Quality of life in patients surviving at least 12 months following high dose chemotherapy with autologous bone marrow support

Working while receiving chemotherapy: a survey of patients' experiences and factors that influence these

The purpose of this study was to estimate the number of patients who continue to work when undergoing ambulatory chemotherapy and to identify personal or treatment-related factors that influence this. Patients undergoing final cycles of adjuvant chemotherapy for breast or colorectal cancer or first-line chemotherapy for lymphoma at two cancer treatment centres were approached to take part in a cross sectional survey (n= 55, RR 55%). Sixty-four per cent (n= 35) of respondents were working when cancer was diagnosed. Fifty-four per cent (n= 19) of respondents were working when chemotherapy began but as treatment progressed only 29% (n= 10) continued to work in any capacity. The most important influencing factor when making decisions about work was the need to concentrate on looking after oneself. Overall, respondents found their employers and colleagues supportive but there was some evidence they became less supportive as treatment progressed. While this was a small study it highlights the need for health care professionals to understand patient's needs and wishes in relation to work while undergoing chemotherapy by including this issue as part of routine assessment. Strategies to allow those who wish to continue to work during treatment should be put in place early to support this.

Sexual desire and satisfaction in sexual life affecting factors in breast cancer survivors after mastectomy

The purpose of this study was to examine impact of treatment and personality characteristics, and support need for femininity and body image on sexual desire and sexual satisfaction of women with breast cancer. The sample consisted of 123 married women who previously underwent mastectomy and applied to medical oncology clinics of a university hospital. Sexual desire of the women in this study was low, and they were slightly satisfied with sexual life. Consequently, the women required supporting needs of femininity and body image. The result of this study could be utilized to determine sexual desire and satisfaction related to sexual life of women with breast cancer.

Sexuality after hematopoietic stem cell transplantation

Severe sexual dysfunction and absence of sexual activity are common for long-term survivors of high-dose chemotherapy with or without total body irradiation and hematopoietic stem cell transplantation (HSCT). These treatments have known effects on gonadal function. Males and females develop abnormal hormone levels and in turn this affects sexual desire and genital organs. The sexual functioning questionnaire (SFQ), designed and tested with this population, has allowed improved understanding of the problems, quality of sexual response, and sexual behaviors in the HSCT population. Male and female HSCT survivors report more problems than age- and gender-matched healthy controls and these problems persist over time if not caught and treated early. Sexual dysfunction is a more striking problem for female survivors than males. Almost no high quality evidence supports the efficacy of interventions to treat sexual dysfunction in this population. However, promising medical and behavioral treatments are discussed for men and women.

Cancer fatigue: a review for psychiatrists

OBJECTIVE

Cancer-related fatigue (CRF) is a ubiquitous and debilitating phenomenon for patients both during and after treatment for cancer of all types. This review will outline the complex neurobiological mechanisms underlying CRF and their relevance to various treatment routes. It will cover aspects of screening, diagnosis and treatment, including both pharmacological and behavioral interventions for CRF. The goal of the article was not to perform a comprehensive literature review or meta-analysis, but rather to integrate clinically relevant information from different areas of research related to cancer fatigue, including etiology, diagnosis and management for a nonspecialist audience.

METHOD

The methodology used involved broadly surveying the literature available on Medline using such search terms as "cancer," "fatigue," "cytokine" and "depression," exploring relevant articles over the past 15 years and relevant citations from these articles and focusing on recent advances in the study of CRF.

RESULTS

CRF occurs at high prevalence rates during and subsequent to cancer treatment. Multidisciplinary approaches are available for the assessment and management of fatigue including underlying contributory factors.

CONCLUSIONS

An increasing base for evidence is present to guide the management of CRF. Additional research is warranted to understand the neurobiological mechanisms, etiology and risk factors for fatigue.

The symptom experience in the first 100 days following allogeneic hematopoietic stem cell transplantation (HSCT)

GOALS OF WORK

Despite advances in allogeneic hematopoietic stem cell transplantation (HSCT), post-transplant complications are common, and patients' symptom experience has not been well documented.

PURPOSE

To characterize the symptom experience of adult patients pre-transplantation and days 0, 30, and 100 after allogeneic HSCT.

