Effect of the severity of acute graft-versus-host disease on physical function after allogeneic hematopoietic stem cell transplantation

Phase 2 study of natalizumab plus standard corticosteroid treatment for high-risk acute graft-versus-host disease

Graft-versus-host disease (GVHD) of the gastrointestinal (GI) tract is the main cause of nonrelapse mortality (NRM) after allogeneic hematopoietic cell transplantation. Ann Arbor (AA) scores derived from serum biomarkers at onset of GVHD quantify GI crypt damage; AA2/3 scores correlate with resistance to treatment and higher NRM. We conducted a multicenter, phase 2 study using natalizumab, a humanized monoclonal antibody that blocks T-cell trafficking to the GI tract through the α4 subunit of α4β7 integrin, combined with corticosteroids as primary treatment for patients with new onset AA2/3 GVHD. Seventy-five patients who were evaluable were enrolled and treated; 81% received natalizumab within 2 days of starting corticosteroids. Therapy was well tolerated with no treatment emergent adverse events in >10% of patients. Outcomes for patients treated with natalizumab plus corticosteroids were compared with 150 well-matched controls from the MAGIC database whose primary treatment was corticosteroids alone. There were no significant differences in overall or complete response between patients treated with natalizumab plus corticosteroids and those treated with corticosteroids alone (60% vs 58%; P = .67% and 48% vs 48%; P = 1.0, respectively) including relevant subgroups. There were also no significant differences in NRM or overall survival at 12 months in patients treated with natalizumab plus corticosteroids compared with controls treated with corticosteroids alone (38% vs 39%; P = .80% and 46% vs 54%; P = .48, respectively). In this multicenter biomarker-based phase 2 study, natalizumab combined with corticosteroids failed to improve outcome of patients with newly diagnosed high-risk GVHD. This trial was registered at www.clinicaltrials.gov as # NCT02133924.

Minimal important difference of the 6-minute walk test after allogenic hematopoietic stem cell transplantation

PURPOSE

The 6-min walk test (6MWT) of allogenic hematopoietic stem cell transplantation (allo-HSCT) recipients has been gaining attention; however, minimal differences have not been reported. This study aimed to determine the minimal important difference (MID) in the 6MWT among hospitalized patients with allo-HSCT.

MATERIALS AND METHODS

The MID of the 6MWT was calculated using three different methodologies based on an anchor-based method; basic anchor-based methods, linear regression analysis, and receiver operating characteristic (ROC) curve analysis. The decrease in the score of Question 2 of the European Organization for Research and Treatment of Cancer Quality of life questionnaire core-30 was included as an anchor question for calculating the MID. Both actual and percentage changes in 6MWT values from baseline and at discharge were used in the MID calculations. In the actual and percentage change of the 6MWT, the one with the larger the area under the curve in the ROC curve was recommended as the MID.

RESULTS

Among the three methods using actual values, the largest MID of the 6MWT was -37.5 m (sensitivity: 54%, specificity: 88%).

CONCLUSION

More careful follow-up after discharge is necessary for allo-HSCT patients who show a reduction of 37.5 m or more in the acute illness phase.

Effect of rehabilitation in patients undergoing hematopoietic stem cell transplantation

Patients undergoing hematopoietic stem cell transplantation (HSCT) tend to experience decline in physical function, mental function, and quality of life (QOL) after HSCT due to low activity caused by adverse reactions to chemotherapy used in pre-transplantation treatment and post-transplant complications. Rehabilitation for HSCT patients is effective in preventing decline in physical function, reducing fatigue, and improving QOL. A combination of aerobic exercise and strength training is recommended for exercise therapy. Risk management is also important in the implementation of exercise therapy, and the exercise intensity should be determined according to the presence of anemia, low platelet counts, or post-transplant complications. On the other hand, post-transplant complications can decrease the patient's motivation and daily activity level. A multidisciplinary approach, which includes physicians and nurses, is important to achieve early discharge from the hospital and as quick a return to society as possible.

