Post-transplant Employment Status of Adult Survivors of Childhood Allogeneic Hematopoietic Cell Transplant: A Report from the CIBMTR

Condensed abstract: Employment outcomes of survivors of childhood allogeneic hematopoietic cell transplant are unknown. In this large multi-institutional and multi-national study including 2,844 patients, survivors of childhood allogeneic transplant had persistently high unemployment rates at all studied attained ages post-HCT (18–32 years).

Abstract

Background:

Data are scarce regarding employment outcomes of survivors of childhood allogeneic hematopoietic cell transplant (alloHCT) and factors affecting their employment status.

Methods:

Using the Center for International Blood and Marrow Transplant Research database, we studied employment outcomes of ≥1-year survivors of childhood alloHCT who were ≥18 years of age at their most recent assessment (year of transplant: 1985–2010). Employment status was assessed at their attained ages (18–22, 23–27, 28–32 years) and according to transplant center (TC) location (United States [US], International). A multivariable analysis assessing the factors affecting employed status (full-time/part-time work or students) was performed.

Results:

Survivors’ (n=2,844) unemployment rates were persistently high at all attained ages (18–22: 14%, 23–27: 15%, 28–32: 13% [US], 18–22: 56%, 23–27: 53%, 28–32: 68% [International]). Factors associated with higher likelihood of employment included: older age at alloHCT [5–9-years: hazard ratio (HR) 2.07, 95% confidence interval (CI): 1.65–2.6; 10–14-years: HR 4.43, 95% CI: 3.58–5.47; 15–18-years: HR 7.13, 95% CI: 5.72–8.88], myeloablative conditioning without total body irradiation (TBI) (HR 1.56, 95% CI: 1.38–1.77), reduced intensity conditioning with (HR 1.47, 95% CI: 1.19–1.8) or without TBI (HR 2.51, 95% CI: 2.15–2.92), and US-based TC (HR 1.84, 95% CI: 1.62–2.08).

Conclusions:

Young adult survivors of childhood alloHCT have high unemployment rates at all studied attained ages post-HCT. Future efforts should be directed towards understanding the causes of unemployment, and its relationship with quality of life using patient-reported outcome measures.

Introduction:

The utilization of allogeneic hematopoietic cell transplantation (alloHCT) as a curative option for both benign and malignant hematological conditions has increased¹. Survival post-HCT has improved over the years, and according to Majhail and colleagues, there will be approximately 500,000 transplant survivors in the US by the year 2030². As survival rates continue to improve, our understanding of the late effects spectrum in survivors is also increasing. In addition to increased risks for life-threatening late effects such as subsequent neoplasms, immune dysregulation, infections, and cardiovascular sequelae, alloHCT also significantly impacts morbidities including psychological (emotional distress, depression, anxiety, post-traumatic stress, cognitive dysfunction), social-environmental (return to work, adherence to treatment), physical (pain, fatigue, sleep disturbance, sexual dysfunction), and health behavior (risk behaviors, unhealthy diet, physical inactivity) aspects of survivors’ lives³.

Post-HCT educational or vocational attainment are important indicators of survivors’ social and economic well-being, overall function and health-related quality of life (QOL)^{4, 5}. Unemployment or work-related difficulties may significantly impact QOL, healthcare access and adherence to medical management^{6, 7}. Similarly, education impacts survivors’ ability to find employment, obtain health insurance, and influences their marital status⁸. Our knowledge regarding employment outcomes of HCT survivors comes from studies focusing on patients transplanted as adults^{4, 7, 9, 10}. It is difficult to extrapolate conclusions from these studies due to differences in study design, inclusion of both allogeneic and autologous transplant survivors, and conflicting results. A few single-center studies have assessed the employment outcomes in adult survivors of childhood HCT, and have consistently shown higher unemployment rates in survivors compared to the general population or sibling controls^{11, 12}. Studies focusing on adult survivors of childhood cancer who did not receive alloHCT have also shown higher unemployment rates in survivors compared to the controls^13–15.

To our knowledge, there are no multi-institutional or multi-national data reporting employment or educational outcomes of survivors of childhood alloHCT. We used data reported to the Center for International Blood and Marrow Transplant Research (CIBMTR) to 1) evaluate the employment status of adult (≥18 years of age at the time of the study) survivors of childhood (<18 years of age at HCT) alloHCT and to 2) identify predictors of post-HCT employment in this population. An exploratory aim of our study was to describe the unemployment rates in our cohort in relation to the national unemployment rates.

