Effect of Inpatient Palliative Care on Quality of Life After Stem Cell Transplant
Integrating palliative care into the treatment of patients undergoing hematopoietic stem cell transplantation for cancers like leukemia and lymphoma can improve their quality of life, relieve symptoms associated with the procedure, and reduce depression and anxiety, not only during the 3- to 4-week hospitalization required for the procedure, but also several months later. In a paper published by El-Jawahri et al in JAMA, a research team from Massachusetts General Hospital (MGH) also reported that caregivers of patients receiving palliative care experienced less depression and were better at coping with the stress associated with the illness of their family member or friend.
Palliative Care for Hematologic Malignancies
“Palliative care clinicians are increasingly asked to help care for patients with solid tumors but are rarely consulted for patients with hematologic malignancies, especially those receiving therapy designed to cure their disease,” said Areej El-Jawahri, MD, Director of the Bone Marrow Transplant Survivorship Program in the MGH Cancer Center, lead and corresponding author of the JAMA report. “The physical and psychological symptoms associated with [stem cell transplant] are sometimes regarded as expected and unavoidable, which—combined with the persistent misperception that equates palliative care with end-of-life care—has contributed to a lack of involvement of palliative care clinicians in the care of these patients.”
After a patient with a hematologic cancer is admitted to the hospital for stem cell transplant, they receive high-dose chemotherapy and/or radiation therapy to eradicate diseased cells in the body. About 1 week into hospitalization, stem cell transplant is conducted to begin repopulating the marrow with healthy stem cells.
In addition to symptoms caused by chemotherapy, including nausea, pain, vomiting, diarrhea, fatigue and insomnia, stem cell transplant recipients must stay in a protective environment to prevent infection, limiting their interactions with family members and friends. That isolation, along with the symptoms produced by the procedure itself, contributes to psychological symptoms of depression and anxiety. For some patients, the grueling process leads to the development of posttraumatic stress disorder.
Study Methodology
The JAMA study enrolled 160 patients who underwent stem cell transplant for a variety of hematologic malignancies at MGH from August 2014 into January 2016. Participants were randomly assigned to receive either standard care or the palliative care intervention. Within 3 days of their admission to the hospital, patients in the intervention group had an initial meeting with a palliative care clinician—a physician or advanced practice nurse—who continued to meet with them at least twice a week during their hospitalization.
At the meetings, which could be attended by a family member or friend of the patient, clinicians first focused on establishing a rapport with patients and their caregivers. They addressed ways of managing the physical and psychological symptoms patients were experiencing and provided support and strategies for coping with distress. Patients received an average of 8 palliative care visits during their hospitalizations, which lasted an average of 20 days.
At the outset of the study and 2 weeks into the process, a time when patients’ blood levels are at their lowest and symptoms tend to be at their worst, patients in both groups and participating caregivers completed questionnaires assessing their mood and quality of life, with patients completing additional questionnaires regarding symptoms of their illness and those associated with the procedure. Patients completed additional assessments 3 months after transplantation.
Major Findings
The primary question the study was designed to investigate was whether receiving palliative care reduced the expected decline in quality of life experienced by patients at 2 weeks. The results indicated significantly better quality-of-life scores for those receiving the palliative care intervention than for the usual treatment group, at both the 2-week and 3-month assessments. Patients receiving the palliative care intervention also reported lower levels of depression, anxiety, and symptoms at 2 weeks and continued to experience less depression, better quality of life, and fewer posttraumatic stress symptoms than the control group at 3 months.
Family member or friend caregivers attended 42% of the palliative care sessions, and at the 2-week assessment, caregivers in the intervention group were found to have fewer depression symptoms and improved coping skills, compared with caregivers in the control group. “Caregivers play a crucial role in supporting patients during the transplant process, and they are substantially impacted as they watch their loved ones struggle with side effects that can be emotionally challenging,” explained Dr. El-Jawahri, who is an Instructor of Medicine at Harvard Medical School.
She and her colleagues noted that additional, larger studies are needed to assess caregiver impacts more completely; to replicate patient results at centers with more diverse patient populations; to assess the inclusion of more complete palliative care teams; to collect cost data; and to adapt the palliative care intervention to assist patients receiving other potentially curative treatment for hematologic or other cancers.
Jennifer Temel, MD, of the MGH Cancer Center, senior author of the JAMA paper and Associate Professor of Medicine at Harvard Medical School, added, “An important aspect of this study is its extension of the benefits of palliative care beyond patients with advanced solid tumors to those receiving curative therapy for hematologic malignancies. Our results highlight how palliative care can be beneficial for patients with cancer, regardless of their prognosis.”
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
