Psychosocial risk predicts high readmission rates for hematopoietic cell transplant recipients

eHealth mindfulness-based music therapy for patients undergoing allogeneic hematopoietic stem cell transplantation: A pilot randomized controlled trial protocol

BACKGROUND

Allogeneic stem cell transplantation (allo-SCT) is the preferred therapy for patients with high-risk or relapsed hematologic malignancies, but may be complicated by psychological distress (e.g., depression, anxiety) and symptom burden (e.g., fatigue, pain). Mindfulness-based music therapy (MBMT), a relatively novel integrative medicine intervention that draws from mindfulness and music therapy principles, has shown promise in improving psychosocial outcomes and symptom burden in cancer patients. We outline an eHealth-based MBMT (eMBMT) intervention protocol examining: (1) feasibility, acceptability, and intended effects of eMBMT in improving HRQOL, symptom burden, and clinical markers of disease activity (e.g., infections), and (2) the extent to which eMBMT music therapy component-associated improvements in HRQOL, symptom burden, and disease activity are mediated by improvements in psychosocial and physiological (e.g., systemic inflammation, immune recovery) adaptation.

METHODS

Participants (n = 60) with a hematologic malignancy undergoing allo-SCT will be randomized to receive eMBMT or an eHealth-based mindfulness meditation (eMM) intervention. eMBMT includes eight 60-min sessions facilitated by a music therapist focusing on mindfulness and music therapy. eMM includes eight 60-min self-led MM practices.

RESULTS

Feasibility, acceptability, HRQOL, symptom burden, disease activity, and mediation effects of psychosocial and physiological adaptation will be assessed at baseline, pre-infusion, and post-engraftment with blood collection at baseline and post-engraftment.

CONCLUSION

The current pilot RCT is the first eMBMT intervention to address the HRQOL and symptom burden of patients who are undergoing allo-SCT. Results will inform a fully powered RCT to establish preliminary efficacy of eMBMT on improvements in HRQOL, symptom burden, and disease activity.

Psychoneuroimmunology in multiple myeloma and autologous hematopoietic stem cell transplant: Opportunities for research among patients and caregivers

Multiple myeloma (MM) is an incurable cancer and is the leading indication for autologous hematopoietic stem cell transplantation (HSCT). To be eligible for HSCT, a patient must have a caregiver, as caregivers play a central role in HSCT preparation and recovery. MM patients remain on treatment indefinitely, and thus patients and their caregivers face long-term challenges including the intensity of HSCT and perpetual therapy after transplant. Importantly, both patients and their caregivers show heightened depressive and anxiety symptoms, with dyadic correspondence evidenced and caregivers' distress often exceeding that of patients. An extensive psychoneuroimmunology (PNI) literature links distress with health via immune and neuroendocrine dysregulation as well as biological aging. However, data on PNI in the context of multiple myeloma - in patients or caregivers - are remarkably limited. Distress in MM patients has been associated with poorer outcomes including higher inflammation, greater one year post-HSCT hospital readmissions, and worse overall survival. Further, anxiety and depression are linked to biological aging and may contribute to the poor long-term health of both patients and caregivers. Because MM generally affects older adults, individual differences in biological aging may represent an important modifier of MM biology and HSCT treatment outcomes. There are a number of clinical scenarios in which biologically younger people could be prescribed more intensive therapies, with potential for greater benefit, by using a personalized cancer therapy approach based on the quantification of physiologic reserve. Further, despite considerable psychological demands, the effects of distress on health among MM caregivers is largely unexamined. Within this context, the current critical review highlights gaps in knowledge at the intersection of HSCT, inflammation, and biological aging in the context of MM. Research in this area hold promise for opportunities for novel and impactful psychoneuroimmunology (PNI) research to enhance health outcomes, quality of life, and longevity among both MM patients and their caregivers.

Coping in patients with hematologic malignancies undergoing hematopoietic cell transplantation

