Abstract
Background
During hospitalization for hematopoietic stem cell transplantation (HCT), patients experience a steep deterioration in quality of life (QOL) and mood. The impact of this deterioration on patients’ post-HCT QOL and post-traumatic stress disorder (PTSD) symptoms is unknown.
Methods
We conducted a prospective longitudinal study of patients hospitalized for HCT. We assessed QOL (Functional Assessment of Cancer Therapy-Bone Marrow Transplantation [FACT-BMT]) and depression and anxiety symptoms (Patient Health Questionnaire-9 (PHQ-9)) at the time of admission for HCT, during hospitalization, and 6-month post-HCT. We also used the Hospital Anxiety and Depression Scale (HADS) to measure patients’ anxiety and depression symptoms at baseline and during HCT hospitalization. We used the PTSD Checklist to assess for PTSD symptoms. We used multivariable linear regression models to identify predictors of QOL and PTSD symptoms at six months.
Results
We enrolled 97% (90/93) of consecutively eligible patients undergoing autologous and allogeneic HCT. Data at six months were available for 67 participants. At six months, 28.4% of participants met criteria for PTSD and 43.3% had clinically significant depression. In multivariable regression analyses adjusting for significant covariates, change in QOL and depression scores from week-2 of HCT hospitalization to baseline predicted worse QOL (ΔQOL β= 0.94, P < 0.0001, ΔPHQ-9 β= −2.59, P = 0.001) and PTSD symptoms (ΔQOL β= −0.40, P < 0.0001, ΔPHQ-9 β= 1.26, P < 0.0001) at six months post-HCT.
Conclusions
Six months after HCT, a significant proportion of patients met criteria for PTSD and depression. Decline in QOL and increase in depressive symptoms during hospitalization for HCT were the most important predictors of 6-month QOL impairment and PTSD symptoms. Therefore, managing depression symptoms and QOL deterioration during HCT hospitalization may be critical to improving QOL at six months and reduce the risk of PTSD.
Keywords: PTSD, QOL, Depression, Mood, Stem Cell Transplant
Introduction
Patients with hematologic malignancies undergoing hematopoietic stem cell transplantation (HCT) endure significant short- and long-term toxicities that affect their quality of life (QOL) and their physical and psychological well-being.1-6 Studies have shown that even years after HCT, many patients experience significant psychological distress, which negatively impacts their QOL and overall functioning.1-6 Psychological distress including depression and post-traumatic stress disorder (PTSD) are prevalent in HCT survivors affecting 40% and 20% of this population, respectively.3,5,7-9 The American Society of Bone Marrow Transplantation (ASBMT) identifies psychological distress as one of the most important issues affecting survivorship care for patients with hematologic malignancies after the receipt of HCT.10 Therefore, the long-term psychological complications of HCT clearly add to the morbidity of transplant and negatively impact patients’ QOL and post-transplant recovery.
Although many studies have described the QOL and physical and psychological burden experienced by HCT survivors, only a few have examined the experience of patients during hospitalization for HCT.2,4,8,12 Despite the limited research efforts, there is a general acceptance by transplant clinicians that patients experience the highest degree of distress while hospitalized for HCT.4,12 We have recently reported that patients undergoing HCT experience a steep deterioration in QOL and substantially worsening depression during their transplant hospitalization.12 This hospitalization experience may in fact be the ‘traumatic event’ that leads to the development of psychological distress and PTSD after HCT. However, the impact of the patients’ experience during hospitalization for HCT on their post-transplant PTSD symptoms and QOL is currently unknown. Moreover, very few studies have examined predictors of PTSD and QOL after HCT.11 Notably, prior research has identified factors such as social supports and disease- and transplant-related complications as potential predictors for worse psychological and QOL outcomes.2 However, many of these factors are not modifiable and are very difficult to intervene upon. Identifying potentially modifiable risk factors for PTSD and QOL post-HCT would enable the development of interventions that can target such factors and improve the care for HCT survivors.
In this prospective longitudinal study, we sought to describe the rate of PTSD and depression at six months post-HCT for patients with hematologic malignancies. Second, we investigated whether the decline in QOL and increase in depression and anxiety symptoms during the hospitalization for HCT can predict the risk of PTSD symptoms and QOL at six months post HCT.
