Extracorporeal Photopheresis for Medicare Recipients of Lung Allografts

Lung transplantation has become the treatment of choice for selected patients with end-stage lung disease. Long-term survival after transplantation remains disappointing. Chronic rejection in the form of bronchiolitis obliterans syndrome (BOS) has emerged as the leading obstacle to better long-term outcomes, and is the leading cause of death beyond the first year after transplantation. This disorder is a fibroproliferative scarring process that involves the narrowing of the airway lumen and ultimately complete luminal obliteration. Physiologically and clinically, this luminal narrowing results in airflow limitation and breathlessness. Histologic confirmation of BOS is difficult with bronchoscopy obtained lung biopsies because of the patchy distribution of the disorder and inadequate sampling of small airways with transbronchial lung biopsies. As a result, BOS is diagnosed and staged by the decline in Forced Expiratory Volume in 1 Second (FEV1) measurement from a pulmonary function test. In general, BOS is treated by intensifying the immunosuppressive regimen. The specific approach is variable from center to center, but typically includes optimizing the maintenance immunosuppressive regimen to include tacrolimus and mycophenolate mofetil, high-dose steroids, and a course of anti-thymocyte globulin. Despite treatment, most patients continue to show progressive decline in lung function resulting in worsening functional status, quality of life, and ultimately graft failure and death. Extracorporeal photopheresis (ECP) has been used at some centers as a salvage treatment for progressive BOS. ECP involves separating the patient's blood into a leukocyte-enriched component (buffy coat) and a leukocyte-depleted component. The buffy coat is then photosensitized with 8-methoxypsoralen and treated with ultraviolet light within a photosensitization chamber, resulting in leukocyte apoptosis. Although the exact mechanism of action of ECP is unclear, re-infusion of this apoptotic leukocyte population into the patient's circulation is thought to result in alterations in antigen presenting cells, cytokine profiles, and the expansion of regulatory T cells. On May 2, 2012, the Centers for Medicare \& Medicaid Services issued a Decision Memo stating that ECP is covered for Medicare beneficiaries for the treatment of BOS following lung allograft transplantation only when the procedure is provided under a clinical research study. This study looks at (1) Early detection of refractory BOS using a standardized, more frequent spirometry monitoring approach (i.e., defined as using frequent laboratory based spirometry every 4-8 weeks) and (2) Early implementation of ECP in both participants with early stage refractory BOS and also as first line therapy in a subset of participants at the initial diagnosis of BOS, in the context of a new randomized controlled trial. The study will look at whether certain coexisting disease states or patient-related demographic, functional, treatment-related or diagnostic variables (e.g. extent or statistical significance of the rate of pre-ECP FEV1 decline) might prove to have predictive value in identifying subsets of BOS patients that are likely, or unlikely, to experience reduced rate of decline or stabilization in FEV1 following ECP treatment. Therefore this study will look to enroll a large series of patients from multiple U.S. centers to confirm that ECP significantly reduces the rate of FEV1 decline in BOS patients refractory to standard immunosuppressive drug therapy, and to capture and assess specified patient demographic, treatment-related, diagnostic, functional and co-morbidity-related variables that may predict outcomes after ECP therapy. Enrollment is now complete and ended April 6, 2002. Patients are now in follow-up and will be followed no later than the end of the study December 2028. This study includes a randomized controlled trial that will compare outcomes in patients with newly diagnosed BOS who receive either conventional (i.e., that involves the standard of care at the respective enrolling center) or ECP for first line management of New BOS. The randomized controlled trial component of the study will enable evaluation of potential survival and quality of life benefits of early treatment of BOS with first-line ECP. The randomized control trial was placed on hold in February of 2022. Twenty-two patients were enrolled study wide. Patients are now in follow-up and will be followed no later than the end of the study December 2028. Subjects with Refractory BOS who agreed to participate in the study were informed of the following: to limit the use (and attendant risks) of ECP therapy to those patients who are most likely to benefit, their eligibility to receive ECP within the study will be determined by the study team's analysis of their pre-enrollment pulmonary function testing along with input from their physician. Subjects with Newly-Diagnosed BOS who agreed to participate in the study were informed that they will be randomly assigned to either a control group (Control) who will receive the local Standard of Care for management of their BOS or to an Early Photopheresis Intervention (EPI) group who will receive ECP as first line management of BOS. The protocol states specific inclusion and exclusion criteria for both the Refractory BOS participant and the newly diagnosed BOS participant. Once eligibility is confirmed and the patient has provided informed consent, all FEV1 measurements captured within the 12 months prior to enrollment will be entered in the electronic database. Based on the slope of the FEV1 decline over time and achievement of a statistically significant rate of decline in lung function in the FEV1 the Refractory BOS participant will be electronically assigned to either ECP treatment or Observation. The newly diagnosed BOS participant will be randomized to either ECP treatment and standard immunosuppression