Belt Electrode-Skeletal Muscle Electrical Stimulation During Early Hematopoietic Post-Transplantation To Prevent Skeletal Muscle Atrophy and Weakness

A decline in physical functions at the early stage of allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a serious issue. Belt electrode-skeletal muscle electrical stimulation (B-SES) can induce significant muscle contractions with electrical stimulation and reduce muscle weakness. However, this approach has not been used in allo-HSCT patients. This study aimed to examine the effect of B-SES on physical function, and safety in patients during the early post-transplantation period. Forty-three adult patients who underwent B-SES after allo-HSCT were stratified into 2 groups based on the intensity of electrical stimulation (high versus low). B-SES was performed in combination with exercise therapy for 4 post-transplantation weeks. Knee extensor strength (KES) in the low B-SES group decreased significantly, whereas no change was observed in the high-intervention group. A significant positive correlation was observed between total intensity and ΔKES. A reduction in the 6-minute walking distance in the high B-SES group patients was lower than that of historical data. Two patients had B-SES-related complications including muscle pain. This study is the first to propose a new rehabilitation intervention strategy for allo-HSCT. Combined use of B-SES may be a new approach to reducing the decline of physical function in the early post-transplantation period.

Late Effects of Severe Acute Graft-versus-Host Disease on Quality of Life, Medical Comorbidities, and Survival

Grade III-IV acute graft-versus-host disease (aGVHD) is associated with high short-term morbidity and mortality following allogeneic hematopoietic cell transplantation (HCT). The long-term effects after recovery from grade III-IV aGVHD are unknown. This study aimed to analyze late medical comorbidities, quality of life, nonrelapse mortality, and survival in patients treated for grade III-IV aGVHD. Chart review identified late effects, and patients were asked to complete annual surveys to collect patient-reported outcomes. Outcomes were compared between patients with grade 0-I aGVHD and grade III-IV aGVHD who underwent HCT between 2001 and 2019 and survived for at least 1 year post-transplantation. Patients with a history of grade III-IV aGVHD (n = 192) had significantly higher rates of late medical comorbidities (P < .001) and worse physical (P = .01) and mental (P = .04) functioning compared with patients with grade 0-I aGVHD (n = 615). Patients who survived for >1 year post-transplantation and had prior grade III-IV aGVHD also had worse 5-year overall survival (77.5% versus 83.6%; P = .006) and higher nonrelapse mortality (19.2% versus 10.6%; P < .001) compared with those with a history of grade 0-I aGVHD. No between-group difference was found in cumulative incidence of chronic GVHD. Patients who recover from severe aGVHD remain vulnerable to developing late comorbidities. These patients would likely benefit from continued monitoring and supportive care in an attempt to prevent late effects and improve survival.

Reliability and validity of ultrasound to measure of muscle mass following allogeneic hematopoietic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients frequently show physical dysfunction due to loss of muscle mass. This study aimed to clarify the reliability and validity of ultrasound in evaluating muscle mass and to analyze the patterns of change in muscle mass before and after allo-HSCT. We conducted a prospective observational study using data from 68 patients who had undergone their first allo-HSCT. We evaluated the thickness of the quadriceps, biceps, and suprahyoid muscle. Three individual evaluators underwent this examination for each muscle before transplantation and on days 30, 90, and 180 after allo-HSCT. Inter-rater reliability was calculated using the interclass correlation (ICC), and the level of correlation between muscle mass measured by ultrasound and psoas muscle mass assessed using computed tomography (CT) was assessed using Pearson correlation. ICC values ranged from 0.897 to 0.977 in the measurement. The correlation scores were 0.730, 0.546 and 0.579 between psoas muscle and the biceps, quadriceps, and suprahyoid muscle. The thickness of the biceps and quadriceps muscle were both significantly decreased after allo-HSCT from baseline. These results showed that the ultrasound technique was a reliable tool for evaluating muscle mass and detecting changes in muscle mass following allo-HSCT.

Evaluation of indices for predicting recovery of exercise tolerance in patients surviving allogenic hematopoietic stem cell transplantation

PURPOSE

Decline in physical function in the early stage after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a major challenge. Exercise tolerance tests, such as the 6-min walk test, are useful markers for predicting exercise tolerance and various other traits, including cardiometabolic risk and non-relapse mortality. This retrospective cohort study aimed to investigate and identify predictors of recovery of exercise tolerance in the early stage after allo-HSCT.

METHODS

Ninety-eight patients were classified into recovery and non-recovery groups according to the median 6-min walk distance (6MWD) at discharge.

RESULTS

Logistic regression analysis revealed that pre-post change in knee extensor strength (ΔKES) and hematopoietic cell transplantation comorbidity index were useful predictors of recovery of exercise tolerance at discharge and moderate predictors of 6MWD recovery in the early post-transplant period. Receiver operating characteristic analysis showed that pre-transplant ΔKES was an accurate predictor of 6MWD recovery in the early post-transplant period. The cutoff point for ΔKES calculated using the Youden index was - 1.17 Nm/kg.