ABSTRACT

Patients undergoing hematopoietic cell transplantation (HCT) must cope with physical and psychological symptoms. Yet, studies examining pre-HCT coping are limited. We aimed to characterize pre-HCT coping, evaluate the association of coping with baseline quality of life (QOL) and psychological distress, and identify sociodemographic factors associated with pre-HCT coping. We conducted a cross-sectional analysis of baseline data from a multisite randomized supportive care intervention trial among patients with hematologic malignancies undergoing allogeneic or autologous HCT. We assessed patient-reported QOL, psychological distress, and coping within 72 hours of admission for HCT. We used the median split method to dichotomize coping and multivariate regression analyses to characterize the association of coping with psychological distress and QOL. Of patients awaiting HCT (n = 360; mean age, 55.4 years; 49.7% autologous), 43.5% were high users of approach-oriented coping, whereas 31.3% were high users of avoidant coping. Patients reported high use of emotional support (60.9%), acceptance (51.2%), self-blame (33%), and denial (31.3%). Older age (≥65 years) was associated with less frequent use of avoidant coping (odds ratio, 0.5; P = .01). Approach-oriented coping was associated with better pre-HCT QOL (Beta(B) = 6.7; P = .001), and lower depression (B = -1.1; P = .001) and anxiety (B = -0.9; P = .02) symptoms. Avoidant coping was associated with worse pre-HCT QOL (B = -13.3; P < .001) and symptoms of depression (B = 1.9; P < .001), anxiety (B = 3.1; P < .001), and posttraumatic stress disorder (B = 8.1; P < .001). Pre-HCT coping is strongly associated with psychological distress and QOL. These data support the need for interventions to address coping during HCT hospitalization. This clinical trial was registered at www.clinicaltrials.gov as #NCT03641378.

A prospective study of the relationship between illness perception, depression, anxiety, and quality of life in hematopoietic stem cell transplant patients

AIM

The aim of study was to investigate whether depression and anxiety symptoms and illness perception prior to hematopoietic stem cell transplantation (HSCT) predict health related quality of life (HRQOL) at Day 100 and 1 year following HSCT.

METHODS

A total of 205 patients who underwent HSCT (N = 127 autologous transplants, N = 78 allogeneic transplants) were included in this prospective study. Baseline assessment was assessed prior to transplantation and post HSCT data were collected at Day 100 and 1 year. At baseline we assessed depressive symptoms (Patient Health Questionnaire-9), anxiety symptoms (Generalized Anxiety Disorder-7), illness perception (Brief Illness Perception Questionnaire), and HRQOL (Functional Assessment of Cancer Therapy-BMT).

RESULTS

Patients who expressed a greater level of concern about the severity, course, and ability to exert control over one's illness (i.e., illness perception) and who reported a greater level of depression and anxiety symptoms prior to HSCT reported lower HRQOL at both Day 100 and 1 year posttransplant, with a similar degree of association observed at the two follow-up time points.

CONCLUSIONS

Our findings suggest that pretransplant perceptions about their illness and negative mood are significant predictors of HRQOL following HSCT. Illness perception, depression, and anxiety are potentially modifiable risk factors for less than optimal outcome after HCSCT and intervention strategies should be explored.

[Allogeneic hematopoietic stem cell transplantation and treatment with CAR-T cells - identification of psycho-social vulnerability factors: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

Allogeneic hematopoietic stem cell transplantation (HCT) and CAR-T cells therapy are treatments with curative aim for certain hematological malignancies, refractory or relapse. Nevertheless, they carry the risk of morbidity and mortality and may have a significant psychosocial impact, particularly for HCT. It is therefore necessary to identify psychological difficulties and social problems, as well as the patient's resources, and those of his entourage, in order to improve his overall management. The objective of this evaluation is not to pose contraindications to treatments, but to adapt the personalized care project. This identification must be carried out early on in the pre-HCT assessment journey to enable the implementation of appropriate actions by the various care providers. Based on a review of the literature, we designed a psychosocial data collection grid that can be initiated in pre-transplant and updated by accompanying the patient at each stage of follow-up (discharge from hospital, day-hospital follow-up, D100 evaluation). This grid is divided into 3 axes: socio-family context, psychological and somatic aspects. This tool allows the traceability of the interventions of different professionals and is a support for multidisciplinary exchanges.

Psychosocial assessment practices for hematopoietic stem cell transplantation: a national survey study

Psychosocial health predicts and contributes to medical outcomes for patients undergoing hematopoietic stem cell transplantation (HSCT). Yet, there are no standards for psychosocial assessments or support for both patients and caregivers across the care continuum. To examine the current state of psychosocial care, clinicians were sent a survey of their psychosocial assessment practices for patients and caregivers undergoing HSCT via the Listservs of professional organizations. Descriptive statistics and bivariate analyses were performed to summarize the findings. While 96% of participants reported routine pre-HSCT psychosocial assessment of patients, only 10.6% routinely used a validated transplant risk-assessment measure. Just 27% routinely performed follow-up psychosocial assessments. In contrast, only 47% of participants routinely assessed the psychosocial needs of family caregivers pre-HSCT, and 13% routinely performed follow-up assessments for caregivers. Most (90%) reported social workers were the primary providers of assessments. While patient-report measures were used for evaluation, the majority of assessments were clinical interviews. No significant differences were found between programs that treated adult and pediatric patients versus those only treating adult patients. Our findings highlight the lack of standard psychosocial practices for patients and family caregivers undergoing HSCT and we offer recommendations to fill this gap.

