Quality of life and social integration after allogeneic hematopoietic SCT

Exercise in the setting of hematopoietic stem cell transplantation

The procedure of hematopoietic stem cell transplantation (HSCT) is an intense treatment approach to cure patients from leukemia or lymphoma. Prior, during, and after HSCT, patients experience considerable physical and psychosocial distress. In light of the increasing number of successfully treated patients, the need is growing for evidence-based adjuvant therapy options, which are able to reduce treatment-related side effects and enhance the rehabilitation process. Exercise constitutes to be a promising intervention in this setting due to its multidimensional effectiveness. The purpose of this article was to review the current knowledge in the field of exercise and HSCT. Therefore, an electronic literature search in PubMed on the topic was performed. Twenty-nine articles could be identified and classified as relevant for this paper. Reviewed studies suggest that exercise training is an important therapeutic approach in the supportive care for transplant patients. Significant benefits from the exercise interventions have been reported for physical performance, quality of life (QoL), and fatigue status. Several other benefits, such as a more rapid immune recovery or alleviation of therapy-related side effects have been reported in some studies. Future studies should address existing methodological problems, identify further effect levels of exercise and integrate a long-term perspective for the participants in the context of hematopoietic stem cell transplantation. Furthermore, potential biological pathways of exercise in HSCT patients should be investigated.

Life satisfaction in young adults 10 or more years after hematopoietic stem cell transplantation for childhood malignant and nonmalignant diseases does not show significant impairment compared with healthy controls: a case-matched study

Patients undergoing hematopoietic stem cell transplantation (HSCT) may experience physical and psychological deterioration that impairs their life satisfaction (LS). This study focused on LS in long-term survivors at 10 or more years after HSCT. Fifty-five patients (39 males, median age 25 years) undergoing allogeneic HSCT for childhood malignant (n = 52) or nonmalignant diseases (n = 3) were enrolled. A control group of 98 young adults (59 males, median age 24 years) was considered. A questionnaire with a modified Satisfaction Life Domain Scale was administered. We assessed such domains as education, employment, leisure time, social relationships, and perception of physical status with a 30-item questionnaire. To investigate the association between the domains and the probability of diminished LS, we performed a logistical procedure using the maximum likelihood method. Predictive factors of LS were adjusted for sociodemographic variables. In the multivariate analysis, the participant's level of LS was not significantly correlated with sociodemographic factors or with HSCT status. The same analysis showed a slight trend in favor of the control group (P = .06) for body perception. Our data suggest that the patients who undergo HSCT in childhood have no significant difference in long-term LS compared with healthy controls.

Rehabilitation using high-intensity physical training and long-term return-to-work in cancer survivors

INTRODUCTION

Due to large and increasing numbers of cancer survivors, long-term cancer-related health issues have become a major focus of attention. This study examined the relation between a high-intensity physical rehabilitation program and return-to-work in cancer survivors who had received chemotherapy.

METHODS

The intervention group, consisting of 72 cancer survivors from one hospital (8 men and 64 women, mean age 49 years), followed an 18-weeks rehabilitation program including strength and interval training, and home-based activities. An age-matched control group, consisting of 38 cancer survivors (9 men and 29 women), was recruited from two other hospitals. They received only standard medical care. All subjects were evaluated during a telephone interview on employment issues, conducted at ±3 years after diagnosis. The main outcomes were change in working hours per week and time until return-to-work.

RESULTS

Patients in the intervention group showed significant less reduction in working hours per week [-5.0 h/week vs. -10.8 h/week (P = .03)]. Multivariate analyses showed that the training intervention, the age of patients, and the number of working hours pre-diagnosis could explain the improvement in long-term participation at work. Time until (partial) return-to-work was 11.5 weeks for the intervention group versus 13.2 weeks for the control group (P = .40). On long-term follow-up, 78% of the participants from the intervention group versus 66% from the control group had returned to work on the pre-diagnosis level of working hours (P = .18).

CONCLUSION

Rehabilitation using high-intensity physical training is useful for working patients to minimize the decreased ability to work resulting from cancer and its treatment.

