Sexual health in hematopoietic stem cell transplant recipients

Enhancing Sexual Health for Cancer Survivors

Changes to sexual function after cancer treatment are extremely prevalent, affecting up to 90% of female patients with cancer and 40%-85% of male patients with cancer. Sexual health concerns include low libido, genitourinary syndrome of menopause, dyspareunia, erectile dysfunction (ED), hypogonadism, body image concerns, and impacts on intimate relationships. Given the significant impact of sexual dysfunction on quality of life, oncology professionals should integrate sexual health discussions into routine patient care, regardless of the patient's age, sex, or cancer type. Sexuality is best understood in a biopsychosocial framework and cancer treatments including chemotherapy, surgery, radiation, and endocrine therapy can affect all of these domains. Management of genitourinary syndrome of menopause includes nonhormonal and low-dose local hormonal options. Pelvic floor dysfunction and vaginal stenosis can be treated with pelvic floor physical therapy and use of vaginal dilator therapy. ED can be treated with phosphodiesterase type 5 inhibitors and if needed, interventions such as intracavernosal injection of vasoactive agents, urethral suppositories, vacuum erection devices, and surgical implants are available. Cancer treatments such as chemotherapy, radiation, and androgen-deprivation therapy can lead to hypogonadism in men, which can be treated with testosterone therapy, unless contraindicated. Psychosocial counseling, sex therapy, and couples counseling are options for impact to sexual response, body image, and relationship concerns. A comprehensive, patient-centered approach to sexual health can help improve outcomes and overall well-being for cancer survivors.

Effects of Treatment With Premarin Alone and the Combination of Premarin + Beclomethasone in Vaginal Involvement of GVHD After Hematopoietic Stem Cell Transplantation

BACKGROUND

Vaginal Graft-versus-Host Disease (GVHD) is a common complication after hematopoietic stem cell transplantation, leading to inflammation and fibrosis of the vaginal tissue. This study was conducted to compare the effectiveness of Premarin alone versus Premarin + Beclomethasone in patients with vaginal GVHD.

METHODS

40 patients with vaginal GVHD after hematopoietic stem cell transplantation at (XXX) during the years 2018 to 2020 were randomly assigned to 2 groups: the Premarin recipient group (22 individuals) or the Premarin + Beclomethasone group (18 individuals). Symptoms, including vaginal dryness, dyspareunia, discharge, vaginal tightness, etc., were assessed before and after 6 weeks of treatment.

RESULTS

After treatment, most symptoms improved in both groups. The Premarin group showed improvement in 21 out of 25 symptoms (84%), while the combination group demonstrated improvement in 22 out of 25 symptoms (88%), with no significant difference between the groups (P > .05). The only symptom with significantly greater improvement in the combination group was vaginal tightness, which occurred in 3 out of 18 patients (17%) compared to 1 out of 22 patients (4.5%) in the Premarin group (P = .03).

CONCLUSIONS

The combination of Premarin and Clobetasol is more effective than Premarin alone, particularly in cases of vaginal tightness. Other symptoms may be associated with atrophic manifestations.

Evaluation and preservation of fertility in patients with hematologic malignancies

For patients with hematologic malignancies, novel therapeutic strategies offer the potential to achieve a complete clinical response and long-term survival. However, declining fertility has become a significant concern, impacting long-term quality of life. Conventional high-dose chemotherapy and radiotherapy are known to reduce fertility or cause sterility. Moreover, limited clinical data are available on the effects of newer therapies, such as targeted treatments and chimeric antigen receptor (CAR)-T cell therapy, on fertility. Additionally, there is no standard method for preserving fertility in these patients. Male patients can opt for sperm cryopreservation, whereas female patients may preserve fertility through embryo, oocyte, or ovarian tissue cryopreservation. However, preserving fertility in prepubescent patients remains particularly challenging. Therefore, hematologists must educate patients about the potential gonadal toxicity of cancer treatments and offer the most appropriate fertility preservation options.