Standardization of Pediatric Hematopoietic Stem Cell Transplant Patient Discharge to Reduce Readmission Rates

Background: The time period after a pediatric hematopoietic stem cell transplant (P-HSCT) is tenuous as the patient is severely immunocompromised and awaiting immune reconstitution. Managing activities of daily living and medication administration after discharge from the hospital requires 24-hour care placing a heavy burden on caregivers and patients. Patients who do not adhere to the posttransplant regimen are at a higher risk for hospital readmission within the first 30 days of initial discharge with serious potential for life-threatening complications. The objective of this project was to improve 30-day readmission rates and caregiver readiness for discharge through the implementation of an evidence-based discharge protocol for P-HSCT patients and caregivers. Methods: This quality improvement project included development and implementation of comprehensive Pediatric Blood & Marrow Transplant Guidelines and discharge protocol for patients who received an inpatient autologous or allogeneic HSCT and were scheduled for discharge from a 16-bed inpatient pediatric hematology-oncology unit of a children's hospital in the southeastern United States. Readmission rates were captured through the hospital-monitored system. Results: The comprehensive discharge protocol was implemented for six patients, and 30-day readmission rates decreased from 27.29% to 3.57% following the intervention. Discussion: Results suggest the combination of an evidence-based discharge protocol with a focus on caregiver readiness for discharge and a 24-hour Rooming-In period can influence caregiver confidence and reduce 30-day readmission rates after initial discharge from a P-HSCT.

Assessing and Preparing Patients for Hematopoietic Stem Cell Transplant in Canada: An Environmental Scan of Psychosocial Care

Recipients and caregivers of Hematopoietic Stem Cell Transplant (HCT) have extensive physical and psychosocial needs. HCT programs recognize the need to support psychosocial wellbeing. However, evidence-based guidance for pre-HCT psychosocial services is sparse. We conducted a qualitative environmental scan of programs across Canada to better understand how programs evaluate and support patients and caregivers prior to HCT.

METHODS

HCT programs across Canada were contacted with a list of questions about their psychosocial assessment and preparation process with patients and caregivers. They could respond via email or participate in an interview over the phone. Descriptive qualitative content analysis was conducted, using steps outlined by Vaismoradi and colleagues (2013).

RESULTS

Most participants were social workers from hospitals (64%). Four qualitative themes arose: (a) Psychosocial Team Composition. Psychosocial assessment for HCT patients was often provided by social workers, with limited availability of psychologists and psychiatrists. (b) Criteria for assessing select HCT patients. Participants prioritized psychosocial assessments for patients with higher perceived psychosocial needs or risk, and/or according to transplant type. Limited time and high psychosocial staff demands also played into decision-making. (c) Components and Practices of Pre-HCT Psychosocial Assessment. Common components and differences of assessments were identified, as well as a lack of standardized tools. (d) Patient Education Sessions. Many sites provided adjunct patient education sessions, of varying depth.

CONCLUSION

Significant variation exists in the way programs across the country assess their patients' psychosocial pre-transplant needs and assist in preparing patients for the psychosocial aspects of HCT. This environmental scan identified several strategies used in diverse ways. Further in-depth research on program outcomes across Canada could help to identify which strategies are the most successful.

Psychosocial Assessment Practices for Hematopoietic Stem Cell Transplantation: A National Survey Study

Psychosocial health predicts and contributes to medical outcomes for patients undergoing hematopoietic stem cell transplantation (HSCT). Yet, there are no standards for psychosocial assessments or support for both patients and caregivers across the care continuum. To examine the current state of psychosocial care, clinicians were sent a survey of their psychosocial assessment practices for patients and caregivers undergoing HSCT via the Listservs of professional organizations. Descriptive statistics and bivariate analyses were performed to summarize the findings. While 96% of participants reported routine pre-HSCT psychosocial assessment of patients, only 10.6% routinely used a validated transplant risk-assessment measure. Just 27% routinely performed follow-up psychosocial assessments. In contrast, only 47% of participants routinely assessed the psychosocial needs of family caregivers pre-HSCT, and 13% routinely performed follow-up assessments for caregivers. Most (90%) reported social workers were the primary providers of assessments. While patient-report measures were used for evaluation, the majority of assessments were clinical interviews. No significant differences were found between programs that treated adult and pediatric patients versus those only treating adult patients. Our findings highlight the lack of standard psychosocial practices for patients and family caregivers undergoing HSCT and we offer recommendations to fill this gap.