therapy or Control treatment which is Standard immunosuppression Therapy alone. The participant will be assigned a unique identification number created from the electronic data base. The patient demographics, co-morbidities, medical history including date of lung transplantation, underlying disease necessitating lung transplantation, vital signs, height, weight, and current immunosuppression regimen will be entered at baseline. A Quality of Life Questionnaire will be asked at baseline and every 3 months the first year and then annually. A pulmonary function test will be captured every 30 days for the first year on all patients except the Refractory BOS participant assigned to Observation. Pulmonary function tests will be captured every 30 days for the first six months for the Observation patient. Following the first six months, the timing of pulmonary function testing must be every 3 months at the very least to maintain eligibility for ECP Treatment. Certain de-identified source documents will be required and verified on all forms electronically submitted. Data points will be verified against de-identified source by the Data Coordinating Center. The online data entry portal and study database will contain a mechanism to a) clearly denote the status of each submitted Case Report Form, including whether the case report form is complete; b) list the source documentation needed c) indicate if the site staff member and investigator have attested to the validity of the data on the Case Report Form; and d) indicate if the Data Coordinating Center has verified the accuracy of key elements of the study data and what data queries remain. This centralized monitoring will complement our remote monitoring visits during COVID. For most sites an initial remote site monitoring visit will occur after the first three patients are enrolled to ensure that the site personnel understand study processes and expectations, and to permit early completion of additional training to address any deficiencies. Should remote or on-site monitoring reveal areas of particular deficiency or concern, the monitoring plan will be adjusted to focus on those particular areas for the site. In general, sites and patients affiliated with a major violation will be monitored with greater completeness. Sites deemed to be largely compliant with the protocol and regulatory requirements based upon the initial monitoring visit are expected to have subsequent visits performed at a reduced level of frequency. Overall, the study team will seek to optimize resource use by focusing on the most critical data elements that may impact subject safety and/or data quality and integrity. Participants who receive ECP treatment will receive 24 treatments over the 6-month period following enrollment. Allowed Treatment for Refractory BOS patients in the Observation will be ordered at the physicians discretion. Treatment for the Newly Diagnosed BOS patients in the Control Arm of the randomized control trial will be dictated by the standard of care within each enrolling institution and will involve changes in immunosuppressive agents. These patients will not be eligible to receive ECP treatment. Other than ECP, no other interventions for BOS will be used except for Azithromycin for patients in the randomized Early Photopheresis Intervention arm. An improvement in the FEV1 measurement taken from the pulmonary function test will be used to assess the success or the benefit of the ECP treatment. Patients will have spirometry the first week of therapy, which is repeated every 30 days for the first year, and then annually in the Refractory BOS cohort assigned to ECP treatment. Patient's will have spirometry the first week of therapy, and repeated every 30 days for the first year, and then every 2 months in the NEW BOS cohort. All patients will be followed no later than December 2028. There were considerations for crossover built into the early versions of the protocol. Statistical Methods. The primary outcome in the RCT or New BOS will look at cumulative all cause mortality and the rate of decline of lung function: A 25% or greater difference in the percentage of patients within each of the two arms (Control vs Early photopheresis Intervention(EPI) who achieve a clinical response as defined as 50% or greater reduction in the rate of FEV1 decline as assessed by comparing the average rate of FEV1 decline over the 6 months prior to ECP against the average rate of FEV1 decline over the 12 months following randomization. The primary endpoint in the Refractory BOS registry involves a change in the rate of FEV1 decline assessed by comparing the average rate of FEV1 decline over the 6 months prior to ECP against the average rate of FEV1 decline over the 12 months following initiation of ECP. A clinical response will be determined using FEV1 as the primary endpoint and will be defined as a 50% or greater reduction in the rate of decline of FEV1 assessed by comparing the average rate of FEV1 decline over the 6 months prior to ECP against the average rate of FEV1 decline over the 12 months following initiation of ECP. A clinical response will be defined as a 50% or greater reduction in the rate of decline of FEV1 before and after the ECP. The second primary endpoint will include all cause and CLAD related mortality. The participants will be followed until their death but no later than December 2028 and the following data will be collected annually after the first year: Spirometry results, the number of maintenance Extracorporeal Photopheresis treatments performed and Quality Of Life surveys will be tabulated. In parallel, data will be collected retrospectively from up to 250 lung transplant recipients (through an IRB approved waiver of consent) who developed NEW BOS and were treated with standard of care (SOC) therapy and did not receive ECP treatment. The addition of a propensity matched standard of care BOS Cohort may promote a more robust assessment of the potential clinical impact of ECP.