Prospective Association of Psychological Distress and Sexual Quality of Life Among Hematopoietic Stem Cell Transplant Survivors

Sexual health concerns are one of the most common late effects facing hematopoietic stem cell transplant (HSCT) survivors. The current study tested whether self-reported depression and anxiety symptoms before transplant were associated with embedded items assessing two specific areas of sexual health-sexual interest and sexual satisfaction-one year post-HSCT. Of the 158 study participants, 41% were diagnosed with a plasma cell disorder (n = 60) and most received autologous transplantation (n = 128; 81%). At post-HSCT, 21% of participants reported they were not at all satisfied with their sex life, and 22% were not at all interested in sex. Greater pre-HSCT depressive symptomology was significantly predictive of lower sexual interest (β = -.27, p < .001) and satisfaction (β = -.39, p < .001) at post-HSCT. Similarly, greater pre-HSCT trait anxiety was significantly predictive of lower sexual interest (β = -.19, p = .02) whereas higher levels of state and trait anxiety were both predictive of lower satisfaction (β = -.22, p = .02 and β = -.29, p = .001, respectively). Participant sex significantly moderated the relationship between state anxiety and sexual satisfaction (b = -.05, t = -2.03, p = .04). Additional research examining the factors that contribute to sexual health post-HCST is needed to inform and implement clinical interventions to address these commonly overlooked survivorship concerns.

From diagnosis to survivorship addressing the sexuality of women during cancer

For women diagnosed with cancer, side effects affecting their sexuality are extremely common and can be distressing and life-changing; however, most women are left in the dark without any guidance from their oncology teams regarding possible side effects and treatment options. American Society of Clinical Oncology clinical guidelines provide guidance on the recommended assessments related to the domains of sexual function and their respective interventions. Despite the existence of these guidelines, the reality is that only a few women with cancer are asked about sexual concerns that result from cancer treatments. Common barriers to sexuality discussion reported by oncology providers include a lack of qualification and knowledge, not having a place to refer patients, and not knowing how to start the conversation. Social media remains a widely untapped resource regarding sexuality and cancer interventions, as people are increasingly turning to social media for health information and advice. This may be especially relevant for sexuality, as oncologists may not feel comfortable or well-trained to discuss the topic, and patients may be reluctant to bring up sexual concerns during their visits. Social media can play a critical role in studying sexual health and in sexuality interventions, particularly in adolescent and young adult patients with cancer. Here, we discuss the lack of inclusion regarding sexuality in oncology, the rates of sexual dysfunction in patients with cancer, treatment options for common sexual concerns, how to utilize the reach of various social media channels, and provide patient and provider resources.

Design and Development of a Multimodal Digital Intervention (SHIFT App) to Address Sexual Dysfunction in Hematopoietic Stem Cell Transplant (HSCT) Survivors

Hematopoietic stem cell transplant (HSCT) survivors frequently experience persistent sexual dysfunction, which is associated with impaired quality of life and increased psychological distress. The lack of availability of clinicians with expertise in sexual health limits the capacity to address sexual health concerns in HSCT survivors. Digital health applications may offer a patient-centered and scalable solution to address sexual health concerns in cancer survivors. The objective of this report is to delineate the iterative process of adapting an in-person sexual health intervention into a self-administered digital application called "Sexual Health and Intimacy Following Transplant (SHIFT)" and the refinement of SHIFT using stakeholder feedback. We used a five-step development model to adapt SHIFT that included: (1) implementation of a multimodal bio-psycho-social conceptual framework, (2) development of a comprehensive intervention manual and SHIFT content, (3) translation of the intervention manual into an interactive storyline with a focus on enhancing patient engagement, (4) creation of initial SHIFT wireframes, and (5) refinement of SHIFT through iterative alpha and beta testing. At each step, key stakeholders including HSCT survivors, HSCT clinicians, and experts in sexual health, psychology, and digital health provided iterative feedback. We adapted SHIFT based on our conceptual framework, prior in-person intervention work, and iterative stakeholder feedback in each application development stage. SHIFT incorporates medical information, educational materials, intimacy exercises, and activities to address the multiple etiologies of sexual health concerns in HSCT survivors. SHIFT includes strategies to enhance engagement including gamification, personalization, and incorporation of video from HSCT survivors and clinicians. Based on stakeholder feedback, SHIFT was refined with a focus on inclusivity of gender, sexual orientation, relationship status, and body image concerns. SHIFT is novel, patient-centered digital application to address sexual dysfunction in HSCT survivors. Iterative feedback from key stakeholders including HSCT survivors guided SHIFT adaptation and refinement, to optimize patient engagement and ensure inclusivity. The final prototype of SHIFT was initially acceptable to key stakeholders and is now under further testing in a pilot randomized trial to assess its feasibility and preliminary efficacy for improving sexual health outcomes in HSCT survivors.