A conceptual framework of the psychosocial elements that should be assessed in candidates for hematopoietic cell transplant: Social workers' and psychologists' perspectives

Background: The aim of this work was to explicate a conceptual framework of psychosocial elements assessed in candidates for hematopoietic cell transplant (HCT) and to explore differences in the conceptualization based on the use of risk rating scales in clinical practice.Methods: Concept mapping is a mixed methods participatory approach to elicit and organize the ideas of a group of stakeholders and produce a composite conceptual framework. Participants were social workers and psychologists with experience assessing HCT candidates.Results: Participants brainstormed 114 psychosocial elements and conceptualized them into 12 distinct clusters: Transplant Mindset, Support System, Caregiver, Lodging and Transportation, Financial and Legal, Work, Demographic Characteristics, Mental Health, Communication, Educational and Resource Needs, Physical Functioning, and Cognition. Participants who used risk rating scales did not prioritize the importance of the clusters differently than those who did not.Conclusions: The conceptualization converges and diverges with the literature. Divergences are of particular interest since the perspectives of practicing psychosocial professionals have been largely absent from the literature. The conceptual framework can guide psychosocial providers in assessing patients. Assessing the caregiver is a high priority, as is evaluating the patient's mental health and mindset about transplant.

Psychosocial Assessment of Candidates for Hematopoietic Cell Transplantation: A National Survey of Centers' Practices

OBJECTIVE

This study characterizes pre-hematopoietic cell transplant psychosocial assessment practices with adult patients at centers in the U.S. An online, cross-sectional survey was conducted to describe the content and process of assessment including the high risk factors that influence transplant eligibility and how eligibility decisions are made.

METHODS

Psychosocial professionals (one per center) were invited to participate by sharing their center's practice. The questionnaire was developed by the researchers and pre-tested with a group of HCT social workers. Univariate statistics were used to describe the sample as well as the content and process of psychosocial assessment. Content analysis was conducted on textual data.

RESULTS

A total of 90 centers had one psychosocial professional that responded. There was general consistency among centers about the major psychosocial components that are assessed, but variation occurred regarding what, if any, standardized measures were used. Approximately half of centers that used standardized measures used the PACT, TERS, or SIPAT to rate overall psychosocial risk. Most respondents (86%) reported that their center has declined an otherwise medically eligible patient due to psychosocial risk factors. Risk factors most frequently reported as potentially influencing eligibility included no caregiver/poor support system, illicit drug use, and serious, untreated mental illness.

CONCLUSIONS

Study findings provide a fuller understanding of psychosocial assessment practices, including the challenging ethical issue of psychosocial eligibility, and will help inform best practices. This article is protected by copyright. All rights reserved.

Psychosocial Pre-Transplant Screening With the Transplant Evaluation Rating Scale Contributes to Prediction of Survival After Hematopoietic Stem Cell Transplantation

There is no standard in hematopoietic stem cell transplantations (HSCT) for pre-transplant screening of psychosocial risk factors, e.g., regarding immunosuppressant non-adherence. The aim of this prospective study is to explore the predictive value of the pretransplant psychosocial screening instrument Transplant Evaluation Rating Scale (TERS) for mortality in a 3-year follow-up. Between 2012 and 2017 61 patients were included and classified as low (TERS = 26.5-29) and increased-risk group (TERS = 29.5-79.5). Both groups were compared regarding mortality until 36 months after transplantation and secondary outcomes [Medication Experience Scale for Immunosuppressants (MESI); incidence/grade of GvHD]. The increased-risk group (n = 28) showed significantly worse cumulative survival in the outpatient setting (from 3 months to 3 years after HSCT) [Log Rank (Mantel Cox) P = 0.029] compared to low-risk group (n = 29) but there was no significant result for the interval immediately after HSCT until 3 years afterwards. Pre-transplant screening with TERS contributes to prediction of survival after HSCT. The reason remains unclear, since TERS did not correlate with GvHD or MESI. The negative result regarding the interval immediately after HSCT until 3 years could be caused by the intensive in-patient setting with mortality which is explained rather by biological reasons than by non-adherence.