Methods:

Data source:

The CIBMTR is a research collaboration between the National Marrow Donor Program^® (NMDP)/Be The Match^® and the Medical College of Wisconsin. More than 450 transplant centers (TC) worldwide contribute detailed data prospectively on consecutive transplants to the CIBMTR. Compliance and accuracy of data reported to the CIBMTR are monitored by on-site audits. All patients are followed longitudinally until death or loss to follow-up. Patients and/or guardian(s) provide written informed consent for data submission and research participation. The study was conducted in accordance with the Declaration of Helsinki. The institutional review board of the NMDP approved this study.

Patient eligibility:

The study population derivation is depicted in figure 1. We included patients who underwent their first alloHCT in childhood (age <18 years at HCT) for any malignant or non-malignant conditions between January 1, 1985 and December 31, 2010 and reported to the CIBMTR. Patients were excluded if their TC had a 5-year completeness of follow-up less than 80%. Patients who survived alloHCT for at least 1 year and were ≥18 (employment eligible age) at the time of the study were included (n=5,727). Patients with missing employment information at all time-points post-HCT (n=2,862), and with twin/syngeneic donor (n=21) were excluded. Our final study population consisted of 2,844 patients.

Figure 1:

Study population derivation

Employment status:

CIBMTR’s database was used to abstract patient-, disease-, and transplant-related data, and survivors’ employment data. The specific question regarding the work status on the post-HCT data forms was, “What is the recipient’s current or most recent work status during the reporting period?” The answer choices were the following: full-time, part-time, unemployed, medical disability, retired, recipient <16 years of age, or unknown. Information regarding survivors’ student status was obtained from another question asking to specify the category which best described the recipient’s current occupation. “Student” was the answer choice of interest.

Definitions and Statistical analysis:

Descriptive statistics were presented for the patient-, disease-, and transplant-related variables. Chi-square test, Wilcoxon rank-sum test, and Satterthwaite t-test were used to compare US and international survivors’ baseline characteristics. To describe post-HCT employment status, survivors were divided into 6 categories: full-time work, part-time work, unemployed, retired, medical disability, and students. For convenience and due to relatively young survivor cohort, students were described as a separate employment category regardless of their response to the work status question. Frequencies of employment status categories were provided according to survivors’ attained ages based on the age distribution at survival, grouped as 18–22, 23–27, and 28–32 years and according to the TC location (United States [US] and International) to account for the multi-national nature of our study population. For the exploratory aim, a descriptive comparison of the unemployment rates of survivors with the US and international general population using the World Bank’s International Bank for Reconstruction and Development (IBRD) and International Development Association (IDA) unemployment data (https://data.worldbank.org) was performed.

A Cox proportional hazard model was created to study the predictors of survivors’ employed status post-alloHCT, using both pre-HCT variables and post-HCT time-dependent covariates. A stepwise selection model was utilized to identify significant variables in the final model. The included variables were age at alloHCT (grouped as 0–4 vs. 5–9 vs. 10–14 vs. 15–18 years), sex, race/ethnicity (Caucasian vs. others), location of TC (US vs. international), Karnofsky/Lansky score before alloHCT (<90 vs. ≥90), disease diagnosis (malignant vs. non-malignant), a composite graft source and donor type variable (bone marrow[BM]/related vs. peripheral blood[PB]/related vs. cord blood[CB]/related vs. BM/unrelated vs. PB/unrelated vs. CB/unrelated), conditioning regimen (myeloablative conditioning [MAC] with total body irradiation [TBI] vs. reduced intensity conditioning [RIC]/non-myeloablative [NMA] with TBI vs. MAC without TBI vs. RIC/NMA without TBI), anti-thymocyte globulin (ATG) or alemtuzumab use, graft-vs.-host disease (GVHD) prophylaxis (ex-vivo T-cell depletion/CD34 selection vs. calcineurin inhibitors [CNI]±others vs. others), and acute GVHD, chronic GVHD, disease relapse or progression, subsequent neoplasm at any time post-alloHCT. We did not include the year of transplant variable in the model because the age at transplant, choice of donor type/ graft source, and conditioning intensity/ use of TBI highly correlated with the era of transplant (e.g. increasing use of unrelated donor type with increasing year of transplant). The primary outcome was the employment status at age ≥18 (employment eligible age); the first indication of being employed (in full-time/part-time work or students) at age ≥18 was considered an event. Students were considered employed for the convenience of analysis. Patients were considered unemployed if they were never reported being in full-time/part-time work or being students at any time-point at age ≥18. The time to event was calculated from the time of alloHCT to the time when the first employment status at age ≥18 was reported. Unemployed patients were censored at the end of their follow up or death. To adjust for multiple comparisons, a P-value <0.01 was considered statistically significant. SAS 9.4 (SAS Inc., Cary, NC) was used for all analyses.

