Palliative Care Curbs Depression and Trauma in HSCT Patients

Roxanne Nelson, BSN, RN

September 22, 2017

Hematopoietic stem cell transplant (HSCT) is potentially curative for patients with various blood cancers, but the intensity of this treatment leaves some patients with depression and posttraumatic stress disorder (PTSD), even years after the transplant. One study found that as many as 41% of HSCT survivors experience PTSD symptoms up to 10 years post transplant.

New results show that a palliative care intervention at the time of the transplant can greatly reduce this. A new study, published online September 19 in the Journal of Clinical Oncology, has found that patients who received palliative care while hospitalized for HSCT experienced a "remarkable and sustained improvement" in depression and PTSD symptoms 6 months following their transplant.

Patients self-reported lower depression symptoms on the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) and the nine-item Patient Health Questionnaire (PHQ-9) and fewer symptoms of PTSD. However, no differences were observed for anxiety or quality of life (QOL) when compared with those who did not receive the intervention.

"I think these findings are certainly compelling, and we should be seriously thinking about conducting additional studies to ensure their generalizability," said lead author Areej El-Jawahri, MD, an oncologist specializing in hematologic malignancies at Massachusetts General Hospital, Boston.

"Our study was a single-center study conducted at one academic center, and while it shows dramatic results, it needs to be replicated in a multisite study to demonstrate definitively the efficacy of this care model in improving patients quality of life, symptom burden, and psychological outcomes.

"We also need to get a better understanding of the additional cost of integrating palliative care," Dr El-Jawahri told Medscape Medical News. "I do think this is the next step, and if shown to be this effective, we should be thinking about integrating palliative care in the care of patients undergoing HCT."

Palliative Care Beneficial

Recent studies have strengthened the evidence of the benefits of integrating palliative care into oncologic regimens.

Earlier data from Dr El-Jawahri and her team, which were presented at the Palliative Care in Oncology Symposium (PCOS) 2016, found that at week 2 of hospitalization, palliative care led to statistically significant improvements in QOL, depression, anxiety, and symptom burden in patients undergoing HCT. At 3 months post transplant, patients had significant improvements in QOL, depression, and symptoms of PTSD.

As reported by Medscape Medical News at that time, the results were considered "groundbreaking," as it was the first study to show the benefit of palliative care in curative therapy and in the setting of HCT.

Clinical practice guidelines updated in 2016 from the American Society of Clinical Oncology (ASCO) now emphasize the need to begin palliative care as soon as a patient's cancer becomes advanced. Having conducted a systematic review of all randomized clinical trials, systematic reviews, and meta-analyses, as well as secondary analyses of randomized controlled trials published from March 2010 to January 2016, the authors say that it "became clear" that palliative care should be initiated early in the course of the disease, along with active treatment.

Another study found that inpatient palliative care could also affect costs. Researchers from Johns Hopkins Health System in Baltimore, Maryland, found that in addition to improving quality of care and patient satisfaction, combined inpatient and consultation palliative care programs contributed to substantially lower charges and costs per day, with savings of nearly $4 million a year.

Long-term Results

In the current study, the authors investigated long-term effects of inpatient palliative care, integrated with transplant care, on psychological distress and QOL 6 months after transplant.

A cohort of 160 patients with hematologic malignancies who underwent autologous or allogeneic HCT were randomly allocated to receive inpatient palliative care integrated with transplant care (n = 81) or standard transplant care alone (n = 79).

At baseline and at 6 months post transplant, mood, PTSD symptoms, and QOL were evaluated with the HADS-D, the PHQ-9, the Post-Traumatic Stress Disorder Checklist–Civilian Version (PCL), and the Functional Assessment of Cancer Therapy-Bone Marrow Transplant.

At 6 months, patients in the intervention group reported lower depression symptoms, as measured by the HADS-D (adjusted mean difference, 21.21; P = .024) and PHQ-9 (adjusted mean difference, 21.63; P = .027) compared to the control group.

The group who received palliative care also reported lower PTSD symptoms (adjusted mean difference, 24.02; P = .013], but anxiety, QOL, and fatigue were not significantly different between the two groups.

Clinically significant depression symptoms were also lower in the palliative care group (HADS-D, 10.14% v 26.40%; P = .017; PHQ-9, 14.29% v 33.33%; P = .010), as were rates of clinically significant PTSD symptoms (PCL, 7.35% v 21.13%; P = .029).

In an exploratory analysis, the authors found that symptom burden and anxiety during HCT hospitalization partially mediated the effect of palliative care on depression and PTSD after transplant.

Not Just for End of Life

What is attractive about this care model is that it would be relatively easy to implement, Dr El-Jawahri pointed out, because transplants are generally performed at comprehensive cancer centers or tertiary care hospitals where there are palliative care specialists. "So, unlike other situations where we worry about the shortage of palliative care clinicians in rural areas, this model of care can be disseminated to other transplant centers given the available resources," she said.

 

Palliative care can help patients facing a serious illness regardless of their prognosis. Dr Areej El-Jawahri

The visibility of palliative care has increased, and its importance is increasingly being studied. "I think the main goal of our study was to really show that palliative care can help patients facing a serious illness regardless of their prognosis," Dr El-Jawahri said. "In this setting, we see that palliative care can help patients receiving potentially curative therapy."

She emphasized that she hopes these findings really help break down the common misperception that palliative care is "just about end of life care."

"We are learning that integrating palliative care earlier in the course of illness for patients with cancer and now for those undergoing HCT can lead to improvement in a wide range of patient-reported outcomes and also caregiver outcomes," Dr El-Jawahri said.

The study was supported by funds from the National Palliative Care Research Center. Dr El-Jawahri has disclosed no relevant financial relationships. Several coauthors report relationships with industry, as noted in the original article.

J Clin Oncol. Published online September 19, 2017. Abstract

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