METHODS

Data from 76 participants enrolled in a prospective health-related quality of life (HRQL) study were used. Symptom occurrence, distress, and clusters were determined based on the 11 symptoms of the Symptom Distress Scale (SDS).

RESULTS

Participants were on average 40 years old (SD +/- 13.5). The majority (54%) received reduced intensity conditioning. Prevalent symptoms included fatigue (68%) and worry (68%) at baseline, appetite change (88%) at day 0, and fatigue at days 30 (90%) and 100 (81%). Participants reported the following symptoms as severely distressing: worry (16%) [baseline], insomnia (32%) [day 0], appetite change (22%) [day 30], and fatigue (11%) [day 100]. The total SDS score was highest at day 0 (M = 26.6 +/- 7.6) when the highest number of symptoms were reported [median = 8 (1-11)]. Symptoms formed clusters comprised of fatigue, appearance change, and worry at baseline, and fatigue, insomnia, and bowel changes at days 0 and 30. Compared to those with low symptom distress, participants with moderate/severe symptom distress reported poorer HRQL.

CONCLUSION

Allogeneic HSCT patients present for transplantation with low symptom distress yet experience multiple symptoms and high symptom distress after HSCT conditioning. Understanding the symptom experience of allogeneic HSCT patients can guide management strategies and improve HRQL.

Prospective study of long-term impact of adjuvant high-dose and conventional-dose chemotherapy on health-related quality of life

PURPOSE

To evaluate and compare health-related quality of life (HRQOL) after conventional- and high-dose adjuvant chemotherapy in patients with high-risk breast cancer.

PATIENTS AND METHODS

Patients were randomly assigned to either a conventional or high-dose chemotherapy regimen; both regimens were followed by radiotherapy and tamoxifen. HRQOL was evaluated until disease progression using the Short Form-36 (SF-36), Visual Analog Scale, and Rotterdam Symptom Checklist and assessed every 6 months for 5 years after random assignment. For the SF-36, data from healthy Dutch women with the same age distribution served as reference values.

RESULTS

Eight hundred four patients (conventional-dose chemotherapy, n = 405; high-dose chemotherapy, n = 399) were included. Median follow-up time was 57 months. Directly after high-dose chemotherapy, HRQOL decreased more compared with conventional chemotherapy for all SF-36 subscales. After 1 year, the reference value of healthy women was reached in both groups. Small differences were observed between the two groups in the role-physical and role-emotional subscales, but 1 year after treatment, these differences were minor and not clinically relevant. During follow-up, patients with a lower educational level and many complaints before chemotherapy experienced a worse HRQOL.

CONCLUSION

Shortly after high-dose chemotherapy, HRQOL was more affected than after conventional-dose chemotherapy. One year after random assignment, differences were negligible. Identifying patients who have a higher chance of persistent impaired quality of life after treatment (which, in the present study, included patients with a lower educational level and many complaints before chemotherapy) is important and may open the way for better patient-tailored prevention strategies.

Fatigue and physical activity in patients undergoing hematopoietic stem cell transplant

PURPOSE/OBJECTIVES

To examine the patterns of fatigue, physical activity, health status, and quality of life before and after high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT) and to examine the feasibility of obtaining real-time fatigue and physical activity data.

DESIGN

Prospective, repeated measures.

SETTING

Two midwestern academic medical centers.

SAMPLE

Convenience sample of autologous or allogeneic patients undergoing HSCT (N = 20 baseline, N = 17 post-transplant).

METHODS

Subjects were assessed over a five-day period before and after HSCT for a total of 10 days. Subjects rated fatigue intensity three times daily and wore a wrist actigraph to measure physical activity. At the end of both five-day periods, subjects completed measures of perceived health status (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30) and life satisfaction Quality of Life Index).

MAIN RESEARCH VARIABLES

Fatigue, physical activity, perceived health status, and quality of life.

FINDINGS

Study results indicate that fatigue significantly increased and physical activity decreased following high-dose chemotherapy and HSCT. The decline coincided with diminished physical, emotional, role, and cognitive functioning. The symptoms that patients experienced (i.e., fatigue, pain, nausea and vomiting, sleep disturbances, appetite loss, and diarrhea) increased during the acute post-transplant period. No significant changes in life satisfaction were found.