Patients receiving HLA-haploidentical/partially matched related allo-HSCT can achieve desirable health-related QoL that is comparable to that of patients receiving HLA-identical sibling allo-HSCT

To investigate the health-related quality of life (HRQoL) of patients receiving allogeneic hematopoietic SCT (allo-HSCT) from HLA-haploidentical/partially matched related donors (HID/PMRD) and to compare this value with that of patients receiving allo-HSCT from HLA-identical sibling donor (ISD), a total of 350 patients receiving allo-HSCT were enrolled in a study (ISD: 173; HID/PMRD: 177). HRQoL post transplantation was evaluated by an SF-36 questionnaire. The effect of various factors on the HRQoL was analyzed through COX regression. Compared with the ISD group, patients in the HID/PMRD group had higher scores in physical functioning, general health, bodily pain, vitality and emotional role functioning, and these patients functioned significantly better on the physical and mental component summaries. Also, long-term survivors exhibit better HRQoL. Measured by multivariate analysis, extensive chronic GVHD was observed to have a strongly negative impact on patients' HRQoL, while male gender status, lower age when receiving allo-HSCT and returning to work or school were associated with positive impacts on at least one subscale. These results showed that the HRQoL of patients receiving HID/PMRD hematopoietic SCT (HSCT) is comparable to that of patients receiving ISD HSCT, and HLA disparity is not the factor affecting the HRQoL.

A multidisciplinary intervention to facilitate return to work in cancer patients: intervention protocol and design of a feasibility study

INTRODUCTION

Returning to work can be problematic for cancer survivors due to suboptimal workplace support, a heavy workload, decreased physical functioning and fatigue. The timely and permanent return to work (RtW) of cancer patients favourably influences quality of life and economic independence. Multidisciplinary interventions aimed at timely and enduring RtW are lacking. The objectives of this article are (1) to describe the protocol of an intervention aimed at RtW of cancer patients, comprising of counselling by an oncological occupational physician and supervised physical exercise in a clinical setting during treatment and (2) to present the design of the study aimed at evaluating the feasibility of this intervention.

METHODS AND ANALYSIS

The intervention comprises three counselling sessions with an oncological occupational physician and a 12-week moderate-to-high intensity physical exercise programme, starting at the onset of chemotherapy. The intervention is aimed at cancer patients treated with curative intent, aged 18-60 years, employed and on sick leave. It will take place in two large medical centres in the Netherlands. The feasibility of the intervention will be evaluated as follows: the number of sessions, topics discussed and exercises executed will be registered by care providers; patients' and care providers' opinions will be assessed by questionnaires and interviews, respectively; and the proportion of invited patients that participated will be calculated.

ETHICS AND DISSEMINATION

The study results will be used for optimising the intervention content and may serve as a foundation for future implementation. The Medical Ethics Committees of the Academic Medical Center and the participating medical centres approved the study protocol.

Outcome and risk factors for late-onset complications 24 months beyond allogeneic hematopoietic stem cell transplantation

OBJECTIVES

The aim of this retrospective study was to assess the incidence of late complications occurring ≥2 years after allogeneic hematopoietic stem cell transplantation (HSCT) for malignant diseases using a T-cell depletion strategy.

METHODS

Between 1984 and 2004, 142 patients were eligible for the study. Total body irradiation (TBI) was carried out in 85% of the patients and T-cell depletion in 84%.

RESULTS

Non-relapse mortality (NRM) was 3% (95% CI 0-11) at 10 years, and serious late events affected a substantial number of patients. The cumulative incidence (CI) of chronic graft-versus-host disease (cGvHD) was 30% (95% CI 23-40), and that of infectious complications was 17% (95% CI 11-23). Multivariate analysis showed a higher risk for late complications in patients with cGvHD (HR 1.9, 95% CI 1.2-3.2, P=0.011) and patients receiving methylprednisolone during conditioning (HR 1.9, 95% CI 1.1-3.3, P=0.019 1), patients with cGvHD also having a higher risk for NRM (HR 13.2, 95% CI 1.2-143, P=0.03), as well as those receiving steroids for >3 months (HR 40.3, 95% CI 2.3-718, P=0.02) and those receiving antithymocyte globulin (HR 9.6, 95% CI 0.8-68, P=0.024).

CONCLUSIONS

A significant proportion of long-term survivors of HSCT had late complications. cGvHD remained an important risk factor for late complications despite T-cell depletion resulting in immunosuppression and infectious complications.

Quality of life concerns and depression among hematopoietic stem cell transplant survivors

PURPOSE

This study examined quality of life, transplant-related concerns, and depressive symptoms and their demographic and medical correlates at 1 to 3 years following hematopoietic stem cell transplantation (HSCT).

METHODS

HSCT survivors (N=406) completed telephone-administered questionnaires that assessed demographic variables, functional status, quality of life, transplant-related concerns, and depressive symptoms.