Methods
Participants
This study included adult (age ≥18) English-speaking patients with hematologic malignancies admitted to Massachusetts General Hospital for HCT. We enrolled consecutively eligible participants within three transplant cohorts 1) autologous HCT (n=30); 2) myeloablative allogeneic HCT (n=30); and 3) reduced intensity allogeneic HCT (n=30). We excluded patients with significant psychiatric or other comorbidities, which the treating oncologists believed would impair their ability to complete study questionnaires..
Study Design and Procedures
We identified eligible patients for study participation during the weekly bone marrow transplant program meeting which reviews all upcoming scheduled admissions. A trained research assistant obtained permission by email from the treating oncologist to approach eligible patients for study participation within 72 hours of admission to the inpatient transplant unit. Willing participants provided written informed consent and completed baseline questionnaires prior to transplant. We then followed participants longitudinally and obtained self-reported measures weekly during their initial hospitalization for HCT. Participants also completed study questionnaires at six months post-HCT during regularly scheduled clinic visits. The study was approved by the Dana Farber/Harvard Cancer Center Institutional Review Board.
Study Measures
Quality of life
We used the Functional Assessment of Cancer Therapy-BMT (FACT-BMT) questionnaire to assess patients’ QOL.13 The FACT-BMT contains 47 items that comprise five subscales assessing physical, functional, emotional, social well-being, and Bone Marrow Transplant (BMT) specific concerns during the past week. Higher total and subscale scores indicate better QOL.
PTSD
We used the Post-Traumatic Stress Disorder Checklist (PCL) to assess symptoms of post-traumatic stress in patients at six months post HCT.14 The PCL is a 17-item self-reported measure that evaluates symptoms of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). Respondents are considered likely to meet provisional DSM-IV diagnostic criteria for PTSD if 1) they endorse (i.e. rate as ‘moderately’ or greater) one or more intrusion symptoms, three or more avoidance-numbing symptoms, and two or more arousal symptoms. The PCL can also be used as a continuous measure of severity of PTSD symptomatology (higher scores indicate greater PTSD symptom severity).
Depression and anxiety
We measured participants’ anxiety and depression symptoms with the 14-item Hospital Anxiety and Depression Scale (HADS). The HADS consists of two subscales assessing anxiety (HADS-A) and depression (HADS-D) symptoms in the past week, with subscale scores ranging from 0 (no distress) to 21 (maximum distress).15 We also assessed mood using the Patient Health Questionnaire 9 (PHQ-9). The PHQ-9 is a nine-item measure that detects symptoms of major depressive disorder according to the criteria of the DSM-VI.16 Higher PHQ-9 scores indicate greater depression severity. The PHQ-9 and HADS were both administered to all participants at baseline and weekly during hospitalization for HCT. The PHQ-9 was also administered at 6 months post-HCT.
Demographic and clinical factors
Each participant completed a demographic questionnaire that included age, gender, race, marital status, income, and educational level. We reviewed patients’ electronic medical record to obtain data on cancer diagnosis, Eastern Cooperative Oncology Group (ECOG) performance status, disease status at six months, acute or chronic graft-versus-host disease requiring systemic therapy (GVHD) at six months, and comorbidities as measured by the HCT-Comorbidity Index (HCT-CI).17
Statistical Analysis
We first calculated descriptive statistics, including means or medians for continuous variables depending on the normality of the data, and proportions for categorical variables. For all analyses, we considered two-sided p-values < 0.05 to be statistically significant. We used descriptive statistics to examine participants’ QOL, depression, and rate of PTSD symptoms at six months post-HCT.
To identify predictors of QOL and PTSD at six months, we explored unadjusted associations between participants’ demographics, clinical factors, change in QOL and depression and anxiety symptoms from baseline to week-2 of hospitalization for HCT, as well as their outcomes (QOL and PTSD) at six months post-HCT. To control for baseline QOL, depression and anxiety, we examined the change in QOL, depression, and anxiety from baseline to week-two of transplant hospitalization as the predictor of interest. Adjusting for patients’ age, transplant type, gender, relapse, and marital status (covariates known to be related to post-HCT QOL or PTSD), we examined the relationship between the change in QOL and depression and anxiety during hospitalization and patients’ QOL and PTSD symptoms at six months post-HCT. We created two separate models for QOL and PTSD at six months post-HCT. Given the collinearity between QOL and depression and anxiety (condition number test when QOL, depression, and anxiety are included as predictors in a model = 29.5), we constructed separate multivariable linear regression models to examine the relationship between changes in QOL, and depression and anxiety from baseline to week-2 of HCT hospitalization and six-month outcomes. In all analyses, we used all available data without any imputations for missing data.