CONCLUSIONS

The study findings suggest that patients receiving high-dose chemotherapy followed by HSCT experience increased fatigue, reduced physical activity, diminished functioning, and poorer quality of life immediately after transplant. Findings demonstrate that real-time fatigue and physical activity data can feasibly be collected in acutely ill patients.

IMPLICATIONS FOR NURSING

Patients undergoing HSCT require considerable supportive nursing care immediately following transplant. Clinicians and researchers need to strive for effective symptom management to improve the likelihood of successful outcomes.

A qualitative study of work and work return in cancer survivors

Few studies have examined the impact of cancer on the survivor's quality of work life. The purpose of this qualitative study is to describe the work experiences among a diverse group of cancer survivors and to explore factors influencing decisions about work after cancer diagnosis and treatment. We interviewed 28 participants with a broad range of socioeconomic backgrounds and primary cancer sites. Qualitative results indicate that after learning about their cancer diagnosis, participants had diverse and complex patterns of work return and work change, and experienced a variety of factors that influenced post-cancer decisions. Experiences at work after cancer also varied in relation to how others responded, changes in productivity, effects of cancer and treatment on work, and feelings about work. Most respondents received little guidance from their physicians about work, and many participants described their cancer as impacting their priority of work relative to other aspects of their lives. Our findings reinforce the complexity of measuring employment outcomes and the range of adaptations made to improve the quality of work life. Additional research is needed to identify prognostic factors that can guide clinical or workplace efforts to restore cancer survivors to their desired level of work function and economic productivity.

Quality of life among patients with Stage II and III breast carcinoma randomized to receive high-dose chemotherapy with autologous bone marrow support or intermediate-dose chemotherapy: results from Cancer and Leukemia Group B 9066

BACKGROUND

The objective of this study was to compare the quality of life (QOL) after treatment among patients who had breast carcinoma with multiple positive lymph nodes. The patients were randomized to receive either high-dose chemotherapy with autologous stem cell support (HDC) or intermediate-dose chemotherapy (IDC) in the adjuvant setting.

METHODS

Two hundred forty-six patients with AJCC Stage IIA, IIB, or IIIA breast carcinoma who had > or = 10 positive lymph nodes and who were participants in Cancer and Leukemia Group B (CALGB) 9082 were enrolled in this companion study, CALGB 9066. Patients were randomized to receive either high-dose cyclophosphamide, carmustine, and cisplatin (CPA/cDDP/BCNU) and autologous bone marrow transplantation (the HDC arm) or intermediate-dose CPA/cDDP/BCNU as consolidation to adjuvant chemotherapy (the IDC arm). QOL was assessed at baseline and at 3 months, 12 months, 24 months, and 36 months using the Functional Living Index-Cancer (FLIC), the Psychosocial Adjustment to Illness Scale (PAIS)-Self Report, and the McCorkle Symptom Distress Scale (SDS).

RESULTS

At the 3-month assessment, patients in the HDC arm demonstrated significant worsening of QOL compared with the IDC arm in terms of their physical well being (FLIC, P = 0.023), social functioning (FLIC, P = 0.026; PAIS, P < 0.0001), symptom distress (SDS, P = 0.0002), and total QOL scores (FLIC, P = 0.042). At 12 months, the differences in QOL scores between the HDC arm and the IDC arm had resolved.

CONCLUSIONS

Patients who received more intensive adjuvant therapy experienced transient declines in QOL. By 12 months after therapy, QOL was comparable between the 2 arms, regardless of therapy intensity, and many QOL areas were improved from baseline.

