Prognostic significance of pre-transplant quality of life in allogeneic hematopoietic cell transplantation recipients

Abstract

Quality of life (QOL) is an important outcome for hematopoietic cell transplantation (HCT) recipients. Whether pre-HCT QOL adds prognostic information to patient and disease related risk factors has not been well described. We investigated the association of pre-HCT QOL with relapse, non-relapse mortality (NRM), and overall mortality after allogeneic HCT. From 2003 to 2012, the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale instrument was administered before transplantation to 409 first allogeneic HCT recipients. We examined the association of the three outcomes with (1) individual QOL domains, (2) trial outcome index (TOI) and (3) total score. In multivariable models with individual domains, functional well-being (hazard ratio (HR) 0.95, P = 0.025) and additional concerns (HR 1.39, P = 0.002) were associated with reduced risk of relapse, no domain was associated with NRM, and better physical well-being was associated with reduced risk of overall mortality (HR 0.97, P = 0.04). TOI was not associated with relapse or NRM but was associated with reduced risk of overall mortality (HR 0.93, P = 0.05). Total score was not associated with any of the three outcomes. HCT-comorbidity index score was prognostic for greater risk of relapse and mortality but not NRM. QOL assessments, particularly physical functioning and functional well-being, may provide independent prognostic information beyond standard clinical measures in allogeneic HCT recipients. Despite advances in transplantation techniques and supportive care, the morbidity and mortality related to this intensive treatment remain high. Many factors predict survival outcomes after allogeneic HCT, including patient age, comorbidities, donor source, performance status, diagnoses, disease status, and carepartner support. Although several studies have investigated and described QOL after transplantation, including the trajectory of QOL risk factors for QOL impairments and interventions to improve QOL, 13-20 the association of pre-transplantation QOL with recovery and survival after allogeneic HCT has not been well described. We hypothesized that QOL measures before HCT may add to the prognostic information provided by known clinical factors among allogeneic HCT recipients. We therefore undertook this analysis to determine the prognostic impact of pre-transplant QOL scores, as captured by the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT), on post-HCT non-relapse mortality (NRM) and overall mortality.

Centralized patient‐reported outcome data collection in transplantation is feasible and clinically meaningful

“…As in our study, the pre‐HCT PCS was strongly correlated with the pretransplant KPS, but the latter did not predict survival as an independent factor. A single‐center study of 409 allogeneic HCT recipients by Hamilton et al showed that the Trial Outcome Index and the physical well‐being subscales of the FACT‐BMT were associated with mortality after transplantation. Our results extend these findings and suggest that the prognostic value of PRO measures holds true in the real‐world setting of HCT across multiple centers …”

Prognostic Factors on the Graft‐versus‐Host Disease‐Free and Relapse‐Free Survival after Adult Allogeneic Hematopoietic Stem Cell Transplantation

“…According to the reported articles, posttransplant CMV reactivation would increase NRM and influence survival in patients receiving allogeneic HSCT [ 12 , 28 – 30 ]. In addition, pretransplant comorbidities and quality of life were also important factors for HSCT recipients [ 31 ]. Hence, the additional influence of posttransplant CMV reactivation, history of type 2 diabetes mellitus, and smoking history were also evaluated in our study.…”

Does quality of life impact the decision to pursue stem cell transplantation for elderly patients with advanced MDS?

“…Indeed, recent studies have shown that QOL before transplant for hematological malignancies is associated with post transplant mortality even when accounting for patients' performance status and comorbidities. 20,21 Moreover, patients with advanced solid malignancies place as high a value on optimizing their QOL as to other goals of therapy such as extending their life as much as possible. 29,30 Our data begs the question whether the possibility of cure that is unique to patients with advanced hematologic malignancies such as high-risk MDS trumps QOL concerns in this population.…”

“…Indeed, studies have shown that QOL scores before allogeneic HCT are independently associated with post-transplant mortality irrespective of performance status and medical comorbidities. [20][21][22] Moreover, while patients' and clinicians' perception of QOL may influence their decisions regarding pursuit of therapies, 22 the impact of baseline QOL on the likelihood of receiving allogeneic HCT for advanced MDS is not known.…”