CONCLUSIONS

The results of this study emphasize the importance of the need for programs designed to prevent muscle weakness in the early period after allo-HSCT. The results from markers of recovery of exercise tolerance are promising and can be used for patient education in rehabilitation programs after allo-HSCT.

Improvement in the Physical Function and Quality of Life through Exercise and Physical Activity Intervention Using a Smartphone after Allogeneic Hematopoietic Cell Transplantation: A Case Report

PURPOSE

Physical activity (PA) interventions positively affect the physical function (PF) in patients with advanced cancer. However, patients must remain motivated during the intervention. We report a case wherein a smartphone application for PA intervention was useful in motivating the patient to improve adherence.

METHODS

A 40-year-old woman underwent an allogeneic hematopoietic cell transplantation (allo-HCT) for an advanced extranodal natural killer/T-cell lymphoma. On day 6, she developed the posterior reversible encephalopathy syndrome. She was managed in the intensive care unit for 3 days, and her PF declined markedly. We initiated a smartphone-based PA intervention from day 35. She was instructed to maintain a PA diary for self-monitoring of the daily steps and to set a new step-count goal every week.

RESULTS

The PA and PF improved within a short period thereafter. However, she developed severe acute graft-versus-host disease and was administered with high-dose systemic corticosteroids from day 49. The PA, PF, and quality of life (QOL) decreased again. The intervention was continued for 5 months with a high adherence. The PA, PF, and QOL improved gradually. She resumed independent activities of daily living and was discharged on day 202.

CONCLUSION

Smartphone-based PA intervention may be effective against post-allo-HCT physical dysfunction.

What else do I need to worry about when treating graft-versus-host disease?

Graft-versus-host disease (GVHD) is the main cause of morbidity and mortality in allogeneic hematopoietic stem cell transplant survivors. Patients with acute and chronic GVHD often endure substantial symptom burden and quality of life (QOL) and functional impairments. Living with GVHD affects multiple domains of patient-reported QOL, physical functioning, and psychological well-being. Patients describe living with GVHD as a life-altering "full-time job" requiring unique knowledge, personal growth, and resilient coping strategies. Managing the supportive care needs of patients living with GVHD must include (1) monitoring of patient-reported QOL and symptom burden; (2) routine screening for psychological distress and implementing therapeutic strategies to treat depression, anxiety, and posttraumatic stress symptoms; (3) a systematic review of care needs by a multidisciplinary team experienced in managing transplant-related complications and organ-specific GVHD symptoms; and (4) ensuring optimal prevention and management of infection complications in this highly immunocompromised population. Improving the QOL in patients with GVHD requires a multidisciplinary approach with emphasis on aggressive symptom management, psychological coping, and promoting physical activity and rehabilitation in this population living with immense prognostic uncertainty and struggling to adapt to this difficult and unpredictable illness.

Feasibility of early-commencing group-based exercise in allogeneic bone marrow transplantation: the BOOST study

Increasing evidence supports that individualised exercise is safe and beneficial for adults treated with allogeneic bone marrow transplantation (alloBMT), although this is not part of standard care and no research has investigated group-based interventions. This study aimed to determine safety, feasibility and exploratory effects of a supervised group-based inpatient and subsequent home-based exercise programme in alloBMT. This single-site prospective cohort study included consecutive adults treated with alloBMT for haematological disease. All participants received usual care in addition to the protocolised exercise programme pre-transplant until 60 days post transplant. The primary outcome was feasibility; secondary outcomes included exercise capacity, frailty, health-related quality of life and strength. Consent rate was 100% (n = 42); 83% (n = 35) completed all aspects of the intervention and outcome testing; of those, 83% (n = 29) attended ≥2 group-exercise sessions per week; no adverse events occurred. Emotional well-being significantly improved over time, which may highlight benefits of group-based intervention. Other outcomes significantly declined from pre-BMT to hospital discharge, with some improvement at 60 days post-BMT. Participants with early signs of frailty demonstrated the greatest decline in outcomes. Group-based exercise was safe and feasible; observations from this study highlight the importance of baseline identification of frailty to target intervention at those who need it most.

Analysis of factors associated with patient-reported physical functioning scores at discharge of allogeneic hematopoietic stem cell transplantation patients: a cross-sectional study

PURPOSE

The purpose of this study was to clarify the independent factors related to patient-reported physical functioning (PF) scores at discharge of patients who underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

A total of 103 patients who underwent allo-HSCT were included in this cross-sectional study. As a screening method, a single regression analysis was conducted with the PF domain in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 at discharge as the dependent variable, and body mass index, adverse events related to HSCT, and objective physical functions as independent variables. Multiple regression analysis was performed with PF as the dependent variable and variables that passed the screening by single regression analysis and confounders as independent variables.

