BACKGROUND : Allogeneic hematopoietic cell transplantation (HCT) is increasingly offered to older adults with hematologic malignancies, though non-relapse mortality remains a major concern in older patients due to co-morbidities and greater frailty than their younger counterparts. The importance of patient fitness, well-matched donor, and disease control in successful allogeneic HCT have been well documented; however, these factors fail to account for the impact of a complex ecosystem which older adult HCT candidates must navigate.

OBJECTIVES : We propose a definition of the transplant ecosystem, modeled after the social determinants of health. Furthermore, we outline a research agenda to gain understanding of the role individual social determinants of transplant health play in the larger ecosystem and how this may benefit or harm older adult HCT candidates.

DESIGN : Herein, we define the transplant ecosystem and its individual tenets, the social determinants of transplant health. This manuscript provides a review of available literature while incorporating the expertise of the membership of the American Society for Transplantation and Cellular Therapy (ASTCT) Special Interest Group for Aging.

RESULTS : The membership of the ASTCT Special Interest Group for Aging identify knowledge gaps and strategies to address them for each of the described social determinants of transplant health.

CONCLUSION : The ecosystem is an essential, but under-appreciated pillar for transplant access and success. We put forth this novel research agenda seeking to gain better understanding of HCT complexity in older adults and develop strategies to improve access to HCT, survival, and quality of life.