Physical and Psychological Symptom Burden and Prognostic Understanding during Hospitalization for Hematopoietic Stem Cell Transplantation

Introduction: During hematopoietic stem cell transplantation (HSCT), patients receive high dose chemotherapy during a prolonged hospitalization and endure significant side effects in the hopes of curing their disease.  While many studies have focused on the long-term outcomes of patients undergoing HSCT, the acute impact of hospitalization for HSCT on patients' quality of life (QOL), symptom burden, and mood is unknown.  Furthermore, data on patients' perception of their prognosis and likelihood of cure with HSCT are lacking.

Methods: We conducted a prospective longitudinal study of patients hospitalized at the Massachusetts General Hospital for HSCT.  At baseline and weeks 1, 2, and 3 of hospitalization, we assessed QOL (Functional Assessment of Cancer Therapy-Bone Marrow Transplantation [FACT-BMT]; higher scores indicate better QOL), fatigue (FACT-Fatigue; higher scores indicate less fatigue), and mood (Hospital Anxiety and Depression Scale score > 7 on anxiety or depression subscale considered clinically significant).  Using a 10-item questionnaire, we measured patients' information preferences, and perception of their prognosis.

Results: We enrolled 53 consecutive patients undergoing autologous (n=30), or myeloablative allogeneic (n=23) HSCT.  Patients' QOL declined (FACT BMT mean scores week 1:107.5 àweek 2: 96.3 àweek 3: 94.8, p < 0.0001), and fatigue increased (FACT Fatigue mean scores week1: 36.4 à week 2: 30.5 à week 3: 28.3, p < 0.0001) throughout hospitalization.  The proportion of patients with depression symptoms increased from baseline to week 3 (18.9% to 35.8%; p=0.002) whereas the proportion of patients with anxiety symptoms did not change significantly from baseline (22.6%; p=0.7).  These patterns remained consistent when data were stratified by the type of HSCT [Table 1].  Although 90.6% (48/53) of patients stated that it is ‘extremely' or ‘very' important to know about their prognosis, 76.0% (38/50) reported inaccurate and overly optimistic perception of their prognosis compared to their physicians (p < 0.0001) [Figure 1]. 

 

Conclusion:  Patients with hematologic malignancies undergoing HSCT report an overly optimistic perception of their prognosis and experience significant decline in QOL with increasing symptom burden and rates of depression throughout their hospitalization.  Results suggest that interventions to both improve the QOL and psychological outcomes of patients hospitalized for HSCT and enhance their prognostic awareness are clearly warranted.

Table 1: Longitudinal QOL and Mood by type of HSCT

Outcomes	Type HSCT	Week-1	Week-2	Week-3	P-Value
QOL, M	Auto Allo	105.8 101.1	95.4 97.6	93.7 96.3	P = 0.0003 P = 0.01
Fatigue, M	Auto Allo	34.4 39.0	27.0 34.9	27.3 29.7	P < 0.0001 P= 0.01
HADS depression > 7, N (%)	Auto Allo	7 (23%) 3 (13%)	11 (37%) 6 (26%)	13 (43%) 6 (26%)	P = 0.0003 P = 0.05

Figure 1: Perception of Likelihood of cure with HSCT (P < 0.0001)