RESULTS

The mean PF score at discharge of the patients was 76.5 (standard deviation: 15.2). Based on the results of screening by the single regression analysis, length of stay, infections (+ / -), acute graft-versus-host disease grade, brief fatigue inventory score (BFI), knee extensor strength, and 6-min walk distance (6MWD) were included in the multiple regression analysis. BFI (B =  - 11.94, p < 0.001) and 6MWD (per 10 m) (B = 0.56, p = 0.001) were extracted as significant independent variables governing the PF at discharge in the multiple regression model (adjusted R² = 0.59).

CONCLUSION

Higher exercise tolerance and lower fatigue in patients who underwent allo-HSCT were associated independently with patient-reported better PF scores at discharge.

Burden and Needs of Patients with Severe GvHD from the Supportive and Palliative Care Perspective-A Literature Review

Simple Summary

Patients who have been treated with an allogeneic, hematopoietic stem cell transplantation can develop severe graft-versus-host disease. This complication may place patients in a life-threatening situation, in which a curative goal of care can no longer be achieved and needs to be changed into a palliative one. In our clinical experience, this patient group is very heterogenous, with a high disease burden and special needs that are often overlooked. In this review, we summarize the current literature on the needs and burdens of patients with severe forms of graft-versus-host disease from a supportive and palliative care perspective to draw a comprehensive picture of this patient group. Despite a fundamental lack of studies, the findings suggest that the more severe the GvHD, the worse the quality of life and physical functioning. The relative void of data highlights the need for research on this special issue in order to optimize the treatment and care of patients with severe graft-versus-host disease.

Abstract

Graft-versus-host disease (GvHD) is a frequent, and often life-threatening, complication after an allogeneic, hematopoietic stem cell transplantation (allo-SCT). It can appear in an acute or a chronic form and presents different grades of severity. Particularly, the severe forms of GvHD are often responsible for a change of the curative intent for allo-SCT into a palliative goal of care. For this non-systematic review, we conducted a focused literature search in the MEDLINE database via PubMed to examine whether patients with severe forms of GvHD might have special needs and burdens from a supportive and palliative care perspective. To draw a comprehensive picture of this patient group, we included findings on quality of life (QoL) and physical symptoms and function as well as psychological and spiritual well-being. In most domains, patients with severe forms of GvHD showed greater impairment and a higher symptom burden compared to patients with milder forms of GvHD. However, we could not identify any studies that specifically investigated patients with severe forms of GvHD. Further research in this field is necessary to guarantee the highest standard of care for this very special patient group.

Pre-transplant Rehabilitation to Decrease the Post-transplant Length of Stay for Hematological Malignancy Patients Undergoing Allo-HSCT

Objectives:

Pre-transplant rehabilitation for hematological malignancy patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) helps improve physical capacity. However, its benefit with respect to post-transplant hospital length of stay (LOS) is unclear. Consequently, the aim of this study was to investigate the effect of pre-transplant rehabilitation on post-transplant LOS for hematological malignancy patients undergoing allo-HSCT.

Methods:

Data on patients diagnosed between April 2014 and March 2017 were collected from the Japanese Diagnosis Procedure Combination database. The patients were identified using the ICD-10 codes C81–85, C90–94, C96, and D46. Multilevel linear regression analyses were conducted to identify the effects of pre-transplant rehabilitation on post-transplant LOS (log transformed).

Results:

In total, 3614 patients were included in the study. Pre-transplant rehabilitation was associated with a significant reduction in post-transplant hospital LOS (β=–0.134, P<0.001).

Conclusions:

Pre-transplant rehabilitation may be an effective strategy for shortening the post-transplant hospital LOS in hematological malignancy patients undergoing allo-HSCT. Consequently, it may be necessary to consider starting rehabilitation before transplantation.

