December 10, 2011 (San Diego, California) — Hematopoietic cell transplant (HCT) offers the only potential for a cure for many hematological cancers; however, although the cancer may be cured by the transplant, the recipients remain at risk for psychological and chronic health conditions.
"It's important to realize that once a transplant is over, it's not really over," commented Stephanie J. Lee, MD, MPH, professor of medicine at the University of Washington School of Medicine in Seattle. She was speaking here at the American Society of Hematology (ASH) 53rd Annual Meeting and commented on a study that followed-up transplant survivors for more than 10 years.
The study, the first of its kind, found that the burden of long-term physical and emotional morbidity experienced by survivors 10 or more years after their transplant is substantial, and that these individuals require high use of specialized healthcare.
The authors found that 74% of HCT survivors reported at least 1 chronic health condition compared with 29% of their siblings (P < .001). In addition, 25% of the survivors also reported severe/life-threatening conditions vs only 8% of the siblings (P < .001).
"Transplant has now being going on for many decades, and we are constantly working in the short-term to make transplant better, but it's important that we look at the long-term effects on survivors as well," Dr. Lee commented at a press briefing that highlighted the results of the study. "Patients need to be aware that they are at high risk for this. They need preventive care and survivorship care, and as a society we need to realize that they will need long-term treatment."
The study's senior author, Smita Bhatia, MD, MPH, director of the Center for Cancer Survivorship and BMT Long-Term Follow-up Program at City of Hope in Duarte, California, noted that despite the high rate of long-term and potentially lethal complications, "we need to remember that bone marrow transplant and HCT continue to be a lifesaving, and possibly the only, curative option for a large number of hematologic patients."
However, 40% of patients, if they survive the first 10 years posttransplant, may develop severe, life-threatening conditions, or even die from these illnesses, she added. "The main thing that we want to take away from this is that transplanting physicians, third-party payers, as well as patients and their families, are aware of these findings,"
Dr. Bhatia also pointed out that "we do not want to lose these patients in terms of long-term follow-up."
Clinics need to be established where the patients can be followed-up to aggressively screen these patients, detect these complications early, and thus reduce the morbidity rate, she said.
Not Well Studied
Can-Lan Sun, PhD, who presented the results of the study at the briefing and is the first author of the paper, explained that high-intensity therapeutic exposures, as well as prolonged immunosuppression regimens, can increase the risk for long-term complications after HCT, which in turn increases the specialized healthcare needs of this population. In previous research conducted by Dr. Sun and colleagues, results showed that morbidity rises with increasing time after HCT ( Blood. 2010;116:3129-3139).
However, the burden of morbidity in long-term survivors, and the subsequent healthcare needs of these individuals, has not been well-studied. This is the first such study to specifically examine the burden of morbidity in long-term survival of 10 or more years, explained Dr. Sun, an associate research professor at City of Hope.
High Morbidity Risk, Life-Threatening Conditions
Dr. Sun and Dr. Bhatia evaluated the risk for chronic health conditions and psychological health among 366 individuals who had undergone HCT more than 10 years ago, along with their siblings (n = 309). A severity score (grade 1, mild; grade 2, moderate; grade 3, severe; grade 4, life-threatening; and grade 5, death resulting from chronic health condition) was assigned for each health condition. Brief Symptom Inventory was used to describe adverse psychological health, and the authors also assessed healthcare use by the survivors.
Within this cohort, the mean age at HCT was 22 years (range, 0.4 - 59.8 years), and at the time of the study it was 37 years (range, 11 - 72). The mean length of follow-up was 15 years.
The majority of patients underwent transplant for acute and chronic leukemias, explained Dr. Sun, and other diagnoses included non-Hodgkin's lymphoma, aplastic anemia, and Hodgkin's disease. Approximately one quarter of the patients (27%) underwent an autologous transplant, 65% were allogeneic related, and 8% had an unrelated donor.
Nearly three quarters of the cohort (72%) received total-body irradiation-based conditioning.
Long-Term Problems
Commonly reported severe/life-threatening chronic health conditions by the survivors included myocardial infarction, stroke, blindness, diabetes, musculoskeletal problems, and subsequent malignancies. The 15-year cumulative incidence of any chronic health condition (grades 1 - 5) was 71% (95% confidence interval [CI], 67% - 75%), and for severe life-threatening conditions or death, the rate was 40% (95% CI, 33% - 47%). Overall, the HCT survivors were 5.6 times more likely to develop a severe/life-threatening condition when compared with age- and sex-matched siblings.
The cumulative incidence of severe/ life-threatening conditions did not differ by type of HCT (P = .79).
The authors also evaluated somatic distress, anxiety, and depression among HCT survivors and their siblings. Dr. Sun noted that even though the prevalence of anxiety and depression were comparable between survivors and siblings, somatic distress was more common among HCT survivors.
Survivors were 2.7 times more likely to report somatic distress (P < .001), and in addition, female sex (odds ratio [OR], 3.6; 95% CI, 1.4 - 9.0), low household income (<$20,000; OR, 4.4; 95% CI, 1.1 - 17.2), and poor self-rated health status (OR, 10.6; 95% CI, 4.0 - 27.9) were also associated with a higher risk for somatic distress.
The authors note that it is fortunate that the vast majority (90%) of HCT survivors reported having some type of health insurance coverage, as a high proportion require ongoing specialized medical care. More than two thirds (69%) of the HCT survivors had cancer/HCT-related visits to a healthcare provider at an average of 15 years after their transplant.
American Society of Hematology (ASH) 53rd Annual Meeting: Abstract 841. Presented December 12, 2011.
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