Results
Participants Characteristics
We enrolled 97% (90/93) of consecutively eligible patients admitted for autologous and allogeneic HCT between 7/1/2012 and 3/10/2014. Table 1 depicts patients’ demographic and clinical characteristics. Patients were primarily white (91.1%, 82/90) with a mean age of 58.1 (SD = 14.4). The majority of the sample was male (58.9%, 53/90), and 50% (40/90) had a diagnosis of acute myeloid leukemia or myelodysplastic syndrome. The majority were married (66.7%, 60/90), and the median HCT-Comorbidity Index score was 1.0 (range 0-7).
Table 1.
Baseline Characteristics of Participants
| Characteristic | All Patients (n=90) |
|---|---|
| Age mean (SD) | 58.1(14.4) |
| Race: White | 82 (91.1%) |
| Male (%) | 53 (58.9%) |
| Type of Transplant | |
| Autologous HCT | 30 (33.3%) |
| Myeloablative Allogeneic HCT | 30 (33.3%) |
| Reduced Intensity Allogeneic HCT | 30 (33.3%) |
| Diagnosis (%) | |
| ALL | 7 (7.8%) |
| AML/MDS | 45 (50.0%) |
| MF/CML | 2 (2.2%) |
| Lymphoma | 23 (25.6%) |
| MM | 9 (10%) |
| Relationship status | |
| Married | 60 (66.7%) |
| Divorced | 7 (7.8%) |
| Single | 12 (13.3%) |
| Widowed | 11 (12.2%) |
| Education | |
| High school | 23 (25.6%) |
| College | 46 (51.1%) |
| Post graduate | 21 (23.3%) |
| Income | |
| <25,000 | 11 (12.2%) |
| 25,000-50,000 | 14 (15.6%) |
| 51,000-100,000 | 27 (30.0%) |
| 101,000-150,000 | 17 (18.9%) |
| >150,000 | 12 (13.3%) |
| Missing | 9 (10.0%) |
| HCT-Comorbidity Index (HCT-CI) median (range) | 1.0 (0-7) |
ALL = Acute lymphomblastic leukemia, AML = Acute myeloid leukemia, MDS = Myelodysplastic syndrome, MF = Myelofibrosis, CML = Chronic myeloid leukemia, MM = Multiple myeloma, HCT = Hematopoietic stem cell transplantation, SD = Standard deviation.
QOL, mood, and PTSD at six months post-HCT
At six months post-HCT, 22.2% (20/90) of patients had relapsed disease, and 20% (18/90) were deceased. Only 18% (11/60) of patients receiving allogeneic HCT had developed acute or chronic GVHD requiring systemic therapy. Overall, participants’ QOL at six months (mean FACT-BMT = 110, 95% CI [104-116]) returned to baseline pre-transplant values (mean FACT-BMT = 110, 95% CI [107-115]). However, 28.4% (19/67) of HCT survivors met provisional diagnostic criteria for PTSD, and 43.3% (29/67) had clinically significant depression at six months post-HCT. Among all survivors, 39% (26/67) reported moderate to severe re-experiencing symptoms, 33% (22/67) reported moderate to severe avoidance and numbing symptoms, and 48% (32/67) had moderate to severe increased arousal symptoms.
Relationship between change in QOL, depression, and anxiety during HCT hospitalization and PTSD at six months post-HCT
Table 2 depicts the unadjusted analyses examining the relationship between participants’ characteristics, clinical factors, change in QOL and depression and anxiety from baseline to week-2 of HCT hospitalization, and their PTSD symptoms at six months post-HCT. Age, gender, type of transplant, the presence of comorbidities, disease relapse, and development of GVHD were not associated with PTSD symptoms at six months post-HCT. Married patients reported fewer PTSD symptoms post-HCT (ß =−5.9, SE 2.9, P= 0.05). Decline in QOL (ß = −0.34, SE 0.08, P< 0.0001) and increase in depression symptoms (PHQ-9: ß = 1.36, SE 0.31, P <0.0001) and anxiety symptoms (HADS-A: ß = 1.33, SE 0.41, P = 0.002] during hospitalization for HCT (week-2 of hospitalization – baseline) were significantly associated with more PTSD symptoms at six months post-HCT.
