Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation

Abstract

IMPORTANCEDuring hospitalization for hematopoietic stem cell transplantation (HCT), patients receive high-dose chemotherapy before transplantation and experience significant physical and psychological symptoms and poor quality of life (QOL).OBJECTIVE To assess the effect of inpatient palliative care on patient-and caregiver-reported outcomes during hospitalization for HCT and 3 months after transplantation.DESIGN, SETTING, AND PARTICIPANTS Nonblinded randomized clinical trial among 160 adults with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers (n = 94). The study was conducted from August 2014 to January 2016 in a Boston hospital; follow-up was completed in May 2016.INTERVENTIONS Patients assigned to the intervention (n=81) were seen by palliative care clinicians at least twice a week during HCT hospitalization; the palliative intervention was focused on management of physical and psychological symptoms. Patients assigned to standard transplant care (n=79) could be seen by palliative care clinicians on request.MAIN OUTCOMES AND MEASURES Primary: change in patient QOL from baseline to week 2; secondary: patient-assessed mood, fatigue, and symptom burden scores at baseline, 2 weeks, and 3 months after HCT and caregiver-assessed QOL and mood at baseline and 2 weeks after HCT. RESULTS Among 160 patients (mean age, 60 [SD, 13.3] years; 91 women [56.9%]; median hospital stay, 21 days) and 94 caregivers, 157 (98.1%) and 89 (94.7%), respectively, completed 2-week followup, and 149 patients (93.1%) completed 3-month follow-up. Intervention patients reported a smaller decrease in QOL from baseline to week 2 vs controls. Intervention patients had less increase in depression,loweranxiety,nodifferenceinfatigue,andlessincreaseinsymptomburden.At3months, intervention patients had higher QOL and less depression but no significant differences in anxiety, fatigue, or symptom burden. From baseline to week 2 after HCT, caregivers of intervention patients vs controls reported no significant differences in QOL or anxiety but had a smaller increase in depression (mean, 0.25 vs 1.80; mean difference, 1.55; 95% CI, 0.14-2.96; P = .03). Patient Outcomes Mean Score at Week 2 Mean Difference Between Groups (95% CI) P Value Standard Care Palliative Care Quality of life (change from baseline) −21.54 −14.72 −6.82 (−13.48 to −0.16) .045 Fatigue −13.65 −10.30 −3.34 (−7.25 to 0.56) .09 Symptom burden 23.14 17.35 5.80 (0.49 to 11.10) .03 Depression 3.92 2.43 1.49 (0.20 to 2.78) .02 Anxiety 1.12 −0.80 1.92 (0.83 to 3.01) <.001CONCLUSIONS AND RELEVANCE Among adults at a single institution undergoing HCT for hematologic malignancy, the use of inpatient palliative care compared with standard transplant care resulted in a smaller decrease in QOL 2 weeks after transplantation. Further research is needed for replication and to assess longer-term outcomes and cost implications.

Treatment intensity and symptom burden in hospitalized adolescent and young adult hematopoietic cell transplant recipients at the end of life

“…Recent data from adult patients undergoing HCT for the treatment of hematologic malignancies demonstrates that integration of PC mitigates transplant-related reduction in patient quality of life as early as 2 weeks after transplant, although long-term impact on quality of life remains less well demonstrated. (29)…”

The impact of remission status on patients’ experiences with acute myeloid leukemia (AML): an exploratory analysis of longitudinal patient-reported outcomes data

“…Our results also demonstrate the same pattern of distress between initial disease status ( de novo versus secondary/relapsed AML) and current disease status (relapse versus remission). With this information, early interventions aimed at alleviating distress, such as psychological interventions, or concurrent specialty palliative care, can be targeted to those with a diagnosis of secondary/relapsed AML, as they can be expected to experience significant distress throughout the course of their disease [17], [32], [33]. …”

“…Targeted interventions are needed in this population to improve patients’ lived experiences of illness. We are currently conducting a randomized trial of concurrent specialist palliative care at initiation of induction chemotherapy in patients with high-risk disease, to test this hypothesis, given that concurrent specialist palliative care has been shown to improve symptoms, QOL, and other patient-centered outcomes among those undergoing intensive treatments like stem cell transplantation (Clinicaltrials.gov NCT02975869) [17]. …”

Palliative Care in Patients with Hematological Malignancies

“…After 2 weeks, patients in the palliative care group reported a smaller decrease in quality of life, less increase in depression, lower anxiety, and less increase in overall symptom burden. 3 months post transplantation, these patients still presented with higher quality of life scores and less depression symptoms, but anxiety, fatigue, or symptom burden were similar in both groups [28]. After 6 months, patients who had received early palliative care reported lower symptoms of depression and post-traumatic stress disorder than patients in the control group, but quality of life and anxiety levels were similar [29].…”