Multidisciplinary Management of Morbidities Associated with Chronic Graft-Versus-Host Disease

Chronic graft-versus-host disease (cGVHD) represents a common long-term complication after allogeneic hematopoietic stem cell transplantation (HSCT). It imposes a significant morbidity burden and is the leading cause of non-relapse mortality among long-term HSCT survivors. cGVHD can manifest in nearly any organ, severely affecting the quality of life of a transplant survivor. While the mainstay of treatment has remained systemic immunosuppression with glucocorticoids, progress has been made within the last few years with approvals of three oral agents to treat steroid-refractory cGVHD: ibrutinib, ruxolitinib, and belumosudil. Iatrogenesis contributes a significant portion of the morbidity experienced by patients with cGVHD, primarily from glucocorticoids. This review highlights the myriad impacts of cGVHD, including and beyond the traditional organ systems captured by the National Institutes of Health Consensus Criteria, including iatrogenic complications of long-term immunosuppression. It presents the implications of cGVHD and its treatment on cardiovascular and metabolic health, bone density, endocrine function, sexual health, and ocular and pulmonary disease and outlines a framework around the comprehensive multidisciplinary approach for its evaluation and management.

Sexual health and emotional wellbeing of patients with haematological malignancies: general review

Sexual health is an important aspect of a person's life. Many patients and haematologists believe that intimacy and sexuality issues are substantial during cancer treatment. The haematological cancer disease, diagnosis, shock of the announcement, treatment, and follow-up appointments, can all have negative effects on the quality of life of patients, their partners, other family members, and friends. Addressing the intimate aspects of patients' lives not only enhances their wellbeing but also contributes to the quality of their survivorship. Progress has been made in the management of sexual life-related complications; however, novel strategies in coordination with a multidisciplinary team need to be implemented. New and comprehensive approaches must be developed on a multidisciplinary scale. In this Series paper, we discuss the factors affecting the sexual life of patients with haematological malignancies, different methods to assess sexual function, as well as management approaches of sexual wellbeing among patients with haematological cancers.

Sexual health-related psychological and emotional life after allogeneic haematopoietic stem-cell transplantation

Sexual health is important for the quality of life of patients who have received haematopoietic stem-cell transplantation (HSCT). Sexual dysfunction and couple dissatisfaction can seriously affect a patient's recovery and treatment process. However, this aspect of post-transplantation recovery is still usually neglected in clinical practice. In this Series paper, we aim to elucidate the emotional and psychosocial factors affecting the sexual function in these patients, with a special focus on the partner's role and the psychological consequences of some adverse effects of HSCT. Moreover, we provide an overview of the management approaches and assessment tools of psychological issues associated with sexual dysfunction reported in the literature. These tools can help clinicians in this field to plan essential lifestyle and clinical interventions to help their patients. In conclusion, screening for psychological issues is indispensable when approaching sexual dysfunction in patients with HSCT. Health-care teams in transplantation units should be trained to discuss this aspect of recovery and provide the required treatment and follow-up plan.