RESULTS

The most prevalent concerns among HSCT survivors included physical symptoms (e.g., fatigue and pain), maintaining current health status and employment, changes in appearance, and lack of sexual interest and satisfaction. In addition, almost one-third (32%) of survivors age 40 years and younger reported concern about their ability to have children. Unemployed survivors and those with lower incomes and worse functional status were more likely to experience poorer quality of life in multiple domains. Fifteen percent of the sample reported moderate to severe depressive symptoms, and these symptoms were higher among allogeneic transplant recipients and those with lower functional status.

CONCLUSIONS

Results suggest that interventions are needed to address physical symptoms, coping with an uncertain future, infertility, and sexual issues during the early phase of HSCT survivorship.

Long-term health-related outcomes in survivors of childhood cancer treated with HSCT versus conventional therapy: a report from the Bone Marrow Transplant Survivor Study (BMTSS) and Childhood Cancer Survivor Study (CCSS)

HSCT is being increasingly offered as a curative option for children with hematologic malignancies. Although survival has improved, the long-term morbidity ascribed to the HSCT procedure is not known. We compared the risk of chronic health conditions and adverse health among children with cancer treated with HSCT with survivors treated conventionally, as well as with sibling controls. HSCT survivors were drawn from BMTSS (N = 145), whereas conventionally treated survivors (N = 7207) and siblings (N = 4020) were drawn from CCSS. Self-reported chronic conditions were graded with CTCAEv3.0. Fifty-nine percent of HSCT survivors reported ≥ 2 conditions, and 25.5% reported severe/life-threatening conditions. HSCT survivors were more likely than sibling controls to have severe/life-threatening (relative risk [RR] = 8.1, P < .01) and 2 or more (RR = 5.7, P < .01) conditions, as well as functional impairment (RR = 7.7, P < .01) and activity limitation (RR = 6.3, P < .01). More importantly, compared with CCSS survivors, BMTSS survivors demonstrated significantly elevated risks (severe/life-threatening conditions: RR = 3.9, P < .01; multiple conditions: RR = 2.6, P < .01; functional impairment: RR = 3.5, P < .01; activity limitation: RR = 5.8, P < .01). Unrelated donor HSCT recipients were at greatest risk. Childhood HSCT survivors carry a significantly greater burden of morbidity not only compared with noncancer populations but also compared with conventionally treated cancer patients, providing evidence for close monitoring of this high-risk population.

Quality of life in patients before and after haematopoietic stem cell transplantation measured with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core Questionnaire QLQ-C30

The EORTC Quality of Life Core Questionnaire QLQ-C30 is widely used, but no reference values are available for patients receiving HSCT. We retrieved data for 38 samples from 33 papers in English and German that provided evaluable information on QLQ-C30 scores (mean, s.d.) covering about 2800 patients. Results are presented as a table that provides reference data that allow QLQ-C30 scores at different points during the disease trajectory to be put in context. With respect to their central tendency and their variance, scores vary over time. Quality of life is lowest during inpatient time. About 1 year after HSCT, the pre-transplant level is reached. Physical functioning is the scale reaching the highest level of all scales. Fatigue, dyspnoea and insomnia are symptoms that remain at an elevated level and should thus be considered as persisting problems after HSCT. For the interpretation of differences between scores, a very conservative recommendation would be to set the s.d. at 30 points. Doing so, one could be quite sure of having found a clinically significant change if the difference of two scores exceeds 15 points. Differences below 5 points should be interpreted with caution.

Positive correlation of employment and psychological well-being for veterans with major abdominal surgery

BACKGROUND

Intestinal stomas (ostomies) have been associated negatively with multiple aspects of health-related quality of life. This article examines the relationship between employment status and psychological well-being (PWB) in veterans who underwent major bowel procedures with or without ostomy.

METHODS

Veterans from 3 Veterans Affairs (VA) medical centers were surveyed using the City of Hope ostomy-specific questionnaire and the Short Form 36 item Veteran's version (SF-36V). Response rate was 48% (511 of 1,063). Employment and PWB relationship was assessed using multiple regression with age, income, SF-36V physical component summary (PCS), and employment status as independent variables.

RESULTS

Employed veterans reported higher PWB compared with unemployed veterans (P = .003). Full-time workers also reported higher PWB than part-time or unemployed workers (P = .001). Ostomy was not an independent predictor of PWB.