The impact of a second breast cancer diagnosis on health related quality of life

A growing of research documents the negative impact of recurrent breast cancer on quality of life (QOL), however few prospective investigations are available that compare QOL outcomes across different types of second cancer events (e.g., local/regional recurrence (LR) versus distant/metastatic recurrence (DR) versus a new primary breast cancer (NP)). In addition, although participant attrition is a major issue in this group of cancer patients, the potential impact of attrition or response bias on QOL outcomes is not typically examined. To address these issues, we prospectively examined QOL data obtained from a sample of women (n=140) participating in the Women's Healthy Eating and Living (WHEL) Study who experienced a second cancer event (LR, DR or NP). Women in our study reported significant worsening in most areas of QOL, except for emotional wellbeing, from pre- to post-second cancer event. Although the patterns of change to QOL differed slightly within each category (LR versus DR versus NP), participants were more similar than different in their QOL ratings. However, the perceived health status of women with DR was significantly lower than women with LR or NP. We also identify important sources of response bias that should be considered when interpreting findings. Specifically, women diagnosed with DR (a) were more likely to decline to complete the post-recurrence QOL questionnaire (27% refusal rate versus 14% LR and 13% NP), and (b) had higher death rates (28% death rate versus 4% LR and 6% NP) after agreeing to but before completing the post-second diagnosis QOL questionnaire.

A longitudinal prospective study of health-related quality of life in breast cancer patients following high-dose chemotherapy with autologous blood stem cell transplantation

This prospective longitudinal study examined both short- and long-term changes in health-related quality of life (HRQL) in 52 breast cancer patients with poor prognosis receiving high-dose chemotherapy (HDC) treatment with autologous blood stem cell transplantation (ASCT). HRQL was measured seven times from baseline to 2 years post enrollment with the Functional Living Index-Cancer (FLIC), the EuroQol (EQ-5D), and a quality of life visual analogue scale. The percentage of questionnaires returned at each assessment time ranged from 80 to 92%. All three measures showed a similar pattern of change, with HRQL decreasing following administration of HDC, and returning to baseline levels 8 weeks post HDC. A repeated-measures analysis of variance showed that the FLIC at 2 years was significantly better than baseline (P=<0.0001). Difficulty sleeping, headaches, and decreased sexual interest were the most common symptoms reported in the longer term. Our results have implications for early psychosocial intervention in the care of breast cancer patients with poor prognosis undergoing treatment with HDC and ASCT because such interventions can further improve the quality of their survival.

Perceived partner reactions to diagnosis and treatment of breast cancer: impact on psychosocial and psychosexual adjustment

Two studies examined breast cancer patients' perceptions of their partners' reactions to their diagnosis and treatment as influences on 3 aspects of patients' well-being: psychosexual adjustment, emotional distress, and marital satisfaction. Study 1, cross-sectional, indicated that partner initiation of sex, frequency of sex, a positive 1st sexual experience after treatment, and especially perception of the partner's emotional involvement in the relationship, were relevant to these outcomes. Study 2, longitudinal, confirmed many of these findings in prospective tests across 1 year of recovery after surgery. Partner involvement prospectively predicted all 3 outcomes. Partner initiation of sex predicted greater marital satisfaction; partner adverse reaction to the scar predicted less marital satisfaction. Rated quality of the 1st sexual experience after treatment predicted less distress. The pattern suggests that women's impressions of their partners' emotional involvement after surgery for breast cancer forecast their adjustment in sexual, marital, and emotional arenas over the following year.

Prospective, randomized comparison of high-dose chemotherapy with stem-cell support versus intermediate-dose chemotherapy after surgery and adjuvant chemotherapy in women with high-risk primary breast cancer: a report of CALGB 9082, SWOG 9114, and NCIC MA-13

PURPOSE

The prognosis for women with primary breast cancer involving multiple axillary nodes remains poor. High-dose chemotherapy with stem-cell support produced promising results in initial clinical trials conducted at single institutions.

PATIENTS AND METHODS

Seven hundred eighty-five women aged 22 to 66 years with stage IIA, IIB, or IIIA breast cancer involving 10 or more axillary lymph nodes were randomized after surgery and standard adjuvant chemotherapy to either high-dose cyclophosphamide, cisplatin, and carmustine (HD-CPB) with stem-cell support or intermediate-dose cyclophosphamide, cisplatin, and carmustine (ID-CPB) with G-CSF support but without stem cells. Planned treatment for all patients included locoregional radiation therapy. Hormone-receptor-positive patients were to receive 5 years of tamoxifen. Event-free survival (EFS) was the primary end point.