A Biobehavioral Perspective on Caring for Allogeneic Hematopoietic Stem Cell Transplant Survivors with Graft-Versus-Host Disease

Among the potential complications of allogeneic hematopoietic stem cell transplantation (HSCT), graft-versus-host disease (GVHD) is common and associated with significant physical and psychosocial symptom burden. Despite substantial advances in GVHD treatment, the global immune suppression that frequently accompanies GVHD treatment also contributes to high rates of physical and emotional suffering and mortality. The complex manifestations of GVHD and its treatment warrant a multidisciplinary team-based approach to managing patients' multi-organ system comorbidities. A biobehavioral framework can enhance our understanding of the complex association between medications, physical symptoms, and psychosocial distress in patients with GVHD. Hence, for this perspective, we highlight the importance of addressing both the physical and psychosocial needs experienced by patients with GVHD and provide guidance on how to approach and manage those symptoms and concerns as part of comprehensive cancer care.

Vaginal complications of graft-versus-host disease after hematopoietic stem cell transplantation: a cross-sectional study

Background

Stem cell transplantation is a clinical approach used to treat certain types of cancers, such as hematologic malignancies. Graft-versus-host disease (GVHD) occurs in 30-70% of cases and often diminishes the quality of life of transplant patients. This study aimed to determine the prevalence of vaginal complications of GVHD following hematopoietic stem cell transplantation.

Methods

This study employed an analytical cross-sectional design. All patients referred to Shariati Hospital in Tehran between 2019 and 2020 who underwent hematopoietic stem cell transplantation were considered for inclusion in this study if they met the inclusion criteria. Inclusion criteria encompassed nonnot sexually active women aged 18-70 who received stem cell transplantation more than 100 days prior. Exclusion criteria comprised patients who experienced GVHD during the first 100 days posttransplantation. Additionally, individuals over 75 and patients with metastatic cancer were excluded.

Results

A total of 55 patients were recruited, with ages averaging 40±9.9 years for recipients and 38.5±12.8 years for donors. Notably, 63.3 and 58.2% of patients exhibited oral and ocular symptoms, respectively. Regarding genital involvement, 49.1% experienced vaginal symptoms, while 25.5% had vulvar involvement. Among the 27 patients with vaginal involvement, two (7.4%) were categorized as mild, 17 (63%) as moderate, and eight (29.6%) as severe. Univariate analysis identified reduced vaginal discharge [odds ratio (OR=6.56)], vaginal tightness (OR=6.23), pelvic pain (OR=5.50), and vaginal involvement (OR=3.81) as significant predictors of other organ symptoms. Moreover, vaginal involvement (OR=3.68) emerged as the sole significant predictor of the cooccurrence of oral, ocular, and other organ symptoms. In the multivariate analysis, reduced vaginal discharge (OR=8.24) and vaginal tightness (OR=3.92) significantly predicted other organ symptoms (P=0.009).

Conclusion

Reduced vaginal discharge and vaginal tightness remained significant predictors of other organ symptoms.

The sequelae of hematopoietic stem cell transplantation in adolescents and young adults: protocol for a systematic review

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a life-saving treatment for adolescents and young adults (ages 15-39) with hematologic malignancy. Given the significant developmental milestones usually achieved during this unique life stage, this population is especially vulnerable to the interruption caused by a cancer diagnosis and its treatment. HSCT is a particularly invasive form of cancer therapy with many negative physical, social, and psychological sequelae. The long-term impact of HSCT in adolescents and young adults with hematologic malignancies warrants a systematic investigation of its effects to best shape clinical care and health policy.

METHODS

This protocol for a systematic review will focus on the long-term physical, psychological, social, spiritual, and health behavior effects experienced by adolescents and young adults who undergo HSCT for hematologic malignancy. We have constructed a specific search strategy that queries these five domains, which will be applied to five databases-Embase, PubMed, Cochrane Trials and Reviews, PsychInfo, and CINAHL-to identify the key literature. Two independent reviewers will perform a title/abstract screen followed by a full-text screen using standard screening templates to ensure the inclusion of outcomes in the post-acute HSCT period. Risk of bias will be assessed using the University of Adelaide Joanna Briggs Institute Collaboration Critical Appraisal Tools. Data from included studies will be abstracted on study characteristics, study setting, sample characteristics, and outcomes. Given the broad scope of the research question, data synthesis will focus on qualitative methods in accordance with Institute of Medicine standards.