CONCLUSIONS

Employment among veterans after major abdominal surgery may have intrinsic value for PWB. Patients should be encouraged to return to work, or do volunteer work after recovery.

Factors associated with self-reported physical and mental health after hematopoietic cell transplantation

Hematopoietic cell transplantation (HCT) is an intensive treatment for hematologic malignancies that has the potential to cure disease or prolong life, but also to impair quality of life for survivors. Earlier studies have suggested that various factors are associated with physical and mental health after HCT. In this study, we evaluated demographic and clinical factors before and after HCT and selected psychosocial factors after HCT, exploring their association with self-reported physical and mental health. We studied a cohort of 662 survivors at a median of 6.6 years after HCT. Pre-HCT demographic and clinical factors accounted for only a small amount of the variance in physical and mental health post-HCT (3% and 1%, respectively). Adding post-HCT clinical variables to the pre-HCT factors accounted for 32% and 7% of physical and mental outcomes, respectively. When both clinical and psychosocial factors were considered, better physical health post-HCT was associated with younger age, race other than white, higher current family income, currently working or being a student, less severe transplantation experience (ie, not experiencing graft-versus-host disease), fewer current comorbidities, higher Karnofsky status, less social constraint, less social support, and less trait anxiety. This multivariate model accounted for 36% of the variance in physical health, with the psychosocial variables contributing very little. When both clinical and psychosocial factors were considered, better mental health after HCT was associated with more severe transplantation experience, less social constraint, greater spiritual well being, and less trait anxiety. This multivariate model accounted for 56% of the variance in mental health, with the psychosocial factors accounting for most of the variance. These data suggest that clinical factors are explanatory for much of the post-HCT physical health reported by HCT survivors, but very little of self-perceived mental health. These observations provide insight into the identification of factors that can allow recognition of at-risk patients, as well as factors amenable to intervention.

Long-term recovery after hematopoietic cell transplantation: predictors of quality-of-life concerns

This prospective longitudinal study examined the quality of life (QOL) after hematopoietic cell transplantation (HCT) and identified risk factors of poor QOL in 312 adult autologous and allogeneic HCT patients. Physical, psychological, social, and spiritual well-being was assessed before HCT, 6 months, and 1, 2, and 3 years after HCT. For all HCT patients, physical QOL was stable from before to after HCT (P > .05); psychologic (P < .001), social (P < .001), and spiritual (P = .03) QOL improved at 6 months. Study noncompleters (because of illness or death) had worse QOL. Allogeneic patients reported worse physical and psychologic well-being (P < .05). Older patients reported worse physical but better social well-being regardless of HCT type (P < .05). Two or more domains were affected by race/ethnicity, household income, and education in autologous patients, and by body mass index (BMI), decline in BMI, primary diagnosis, and chronic graft-versus-host disease (GVHD) in allogeneic patients (P < .05). At 3 years, 74% of HCT patients were employed full or part time. Older autologous patients with lower pre-HCT income were less likely to work (P < .05); allogeneic patients with chronic GVHD were less likely to work (P = .002). Multidisciplinary efforts to identify and support vulnerable subgroups after HCT need to be developed.

Determinants of functional performance in long-term survivors of allogeneic hematopoietic stem cell transplantation with chronic graft-versus-host disease (cGVHD)

This study examined factors accounting for functional performance limitations in 100 long-term survivors of allogeneic hematopoietic stem cell transplantation with chronic graft-versus-host disease (cGVHD). Functional performance, measured by the SF-36 physical component summary score, was substantially lower (mean=36.8+/-10.7) than the US population norm of 50 (P<0.001). The most severe decrements were in physical function (mean=38.8+/-10.9) and physical role function (mean=37.88+/-11.88); 68% of respondents exceeded the five-point threshold of minimum clinically important difference below the norm on these subscales. Controlling for age and gender, six variables explained 56% of the variance in functional performance: time since cGVHD diagnosis, cGVHD severity, intensity of immunosuppression, comorbidity, functional capacity (distance walked in 2 min, grip strength, and range of motion), and cGVHD symptom bother (F=11.26; P<0.001). Significant independent predictors of impaired performance were intensive systemic immunosuppression, reduced capacity for ambulation, and greater cGVHD symptom bother (P<0.05). Symptom bother had a direct effect on functional performance, as well as an indirect effect partially mediated by functional capacity (Sobel test, P=0.004). Results suggest two possible mechanisms underlying impaired functional performance in survivors with cGVHD and underscore the importance of testing interventions to enhance functional capacity and reduce symptom bother.