Results:

Baseline characteristics:

Baseline characteristics of the patient population are described in table 1. Forty-eight percent of the patients were transplanted at US TCs. The remaining population was transplanted in: Europe (18%), Asia (17%), South America (7%), North America (5%), and Australia/ New Zealand (5%). Baseline characteristics were compared between the US and international survivors (Supplemental table S1). Additionally, baseline characteristics of the study population (n=2,844) were compared with the survivors excluded due to missing employment information at all time-points post-HCT (n=2,862), and no significant differences were noted (data not shown).

Table 1:

Characteristics of patients that underwent first allogeneic HCT between 1985–2010 and survived until 18 years of age, reported to CIBMTR

Variable	N=2,8441 (%)
Median age at transplant, years (range)	13 (<1–18)
Median age at survival, years (range)	22 (18–45)
Age groups at transplant, years
0–4	180 (6)
5–9	574 (20)
10–14	1,125 (40)
15–18	965 (34)
Sex
Male	1,642 (58)
Female	1,202 (42)
Race/Ethnicity
Caucasian/White	1,916 (67)
Others2	898 (32)
Missing	30 (1)
Karnofsky/ Lansky score
<90	463 (16)
90–100	2,303 (81)
Missing	78 (3)
Disease type
Malignant3	1,825 (64)
Non-malignant4	1,019 (36)
Graft source and Donor type
Bone Marrow//related	1,420 (50)
Peripheral Blood/related	142 (5)
Cord Blood/related	20 (<1)
Bone Marrow/unrelated	823 (29)
Peripheral Blood/unrelated	156 (5)
Cord Blood/unrelated	281 (10)
Conditioning regimen
Myeloablative with TBI	1,467 (52)
Reduced intensity/ non-myeloablative with TBI	157 (6)
Myeloablative without TBI	874 (31)
Reduced intensity/ non-myeloablative without TBI	331 (12)
Missing	15 (<1)
ATG/ alemtuzumab use
Yes	1090 (39)
None	1685 (59)
Missing	69 (2)
GVHD prophylaxis
T-cell depletion or CD34 selection	325 (11)
Calcineurin inhibitors ± Others	2,422 (85)
Others	76 (3)
Missing	21 (<1)
Year of transplant
1985–1994	660 (23)
1995–2004	1,493 (52)
2005–2010	691 (24)
Median follow-up of survivors (range), months	132 (13–335)

TBI- total body irradiation, ATG- anti thymocyte globulin, GVHD-graft-versus-host disease

¹Number of patients from the US: 1364 (48%)

²African American, Asian/ Hawaiian, Pacific Islander, Hispanic, Native American, Middle Eastern, Other

³Acute lymphoblastic leukemia, acute myeloid leukemia, chronic myelogenous leukemia, myelodysplastic syndrome, other hematologic malignancies, non-Hodgkin lymphoma, solid tumors

⁴Severe aplastic anemia, Fanconi anemia, sickle cell disease, thalassemia, severe combined immunodeficiency and immune system disorders, inherited disorders of metabolism, other non-malignant diseases

Post-HCT complications:

The median follow-up was 11 years (range: 1.1–27.9 years). The overall incidence of acute GVHD was 49% and chronic GVHD was 37%, with a median development time interval of <1 month (range: <1–184 months), and 5 months (range: <1–190 months), respectively. Disease relapse or progression was noted in 9% of the patients at a median interval of 23 months (range: <1–241 months), and development of subsequent neoplasm, lymphoproliferative or myeloproliferative disorders was seen in 7% of the cases at a median interval of 113 months (range: 1–268 months).