Table 2.
Unadjusted analyses of predictors of PTSD at six months post-HCT
| Variable | Estimate (Beta) | Standard Error | P-value |
|---|---|---|---|
| Type of transplant | |||
| Autologous (ref group) | Ref | Ref | Ref |
| Ablative allo | 5.0 | 3.54 | P = 0.20 |
| RIC allo | 2.3 | 3.40 | P = 0.50 |
| HCT-CI | −0.48 | 0.81 | P = 0.56 |
| Female (ref: male) | 1.68 | 2.84 | P = 0.56 |
| Marital status (married vs. other) | −5.9 | 2.9 | P = 0.05 |
| Age | −0.09 | 0.09 | P = 0.32 |
| Δ QOL (FACT-BMT) | −0.34 | 0.08 | P < 0.0001 |
| Δ Depression (HADS-D) | 1.41 | 0.46 | P = 0.003 |
| Δ Depression (PHQ-9) | 1.36 | 0.31 | P < 0.0001 |
| Δ Anxiety (HADS-A) | 1.33 | 0.41 | P = 0.002 |
| Relapse | 5.42 | 3.91 | P = 0.20 |
| GVHD | 4.81 | 4.58 | P = 0.30 |
Ablative Allo = Myeloablative Allogeneic HCT; RIC Allo= reduced intensity conditioning allogeneic HCT; HCT-CI = HCT- Comorbidity Index; GVHD = Graft-versus-host disease requiring systemic therapy.
Given the collinearity between QOL and depression and anxiety, we constructed two separate multivariable models to examine whether changes in QOL and depression and anxiety symptoms from baseline to week-2 of hospitalization predicted PTSD at six months post-HCT while controlling for clinically important variables [Table 3]. Both models controlled for age, gender, type of transplant, marital status, and disease status. In the first model, a decline in QOL during hospitalization was associated with PTSD at six months [ß = −0.40, SE 0.08, P < 0.0001]. In the second model, an increase in depression symptoms [PHQ-9: ß = 1.26, SE 0.32, P < 0.0001], but not anxiety [HADS-A: ß = 0.64, SE 0.42, P =0.13] during hospitalization predicted PTSD at six months post-HCT. Marital status remained a significant predictor of PTSD symptoms at six month in both multivariate model 1 (ß = −6.53, SE =2.59, P = 0.01) and model 2 (ß =− 5.70, SE 2.56, P=0.03) [data not shown].
Table 3.
Multivariate analysis: association of changes in QOL and mood during hospitalization for HCT with PTSD symptoms at six months post-HCT
| Model 1: with change in QOL as a predictor | |||
|---|---|---|---|
| Variable | Estimate (Beta) | Standard Error | P-value |
| Δ QOL (FACT-BMT) | −0.40 | 0.08 | P < 0.0001 |
| Model 2: with change in depression and anxiety as predictors | |||
|---|---|---|---|
| Variable | Estimate (Beta) | CI or Standard Error | P-value |
| Δ Depression (PHQ9) | 1.26 | 0.32 | P < 0.0001 |
| Δ Anxiety (HADS-A) | 0.64 | 0.42 | P = 0.13 |
The models adjust for age, transplant type, gender, relapse, and marital status. Δ QOL (FACT-BMT) = change in QOL (FACT-BMT) between week-2 and baseline. Δ Depression = change in depression scores (PHQ-9) between week-2 and baseline. Δ Anxiety = change in anxiety scores (HADS-anxiety) between week-2 and baseline.
Relationship between change in QOL and depression and anxiety during hospitalization and QOL at six months post-HCT
Table 4 depicts the unadjusted analyses examining the relationship between participants’ characteristics, clinical factors, change in QOL and depression and anxiety symptoms from baseline to week-2 of HCT hospitalization, and their QOL at six months post-HCT. Age, transplant type, gender, marital status, disease relapse, and the development of GVHD were not associated with QOL at six months post-HCT. However, changes in QOL [ß = 0.83, SE 0.18, P < 0.0001], depression symptoms [PHQ-9: ß = −2.95, SE 0.69, P < 0.0001] and anxiety symptoms [HADS-A: ß = −3.06, SE 0.90, P = 0.001] from baseline to week-2 of hospitalization for HCT were strongly associated with patients’ QOL at six months post-transplant.