RESULTS

Median follow-up was 7.3 years. Event-free survival was not significantly different between the two treatment groups (P = .24). The probability of being free of an event at 5 years with HD-CPB was 61% (95% CI, 56% to 65%), and was 58% (95% CI, 53% to 63%) for ID-CPB. Thirty-three patients died of causes attributed to HD-CPB, compared with no therapy-related deaths among women treated with ID-CPB. Overall survival for the two arms was identical at 71% at 5 years (P = .75).

CONCLUSION

HD-CPB with stem-cell support was not superior to ID-CPB for event-free or overall survival among all randomized women with high-risk primary breast cancer.

Psychosocial adjustment and quality of life among multiple myeloma patients undergoing evaluation for autologous stem cell transplantation

Stem cell transplantation has assumed a prominent place in the treatment of multiple myeloma, but relative to patients with other malignancies there is surprisingly little information about the adjustment difficulties and quality-of-life changes that these patients experience. This study examined psychosocial and functional deficits among myeloma patients assessed at a uniform period during their initial diagnostic evaluation, prior to beginning protocols at a transplant center. Validated self-report measures and clinician rating scales were used to assess 213 patients. Outcomes evaluated included emotional distress (Hospital Anxiety and Depression Scale, Brief Symptom Inventory), depression (Hamilton Depression Rating Scale), physical functioning, pain, and energy (SF-12). A significant proportion of patients experienced compromised psychosocial and physical functioning. Roughly one-third reported clinically elevated levels of distress, anxiety, and depression. In all, 59% scored below age-adjusted norms for daily physical functioning, 58% reported at least moderate levels of pain, and over 80% noted at least moderate fatigue. Clinical and demographic correlates of these outcomes were examined. These findings are among the first to characterize quality-of-life outcomes among myeloma patients in the transplant setting, and indicate that many patients experience considerable supportive care needs even prior to beginning aggressive regimens. Results highlight the importance of early screening.

Quantitative measurement of quality of life in adult patients undergoing bone marrow transplant or peripheral blood stem cell transplant: a decade in review

PURPOSE/OBJECTIVES

To critically evaluate a decade of quantitative quality-of-life (QOL) measurement in adult patients undergoing bone marrow transplant (BMT) or peripheral blood stem cell transplant (PBSCT).

DATA SOURCES

Quantitative research articles published between January 1990 and January 2000 in the nursing and medical literature.

DATA SYNTHESIS

QOL measures reported in BMT and PBSCT literature support the multidimensional nature of the construct. The majority of studies used a single instrument to assess QOL. Variations in measurement included use of a single versus multiple instruments to assess QOL, theoretical underpinnings of instruments, and output (overall score, domain scores) provided by the instruments.

CONCLUSIONS

A study's purpose, conceptual approach, patient burden, and resources available to the researcher should guide decisions regarding QOL instrumentation. No gold standard exists for assessing QOL in research or clinical practice.

IMPLICATIONS FOR NURSING

Nurses can select from a variety of tools to measure QOL in the BMT and PBSCT patient populations. Clinicians must consider the clinical meaningfulness of changes in QOL before implementing changes in their practice.

Preliminary evaluation of a clinical syndrome approach to assessing cancer-related fatigue

The objectives of this study were to evaluate the reliability, validity, and utility of a newly developed clinical syndrome approach to assessing cancer-related fatigue. Fifty-one patients who underwent blood or marrow transplantation an average of 6.9 months previously were administered a standardized interview designed to identify the presence of a clinical syndrome of cancer-related fatigue. Patients also completed self-report measures of fatigue, depression, and health-related quality of life. Comparisons among independent raters demonstrated high rates of reliability for the presence or absence of a cancer-related fatigue syndrome and its symptoms. Twenty-one percent of patients (n = 11) were found to meet criteria for diagnosis of a cancer-related fatigue syndrome. Compared to patients not meeting the diagnostic criteria, patients meeting the criteria reported fatigue that was greater (P < or = 0.05) in its severity, frequency, pervasiveness, and interference with quality of life. Patients who met criteria also demonstrated poorer role functioning, less vitality, and more depressive symptomatology (P < or = 0.05). These findings provide preliminary evidence of the reliability and validity of the methods used to assess the proposed clinical syndrome and suggest their utility in identifying patients experiencing clinically significant cancer-related fatigue.