Post-alloHCT employment rate:

The rates of working status (combined full-time, and part-time) increased from 7.3% at 18–22 years, to 45.5% at 23–27 years, to 72.7% at 28–32-year age group in the US survivors, and 3.7%, to 20.6%, to 21% in the international survivors (Figure 2). The percentage of students decreased from 18–22-year age-group (US: 77.2%; International: 39.4%) to 28–32 year-group (US: 10.2%; International: 9%). The rates of unemployment remained steady for the US survivors (18–22: 14.6%, 23–27: 15.5%, 28–32: 13.6%) and increased in the international survivors (18–22: 56.4%, 23–27: 53.8%, 28–32: 68%). The range of the general population unemployment rate between 1996 and 2016 was 5.4–9.6% in the US; and 2.1–27.2% internationally.

Figure 2:

Trend of employment status in adult survivors of pediatric HCT at their attained age ranges and according to their transplant center location. The X axis shows survivors’ attained age groups, and the Y axis shows the percentages of employment categories

Predictors of post-HCT employment:

A multivariable analysis assessing the predictors of post-HCT employment (in full-time/part-time work or students ≥18 years of age) showed that compared to survivors transplanted at international TCs, patients who were transplanted at US TCs had a higher likelihood of being employed post-alloHCT (HR 1.84, 95% CI: 1.62–2.08, P<0.001) (Table 2). Compared to patients receiving MAC with TBI, survivors were more likely to be employed if they had received RIC/NMA conditioning with (HR 1.47, 95% CI: 1.19–1.8) or without TBI (HR 2.51, 95% CI: 2.15–2.92), or MAC without TBI (HR 1.56, 95% CI: 1.38–1.77). Compared to patients <5 years of age at transplant, patients ≥5 years of age at transplant were also more likely to be employed (5–9-years: HR 2.07, 95% CI: 1.65–2.6; 10–14-years: HR 4.43, 95% CI: 3.58–5.47; 15–18-years: HR 7.13, 95% CI: 5.72–8.88). Similarly, patients with pre-HCT Karnofsky/Lansky score ≥90 were more likely to be employed later compared to patients with the score <90 (HR 1.41, 95% CI:1.23–1.63). Stem cell source and donor factors favorably associated with post-HCT employment compared to BM/related were: PB/related (HR 2.15, 95% CI: 1.7–2.72), CB/related (HR 2.21, 95% CI: 1.33–3.66), BM/unrelated (HR 2.002, 95% CI: 1.73–2.32), PB/unrelated (HR 4.33, 95% CI 3.51–5.34), CB/unrelated (HR 3.45, 95% CI: 2.89–4.13). Compared to CD34 selection/T-cell depletion, patients receiving CNI containing GVHD prophylaxis regimen were more likely to be employed at age ≥18 (HR 1.89, 95% CI:1.61–2.22). Sex, race/ethnicity, ATG/alemtuzumab use were not associated with post-HCT employment status. None of the post-HCT complications we studied were significantly associated with post-HCT employment status.

Table 2:

Multivariable cox regression analysis of pre- and post-HCT predictors of post-HCT employment status¹

Variables	N	Hazard ratio (95% CI) employment	P-value
Country
International	1,364	1
US	1,480	1.84 (1.62–2.08)	<0.001
Age at transplant (years)			<0.001
0–4	180	1
5–9	574	2.07 (1.65–2.6)	<0.001
10–14	1,125	4.43 (3.58–5.47)	<0.001
15–18	965	7.13 (5.72–8.88)	<0.001
Karnofsky/ Lansky Score			<0.001
<90	463	1
≥90	2,303	1.41 (1.23–1.63)	<0.001
Missing	78	2.03 (1.53–2.68)	<0.001
Graft/ Donor			<0.001
BM/ related	1,420	1
PB/ related	142	2.15 (1.7–2.72)	<0.001
CB/ related	20	2.21 (1.33–3.66)	0.002
BM/ unrelated	823	2.002 (1.73–2.32)	<0.001
PB/ unrelated	156	4.33 (3.51–5.34)	<0.001
CB/ unrelated	281	3.45 (2.89–4.13)	<0.001
Missing	2	1.61 (0.22–11.48)	0.637
Conditioning			<0.001
MAC with TBI	1,467	1
RIC/NMA with TBI	157	1.47 (1.19–1.8)	<0.001
MAC without TBI	874	1.56 (1.38–1.77)	<0.001
RIC/ NMA without TBI	331	2.51 (2.15–2.92)	<0.001
Missing	15	0.62 (0.3–1.27)	0.191
GVHD prophylaxis			<0.001
CD34 selection/ T depletion	325	1
CNI +/− others	2,422	1.89 (1.61–2.22)	<0.001
Others	76	1.48 (0.99–2.23)	0.057
Missing	21	2.33 (1.37–3.98)	0.002