Table 4.
Unadjusted analyses of predictors of QOL at months post-HCT
| Variable | Estimate (Beta) | Standard Error | P-value |
|---|---|---|---|
| Type of transplant | |||
| Autologous (ref group) | Ref | Ref | |
| Ablative allo | −14.63 | 7.72 | P = 0.06 |
| RIC allo | −5.8 | 7.41 | P = 0.44 |
| HCT-CI | −0.06 | 1.80 | P = 0.97 |
| Female gender | −6.20 | 6.30 | P = 0.33 |
| Age | 0.22 | 0.20 | P = 0.30 |
| Marital status (married vs. other) | 4.52 | 6.62 | P = 0.50 |
| Δ QOL (FACT-BMT) | 0.83 | 0.18 | P < 0.0001 |
| Δ Depression (HADS-D) | −3.03 | 1.02 | P = 0.004 |
| Δ Depression (PHQ-9) | −2.95 | 0.69 | P < 0.0001 |
| Δ Anxiety (HADS-A) | −3.06 | 0.90 | P = 0.001 |
| Relapse | −0.69 | 8.76 | P = 0.94 |
| GVHD | −4.24 | 9.92 | P = 0.67 |
Ablative Allo = Myeloablative Allogeneic HCT; RIC Allo = reduced intensity conditioning allogeneic HCT; HCT-CI = HCT- Comorbidity Index; GVHD = Graft-versus-host disease requiring systemic therapy.
In multivariable models controlling for age, gender, marital status, type of transplant, and disease relapse, the change in QOL from baseline to week 2 of hospitalization remained a strong predictor of QOL at six months post-HCT [ß = 0.94, SE 0.18, P < 0.001]. Similarly, in a separate multivariable models, an increase in depression [PHQ-9: ß = −2.59, SE 0.71, P = 0.001] and anxiety symptoms [HADS-A: ß = −2.12, SE = 0.94, P = 0.03] from baseline to week-2 of HCT hospitalization strongly predicted lower QOL at six months post-transplant [Table 5].
Table 5.
Multivariate analysis: association of changes in QOL and mood during hospitalization for HCT with QOL at six months post-HCT
| Model 1: with change in QOL as a predictor | |||
|---|---|---|---|
| Variable | Estimate (Beta) | Standard Error | P-value |
| Δ QOL (FACT-BMT) | 0.94 | 0.18 | P < 0.0001 |
| Model 2: with changes in depression and anxiety as predictors | |||
|---|---|---|---|
| Variable | Estimate (Beta) | Standard Error | P-value |
| Δ Depression (PHQ9) | −2.59 | 0.71 | P = 0.001 |
| Δ Anxiety (HADS-A) | −2.12 | 0.94 | P = 0.03 |
The models adjust for age, transplant type, gender, relapse, and marital status. Δ QOL (FACT-BMT) = change in QOL (FACT-BMT) between week-2 and baseline. Δ Depression = change in depression scores (PHQ-9) between week-2 and baseline. Δ Anxiety = change in anxiety scores (HADS-anxiety) between week-2 and baseline.
Discussion
A substantial proportion of patients with hematologic malignancies undergoing autologous and allogeneic HCT had clinically significant depression (43.3%) and PTSD symptoms (28.4%) at six months post-HCT. Notably, patients’ QOL decline and increase in depression during hospitalization for HCT emerged as strong predictors for increased PTSD symptoms and lower QOL at six months post-HCT. These data suggest that patients’ experiences during hospitalization for HCT is an important determinant of their post-HCT outcomes. Importantly, future interventions should examine whether improving the QOL and mood of patients during hospitalization for HCT may optimize their QOL at six months and reduce the risk of PTSD.
To our knowledge, this is the first study to report that patients’ experience during hospitalization for HCT affects their post-transplant PTSD symptoms and QOL. Prior work has highlighted the extent of physical and psychological symptoms, as well as QOL deterioration during hospitalization for HCT.8,12,18,19 Our findings suggest that patients’ experience during hospitalization represents the traumatic event. Notably, the degree and extent of this trauma, as measured by worsening QOL and depression, can predict future PTSD symptoms. Hence, the notion that the large symptom burden patients experience during their hospitalization for HCT is a short-lived and has minimal clinical implications on patients’ post-HCT outcomes is incorrect.