Quality of life and rehabilitation in social and professional life after autologous stem cell transplantation

BACKGROUND

In this study, we report on quality of life (QOL) in long-term survivors after high-dose chemotherapy and autologous stem cell transplantation (ASCT) with special emphasis on rehabilitation in social and professional life.

PATIENTS AND METHODS

The European Organization of Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ)-C30 questionnaire was sent by mail to 391 patients 1 to 12 years (median 31 months) after ASCT. The procedure was performed at our institution alone. Of the questionnaires 78% were returned and evaluated.

RESULTS

Of the 238 patients who had an occupation and were employed, 132 (55%) have returned full time (68%) or part time (32%) to their previous occupation. A total of 139 patients (46%) received a 3- to 4-week inpatient rehabilitation treatment in specialised institutions following ASCT. Employment status post-transplantation and QOL were similar in these patients as compared with those who did not participate in rehabilitation programmes. Of the 304 evaluable patients, 39% reported physical problems that reduced their satisfaction with sex and intimacy. The general QOL was significantly reduced in the first year, improved with interval to transplant, and reached the level of the general population after 4 years.

CONCLUSIONS

Our retrospective data showed that ASCT has a significant, unfavourable impact on QOL, including reintegration into social and professional life. Most symptoms and scores returned to normal after 3 to 6 years. Employment status and QOL were similar in patients who participated in a rehabilitation programme and those who did not.

Longitudinal effects of high-dose chemotherapy and autologous stem cell transplantation on quality of life in the treatment of metastatic breast cancer

This study determined the effects of high-dose chemotherapy (HDCT) with autologous blood stem cell transplantation (ASCT) on quality of life (QL) in women with metastatic breast cancer prior to, and during treatment, and up to 1-year post-ASCT. Thirty-three women diagnosed with metastatic breast cancer participated in a phase 1 clinical trial of a new combination of cyclophosphamide (CTX) and mitoxantrone (MXT), with dose escalation of paclitaxel. Longitudinal QL data were collected using the functional living index-cancer (FLIC) and symptom scales at seven time periods: pre-induction chemotherapy (CT), post-induction CT, post-high dose CT (HDCT), and at 3, 6, 9 and 12 months post-ASCT. FLIC scores indicated that the worst problems for patients were feelings of hardship on themselves and their families, followed by psychological functioning and physical functioning problems. The time around diagnosis of the metastatic disease and following HDCT were the worst times for all levels of quality of life, but anxiety and depression symptoms continued to increase in severity across the entire follow-up period. The symptoms that were most problematic were worry about the future, loss of sexual interest, anxiety about the treatment, general worrying, and joint pain. These data highlight the problems that women with metastatic breast cancer encounter at different stages of the disease and treatment process, and can be used to tailor psychosocial interventions appropriate for treating the relevant issues at different points in time.

Secondary leukaemia and myelodysplasia after autografting for lymphoma: is the transplant to blame?

Haemopoietic stem cell autografting is becoming a standard part of the therapeutic repertoire for salvage of relapsed lymphoma patients. Over the last five years or so a number of studies have identified that such patients are at high risk of developing secondary acute myeloid leukaemia (AML) or myelodysplastic syndromes (MDS). The actuarial risks have been estimated to be up to 18% in some series. More recently, studies from France and the EBMT suggest that in Registries containing large numbers of transplanted patients the risks are lower and are of the order of 3-5% at five years. Cytogenetic examination of bone marrow cells taken pre-transplant may also show identical abnormalities to those found in the leukaemic clone after transplant indicating that in many instances the stem cell damage was caused by prior treatment. In addition, a report from the British National Lymphoma Investigation has identified that post-transplant MDS/AML was related to the total quantity of treatment received, with mustine being identified as a particular culprit. It thus seems probable that the additional stem cell insult offered by the transplant may be small although a factor which may increase the risk is the use of total body irradiation.