Abbreviations: US-United States, BM- bone marrow, PB- peripheral blood, CB- cord blood, MAC-myeloablative conditioning, TBI-total body irradiation, RIC- reduced intensity conditioning, NMA-non-myeloablative conditioning, GVHD-graft-versus-host disease, CNI-calcineurin inhibitor

¹Outcome (employment status) dichotomized as employed (in full-time/ part-time job, students) vs unemployed (unemployed, retired, medical disability)

Discussion:

To our knowledge, this is the only multi-institutional and multi-national study assessing the employment status of survivors of childhood alloHCT. With increasing attained age after 18 years, the percentage of students decreased as expected and the percentage of survivors in full-time and part-time work increased. However, unemployment rates were persistently high at all studied attained ages post-HCT even at 28–32 years of age (14% in the US survivors, and 68% in international survivors).

Our study results are consistent with previous smaller studies focusing on employment outcomes of childhood HCT survivors. A study performed by Lof et al. investigated employment status of patients surviving for at least 5 years post-alloHCT performed in childhood (1–16 years) at a single center in Sweden¹¹. Survivors (n=51) were noted to have lower level of post-HCT employment compared to the general population in Sweden and were more likely to have a disability pension. This study also found that 43% of HCT survivors were in the poverty risk zone compared to 6% of the general Swedish population. There was no significant difference between the number of survivors who were students when compared to the general population. Another single center cross-sectional survey assessed the QOL of adult survivors of pediatric allogeneic and autologous HCT (n=214) compared with a control population comprised of age- and sex-matched siblings or friends of survivors¹². At the time of assessment, 82% of survivors were in full-time work, school or working as full-time homemakers; however, the percentage was still significantly lower than the 92% in the control group (P=0.001). Family financial support was more commonly needed by survivors compared to controls (15% vs. 6%, P=0.002).

Information regarding factors influencing post-HCT work or student status was lacking in these studies. While studying the predictors of employment, we found that certain subgroups such as younger age at HCT, use of MAC with TBI, and international survivors had lower likelihood of being employed post-HCT, which is intriguing. Previous studies focusing on employment outcomes in adult survivors of childhood cancer who did not undergo HCT have also shown that younger age at diagnosis was associated with decreased likelihood of being employed. Frobisher and colleagues studied the employment and occupational status of pediatric cancer survivors using the British Childhood Cancer Survivorship Study (BCCSS)¹³. Compared to the general population, survivors were less likely to be employed. Increase in age at diagnosis was significantly associated with increased likelihood of being employed. Trends of employed and student survivors were similar to those reported by our study. Pang and colleagues used the Childhood Cancer Survivor Study (CCSS) and found that survivors who were diagnosed with cancer between 0 to 3 years of age were at significantly higher risk of having never been employed compared to those with an older age at diagnosis¹⁵. Similar findings were noted in another CCSS study, where the mean age of the survivor cohort was 26 years at the time of the study, and survivors who were >30 years from the diagnosis were 1.89 times more likely to be unemployed compared to survivors ≤20 years from diagnosis¹⁴. Based on the results of these studies, we hypothesize that patients receiving a transplant at a younger age would be at higher risk for neurocognitive complications post-HCT as shown by previous literature¹⁶, leading to academic and employment related-difficulties.

Radiation exposure, in particular, TBI when used in the myeloablative conditioning setting has also been postulated as neurotoxic and a cause of post-HCT neurocognitive abnormalities¹⁶. Smedler et al. reported that patients who received TBI between the ages 3 and 11 years had worse perceptual and fine motor abilities compared to their sibling donors¹⁷. These survivors were noted to have verbal reasoning difficulties even at 10 years post-HCT. Additionally, TBI has a known association with debilitating long-term complications such as endocrinopathies, and end-organ damage¹⁸. Similarly, the studies focusing on cancer survivors have consistently shown negative effects of radiation, especially cranial radiotherapy on employment outcomes^13–15. Cranial radiation has also been shown to affect educational outcomes in long-term survivors of childhood cancer¹⁹. These findings could explain the significantly lower likelihood of employment noted in our study in survivors who received TBI at myeloablative dosing.