Higher exercise tolerance early after allogeneic hematopoietic stem cell transplantation is the predictive marker for higher probability of later social reintegration

As the proportion of long-term survivors after allogeneic hematopoietic stem cell transplantation (allo-HSCT) is on the rise, it is essential to consider the significance of quality of life (QOL), including reintegration with society (returning to school or work). This retrospective cohort study aims to illustrate the precise epidemiology of social reintegration later after allo-HSCT and determine its predictive indicators. We enrolled 56 patients, and 40 patients (71%) attained social reintegration at 2 years post-HSCT. Reintegration failure markedly correlated with an inferior performance status and concurrent chronic graft-versus-host disease. In non-reintegrated patients, the physical function at discharge measured by the 6-min walking distance (6MWD) was markedly decreased. On the multivariate risk analyses, sex (female; odds ratio (OR) 0.07; 95% confidence interval (CI) 0.01–0.54; p = 0.01), HCT-CI (≥ 2; OR 0.10; 95% CI 0.01–0.84; p = 0.03), and change in 6MWD (per 5% increase; OR 1.47; 95% CI 1.01–2.13; p = 0.04) were significant predictors of later social reintegration. This study suggests that a multidisciplinary strategy including rehabilitation is essential, especially in patients with poor predictive markers at an early phase, and we should consider suitable rehabilitation programs to prevent a decline in exercise tolerance and improve social reintegration and overall QOL in patients after allo-HSCT.

Muscle oxygen extraction and lung function are related to exercise tolerance after allogeneic hematopoietic stem cell transplantation

PURPOSE

This study aimed to investigate the relationship between exercise intolerance, muscle oxidative metabolism, and cardiopulmonary function following allogeneic hematopoietic stem cell transplantation (allo-HSCT) in a sterile isolation room setting.

METHODS

This was a prospective observational cohort study conducted in a single center. Fourteen patients with hematopoietic malignancies who had undergone allo-HSCT were included in this study from June 2015 to April 2020. Patients received donor HSCT after high dose-chemotherapy and total-body irradiation. Physical activity was limited during treatments. Outcome measures included body anthropometric measurements, exercise tolerance tests using the ramp protocol, pulmonary function tests, and near-infrared spectroscopy (NIRS) measurements. Data of pre- and posttransplant measurements were compared using the paired t test or nonparametric Wilcoxon U test. Associations were assessed using the Pearson or nonparametric Spearman correlations.

RESULTS

NIRS showed reduced muscle consumption and extraction of oxygen in the posttransplant period compared to the pretransplant period (ΔStO_{2 min} pre: -18.6% vs. post: -13.0%, P = 0.04; ΔHHb _max pre: 4.21μmol/l vs. post: 3.31μmol/l: P = 0.048). Exercise tolerance had reduced following allo-HSCT (Peak workload pre: 70.3 W vs. post: 58.0 W: P = 0.014). Furthermore, exercise intolerance was associated with pulmonary function, muscle oxygen consumption, and muscle oxygen extraction (all P <0.05).

CONCLUSION

This analysis revealed that exercise intolerance following allo-HSCT was associated with pulmonary dysfunction and muscle oxidative dysfunction. These findings could help identify the physical function associated with impaired tissue oxygen transport leading to exercise intolerance following allo-HSCT.

Screening supportive care needs, compliance with exercise program, quality of life, and anxiety level during the COVID-19 pandemic in individuals treated with hematopoietic stem cell transplantation

Purpose

The primary aim was to assess supportive care needs, compliance with home exercise program, quality of life level (QOL), and anxiety level during the COVID-19 pandemic in individuals treated with hematopoietic stem cell transplantation (HSCT). The secondary aim was to investigate demographic and medical factors associated with the recorded outcomes.

Methods

The present study included individuals treated with HSCT and previously referred to physical therapy. The data were collected by interviews with the participants on the phone. Supportive care needs were assessed using the Supportive Care Needs Survey-Short Form 29^TR. Compliance with the exercise program was recorded as the number of patients regularly performed strengthening and stretching exercises and the ratio of the walking duration to the recommended duration. The European Cancer Research and Treatment Organization Quality of Life Questionnaire-Cancer30 was used to assess the QOL. The State-Trait Anxiety Inventory-I and the Visual Analogue Scale were used to assess anxiety level.

Results

The present study included 101 individuals treated with HSCT. The psychological and physical supportive care needs were predominant in participants. Compliance with exercise program was low. General anxiety level was low, yet anxiety about COVID-19 was moderate level in participants. Supportive care needs were related to female gender, performance level, time since HSCT, and QOL level (p ˂ 0.05). Anxiety level was correlated with supportive care needs, COVID-19-related anxiety, and QOL (p ˂ 0.05). Compliance with exercise program was associated with age, performance level, and QOL (p ˂ 0.05).

Conclusion

Our results offer that supportive telehealth interventions should be considered during the COVID-19 pandemic for individuals treated with HSCT to decrease unmet supportive care needs and isolation-related physical inactivity.