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Adapted from the NCI Cancer Bulletin, vol. 4/no. 24, August 21, 2007 (see the current issue). People who undergo allogeneic hematopoietic stem cell transplantation (HCT) and survive for at least two years remain at increased risk of premature death even 15 years after treatment, reports a new study published online August 1, 2007, in Blood (see the journal abstract). This group of survivors also faces long-term challenges affecting their overall health and well-being, including difficulty maintaining employment, as well as finding and retaining health and life insurance.Advances in stem-cell transplantation "have made it a curative therapeutic option," explains Dr. Smita Bhatia, professor of population sciences at City of Hope Comprehensive Cancer Center and lead author of the study. "We need to focus on the survivors. Half [of the cohort we studied] has survived longer than nine and a half years, and one thing that we have shown quite definitively is that these survivors continue to face challenges."
These results come from long-term follow-up data from the Bone Marrow Transplant Survivor Study (BMTSS), which began in 2000 and comprises a cohort of 1,479 patients who underwent allogeneic HCT for cancers of the blood or for bone-marrow dysfunction at City of Hope or the University of Minnesota between 1974 and 1998.
Out of all patients who survived at least two years after transplantation, 21.6 percent had died by June 30, 2003. The probability of surviving was 86.6 percent at five years, 80.4 percent at 10 years, and 76.3 percent at 15 years from HCT. "Overall, premature death occurred 10 times more often than expected" compared to the general population, explain the authors. Treatment-related morbidities and chronic graft-versus-host disease accounted for 25 percent and 22 percent of the deaths, respectively.
Relative mortality compared with the general population was highest two to five years after HCT, but remained twice as high even 15 years after transplantation. Survivors had specific risks of mortality related to the effects of treatment on vital organ systems, including a 15.1 percent greater risk of death due to pulmonary dysfunction and a 2.3 percent greater risk of death due to cardiac complications.
To gather a clearer picture of the challenges to functional well-being faced by survivors, the investigators collected survey data from 547 BMTSS participants and 319 nearest-age siblings. Compared with the siblings, survivors were 14 times more likely to report a health problem preventing them from holding a job, seven times more likely to report difficulty obtaining or retaining health insurance, and 10 times more likely to report difficulty obtaining or retaining life insurance. Survivors were also significantly less likely to be married compared with healthy siblings. "They're facing challenges re-integrating back into society," comments Dr. Bhatia.
"This population needs very specialized follow-up to look out for late effects or complications," she continued. "We either need to develop really good communications between the cancer-care and transplant teams and patients’ regular physicians, or we need to have a mechanism available at the transplanting centers to follow transplant patients for life."
Dr. Julia Rowland, director of the National Cancer Institute's Office of Cancer Survivorship, agrees with these conclusions (see related story). "This report argues strongly for the need, which is being supported by the advocacy community, for survivors to receive a treatment summary at the end of their therapy and a care plan going forward," she said. "These documents would detail the type of cancer the survivor had, the treatments received, and potential problems for which she or he might be at increased risk as a result, and, importantly, outline recommended follow-up care. Together, they would serve as a guide for survivors and their health care providers in planning for future cancer surveillance and health care needs.
"A number of the complications identified in this study, both physical and psychosocial, potentially could be mitigated with early interventions. Thus, systematic follow-up, with timely identification and treatment of these complications, could enable us to further reduce the late morbidity and mortality for these survivors," Rowland concluded.
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