These data underscore the potential importance of interventions focused on optimizing patients’ mood and minimizing their symptom burden during their hospitalization for HCT as a potential therapeutic strategy to reduce their risk of PTSD and improve their QOL post-HCT. In our prior work, we identified pain, fatigue, bowel disturbances, insomnia, nausea, and depression as the most prominent symptoms contributing to patients’ QOL decline during their hospitalization for HCT.12 Many, if not all of these symptoms, including depression, are treatable and can be improved by intensive supportive care measures.20-22 Currently, we are conducting a randomized controlled trial assessing the efficacy of a targeted palliative care intervention to improve the QOL and physical and psychological symptoms of patients during hospitalization for HCT (clinical trials.gov: NCT02207322). It will be important to examine the effects of such an intervention on post-HCT PTSD symptoms and QOL.
By viewing the transplant hospitalization as the traumatic event that can lead to the development of PTSD symptoms post-HCT, we can also begin to identify predisposing factors that may put patients at higher risk for future complications. In a study examining predictors of PTSD symptomatology following HCT, lower social supports and higher avoidance coping one month prior to HCT predicted greater PTSD symptom severity at seven months post-HCT.11 Similarly in our study, being married, which is frequently utilized as a proxy for social supports, was protective against the development of PTSD symptoms post-HCT. Therefore, patients with limited social supports and certain coping strategies may represent a more vulnerable population who is predisposed to the development of PTSD and they may benefit from more targeted preventative interventions. Few studies have explored predictors of QOL following HCT. Younger age, female gender, lack of social support, the development of chronic GVHD, and pre-transplant psychological distress have been reported as potential predictors for long-term QOL impairment.2,5,23,24 Contrary to these findings, we did not identify age or gender as predictors of QOL at six months post-HCT. In our study, we focused on patients’ QOL at six months post-HCT, and thus are unable to examine the effect of chronic GVHD on long-term QOL, which has been previously reported.3,5,9,23,25 However, previous studies identifying predictors of PTSD symptoms post-HCT are lacking.11 Several factors have been associated with greater PTSD symptoms among cancer patients in general including poor social support, use of avoidance coping, and pre-morbid depression prior to cancer diagnosis.26-30 Intriguingly, our findings suggest that patients’ increasing depression symptoms during hospitalization for HCT is a very important predictor for PTSD symptoms in this study.
Our study has several important limitations. First, we included a small sample of mostly white patients drawn from a single transplant center and thus, our findings may not be generalizable to more diverse populations, patients in other geographic areas or transplant centers with different practices. Second, we did not measure patients’ coping strategies, social supports, or rates of PTSD at baseline prior to HCT, which are all potentially important variables affecting the risk of PTSD post-HCT. Third, by including a small sample of patients undergoing different types of HCT, we are unable to examine fully the association between the type of transplant and risk of PTSD symptoms. Fourth, anxiety symptoms did not change substantially during hospitalization for HCT, which may have limited our ability to assess the relationship between change in anxiety symptoms and PTSD at six months post-HCT. Lastly, it is possible that the decline in QOL and mood during HCT hospitalization reflects patients’ perception of the illness as more ‘life threatening’, which may result in higher PTSD symptoms at 6 months. Therefore, improving patients’ experience during hospitalization as well as addressing their perception of illness severity utilizing cognitive behavioral therapy approaches may reduce PTSD symptoms at 6 months post-HCT.
In this study, we demonstrate that a significant proportion of patients undergoing HCT report PTSD and depression symptoms at six months post-HCT, further illustrating the substantial psychological burden endured by this population. Importantly, patients’ experience during their hospitalization for HCT, particularly their QOL decline and increase in depression symptoms during hospitalization, strongly predicted an increase in PTSD symptoms and impaired QOL at six months post-HCT. These findings highlight that the physical and psychological symptoms patients experience during hospitalization for HCT represent the extent and degree of the trauma leading to long-term complications such as PTSD. We can no longer view the HCT hospitalization period as a natural and unmodifiable aspect of the HCT process. Future research efforts should be directed at modifying and reducing the physical and psychological burden patients experience during hospitalization for HCT with the hope of improving their post-transplant adjustment and recovery.
Acknowledgments
Funding: This work was supported by funds from National Palliative Care Research Center (El-Jawahri) and K24 CA 181253 (Temel).
Footnotes
Financial Disclosures: None
References
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