Our findings of lower likelihood of employment in survivors transplanted with related donor and BM graft source and use of TBI in conditioning regimen are likely reflective of the era of transplant. Historically patients were transplanted mainly using HLA-identical sibling as their donor choice. Since the early 2000s, there has been significant advances in transplant practice, including better donor availability, and high-resolution HLA-typing. In recent years the number of transplants using unrelated donors have significantly increased²⁰. As the long-term toxicity profile of TBI has become evident, non-irradiation conditioning regimens are increasingly used in the pediatric population in the last decade. Since the majority (75%) of our study population was transplanted before 2005, we might not appreciate the impact of changes in transplant technology. It will be interesting to see if these findings remain the same in the future. In our study, none of the assessed post-HCT complications (acute or chronic GVHD, relapse/progression, or subsequent neoplasm) were associated with post-HCT employment status.

In our study, patients transplanted at US TCs were more likely to be employed compared to international TCs. The US and international survivor cohorts were different in terms of their clinical characteristics, however the difference in likelihood of employment persisted even after adjusting for these variables. Lower unemployment in the US survivors could be explained by the fact that people in the US have to maintain employment to obtain health insurance. The health coverage difficulties faced by patients with pre-existing/chronic health conditions in the US are well-known. A prior study has found that survivors of childhood cancer in the US avoid job changes because of fear of losing health insurance and suffer from “job lock”²¹. In that study, a high prevalence of job lock was seen in survivors with a history of insurance denial and having difficulties paying medical bills. In contrast, higher unemployment rates noted in survivors of international countries could be due to provision of national health coverage which does not rely on employer-based insurance. For example, in a recent study published by Tichelli et al., significantly higher percentage of both allogeneic and autologous HCT survivors in Switzerland were reported to be receiving disability pension compared to the general Swiss population¹⁰. Similar findings were reported by Harder et al., where 40% of the Dutch HCT survivors were still receiving complementary sickness or unemployment insurance benefit at a median 3.7 years post-HCT²². Caution should be exercised while interpreting the results of our study comparing US vs. international data, since we combined all other countries except the US in the international category without accounting for their economic indicators such as gross per capita income, healthcare system setup, health expenditure per capita, and human development index.

Our study has several limitations. CIBMTR are collected by data managers through chart abstraction, not by direct patient-report. Therefore, details regarding causes or duration of unemployment, survivors’ educational attainment, functional status are lacking. We were also unable to address the potential problem of underemployment in the study population. In the current study, several patients were excluded because of unavailability of employment-related data post-HCT. Although there was no significant difference between included and excluded patients based on their baseline characteristics, other sources of post-HCT bias cannot be excluded. Due to the lack of an age-, sex-, and race-matched control population, we were unable to statistically compare the unemployment rates noted in our study. Furthermore, the unequal duration of follow-up after the age of 18 could have impacted the differences in likelihood of employment post-HCT. For convenience, survivors who were reported to be students were included in the employed category for the analysis.

Conclusion:

In conclusion, we found young adult survivors of childhood alloHCT to have high unemployment rates at all studied attained ages post-HCT. The likelihood of post-HCT employment (being in full-time/ part-time work or students) was influenced by the era of transplant. Patients transplanted at a younger age, with poor performance score prior to HCT, transplanted with related donor and BM graft source, and MAC including TBI had a lower likelihood of employment.

Future directions:

With a growing number of alloHCT survivors, the high unemployment rates as seen in our study may in turn significantly affect the economy and healthcare access. Our study findings call for routine screening practices to avoid education or vocation-related difficulties for survivors. Our study also sets the stage for future studies assessing the causes of unemployment in long-term survivors, and the relationship between employment outcomes and their QOL. Based on the results of our study, we anticipate development of future clinical trials to change modifiable risk factors such as avoiding the use of TBI at myeloablative doses especially in younger age patients, and promoting the use of reduced intensity/ non-myeloablative conditioning regimen whenever possible. In the future, we hope to see the development of strategies to increase survivors’ likelihood of successfully returning to work and integration of QOL and employment status as important treatment outcomes along with overall survival and disease-free survival in transplant practice.