Discharge Disposition Following Hematopoietic Cell Transplantation: Predicting the Need for Rehabilitation and Association with Survival

Many hematopoietic cell transplantation (HCT) recipients require rehabilitation due to deconditioning following intensive conditioning regimens and immune reconstitution. HCT recipients are preferentially discharged to home to avoid the risk of exposure to healthcare-associated infection in a rehabilitation facility (RF), with a caregiver who has been provided specific education about the complexity of post-HCT care. This study was conducted to determine the incidence of discharge to an RF following HCT, identify pre-HCT and peri-HCT risk factors for discharge to an RF, and estimate the effect of discharge disposition on overall survival (OS). This retrospective, matched 1:4 case-control study included 56 cases over a 10-year period from a single institution. Controls were matched by transplantation type (autologous versus allogeneic) and date of transplantation. The incidence of discharge to an RF was 2.2%. Controlling for disease, increasing age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04 to 1.15; P < .001), female sex (OR, 3.11; 95% CI, 1.32 to 7.32; P = .01), high-risk HCT Comorbidity Index (HCT-CI) score (≥3) (OR, 3.44; 95% CI, 1.39 to 8.52; P = .008), decreasing pre-HCT serum albumin (OR, 2.60; 95% CI, 1.07 to 6.38; P = .037), and development of acute kidney injury during HCT (OR, 4.10; 95% CI, 1.36 to 12.40; P = .012) were associated with discharge to an RF. Discharge to an RF was associated with worse OS and higher nonrelapse mortality (NRM) compared with discharge to home (1-year OS, 70.5% [95% CI, 55.8% to 81.1%] versus 88.8% [95% CI, 83.6% to 92.4%], P < .001; 100-day NRM: 9.5% [95% CI, 3.5% to 19.2%] versus 1.8% [95% CI, 0.6% to 4.3%]; P = .03). Discharge to an RF following HCT is a rare event but associated with poor OS. Modifiable risk factors for discharge to an RF, including serum albumin as a measure of nutrition and reversible HCT-CI components, should be prospectively studied to determine the effect of mitigation on discharge disposition and survival.

The Transplant Evaluation Rating Scale predicts overall survival after allogeneic hematopoietic stem cell transplantation

To evaluate the impact of psychosocial risks on post-hematopoietic stem cell transplantation (HSCT) outcomes, we prospectively conducted psychosocial assessment of 556 consecutive allogeneic HSCT patients who received their first allogeneic transplant at our center between 2003 and 2017. The Transplant Evaluation Rating Scale (TERS) score was prospectively assessed by a psychologist before transplantation, and patients were categorized as low, intermediate, or high risk based on their TERS score. Patients in the high-risk TERS group had significantly longer hospital stays during the first 180 days and 1 year post-allogeneic HSCT compared with the low-risk group (16 vs 13 and 21 vs 16 days; P = .05 and .02, respectively). The survival estimates for low-, intermediate-, and high-risk TERS groups at 3 year were as follows: overall survival (OS), 73%, 60%, and 65%; disease-free survival (DFS), 63%, 55%, and 60%; nonrelapse mortality (NRM), 11%, 20%, and 17%; and relapse, 26%, 25%, and 23%, respectively. In a multivariable analysis, intermediate- and high-risk TERS scores predicted for inferior OS, similar DFS, and higher NRM compared with low-risk TERS score. In a subset analysis of patients with low/intermediate risk per Disease Risk Index, multivariable analysis showed that high- and intermediate-risk TERS scores predicted for significantly worse OS, worse DFS, higher NRM, and similar relapse rates compared with low-risk TERS score. Our findings show that psychosocial factors as measured by TERS score are strong predictors of morbidity and mortality after HSCT among patients with low/intermediate disease risk.

Psychiatric Care in Hematopoietic Stem Cell Transplantation

BACKGROUND

Patients with cancer frequently experience neuropsychiatric symptoms due to their medical illness or its treatment. In recent decades, psychiatrists have become increasingly involved in the care of patients with cancer. However, psychiatrists may be less familiar with hematopoietic stem cell transplantation (HSCT), a distinct cancer treatment modality associated with multiple neuropsychiatric sequelae.

OBJECTIVE

To provide an overview of HSCT, and describe the prevalence, impact, risk factors, and suggested management of psychiatric consequences of HSCT.

METHODS

We performed literature searches in PubMed and PsychInfo to identify articles describing neuropsychiatric symptoms, including depression, anxiety, distress, post-traumatic stress disorder, delirium and cognitive impairment, resulting from HSCT in adults. Those articles most relevant to this manuscript were included.

RESULTS

Psychiatrists may be involved in the treatment of patients before, during, or after inpatient hospitalization for HSCT. Each phase of treatment introduces unique stressors that may lead to or exacerbate psychiatric disorders. Appropriate management requires evaluation of HSCT-related medications, an understanding of the impact of complications from HSCT, and consideration of how the patient's underlying medical condition should influence psychiatric recommendations.

CONCLUSION

To optimize patient outcomes, consulting psychiatrists should be familiar with the basic principles of HSCT, and the neuropsychiatric sequelae that may result from treatment. Further research is needed to identify strategies to manage psychiatric complications in this unique population.