expectations about the road ahead.

When those pieces come together, these therapies can be both possible — and successful — for many older adults.

These decisions can feel heavy. But I hope that walking through this together helps you feel a little more grounded, a little more informed, and a little more supported as you have these conversations with your care team and with the people you love.

If you’d like to explore this topic further, you can watch Dr. Langston’s full presentation at bmtinfonet.org. The link is in the show notes.

One Last Thought
Before we wrap up, I just want to leave you with this.

When conversations turn to transplant or CAR T-cell therapy later in life, it’s easy for age to feel like the defining factor. But as we’ve heard today, these decisions are rarely about a number. They’re about the whole person — health, support, priorities, and what matters most right now.

For some, these treatments may feel like the right step forward. For others, they may not. Either way, asking questions, weighing options, and taking the time to understand both potential benefits and real risks is part of thoughtful, informed care.

If you’re facing these conversations yourself — or supporting someone who is — I hope today’s discussion helps you feel a little steadier as you navigate them. Not overwhelmed. Not guessing. Not carrying the weight alone. Just better equipped to talk openly with your care team and the people you trust.

In next week’s episode, we’ll continue this conversation by looking at what comes after an allogeneic stem cell transplant — the late effects that can emerge months or even years later, and why long-term follow-up care plays such an important role in protecting both health and quality of life.

Until next time —

Keep asking questions.
Keep seeking answers.
And remember that you. Are not. Alone.