DISCUSSION

While adolescents and young adults undergoing hematopoietic stem cell transplantation for hematologic malignancy are understood to have a unique survivorship experience, the sequelae of this treatment approach in this population have not been previously aggregated. This systematic review intends to expand insight into the adolescent and young adult experiences with HSCT in order to inform age-appropriate survivorship care and deliver this life-saving intervention with the best possible outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022361663.

Disrupted biographies and gendered identities: A qualitative study exploring sexuality and blood cancer

PURPOSE

This study examines how blood cancer impacts patients' sexuality and sense of gendered identity.

METHODS

An interpretive epistemological framework necessitated a qualitative study design. Participants (6 male and 6 female), recruited from a hospital Haematology department in a large Northern English City, took part in semi-structured in-depth interviews to gather rich data about their subjective experiences.

RESULTS

A key theme from the qualitative data was a sense of disruption in relation to several aspects of their gendered identities and sexual life. Participants explained disruption to their sexual function and sexual sense of self. They narrated concerns about future imagined relationships. The emotional burden of sexuality related concerns was strongly articulated. A gendered perspective enabled the similarities and differences between men and women to be explored.

CONCLUSION

This study, drawing on rich qualitative data, documents the sexuality concerns of blood cancer patients; for some such concerns arise many years post treatment. The findings highlight the need for gender appropriate care around sexuality which should continue to be accessible well after diagnosis and treatment phases have ceased.

Point-of-care assessment of sexual concerns among young adult oncology active patients and survivors

PURPOSE

Adolescent and young adult (AYA) oncology populations have unique sexual health concerns that deserve more attention. Our study aimed to describe sexual health and related concerns in young adults (YAs) to move toward integrating sexual health into routine care.

METHODS

A total of 127 YAs (ages 19-39) in active treatment and survivorship from three outpatient oncology clinics provided demographic and clinical information. They completed versions of the NCCN Distress Thermometer and Problem List (AYA-POST; AYA-SPOST) developed specifically for AYAs as part of an ongoing needs assessment study.

RESULTS

Over one quarter (27.6%) of the total sample (Mage = 31.96, SD = 5.33) - 31.9% in active treatment (n = 72) and 21.8% in survivorship (n = 55) - reported at least one sexual health concern (i.e., sexual concern, loss of libido (desire for sex), pain with sex, and unprotected sex). Those undergoing active treatment with sexual concerns had significantly higher distress than those without sexual concerns, whereas this pattern was nonsignificant for those in survivorship. Both genders often endorsed general sexual concerns and loss of libido.

CONCLUSION

The current study adds to the important and burgeoning literature on sexual health concerns of YAs oncology populations. The prevalence of sexual concerns, differences between treatment status and between those with and without sexual concerns highlight the utility and need to embed screening that includes sexual health items at point of care. This can facilitate discussion of these sensitive and multifaceted needs throughout the cancer continuum.

Point of Care Assessment of Sexual Concerns among AYA Oncology Active Patients and Survivors

Purpose Adolescent and young adults (AYAs) oncology populations have unique sexual health concerns that deserve more attention. The current study aimed to describe the prevalence and characteristics of sexual health and related concerns in AYAs in active treatment and survivorship to move toward integrating sexual health in routine care. Methods A total of 127 AYAs (ages 19-39) in active treatment and survivorship were recruited from three outpatient oncology clinics. In addition to providing demographic and clinical information, they completed an adapted version of the NCCN Distress Thermometer and Problem List (AYA-POST; AYA-SPOST) as part of an ongoing needs assessment study. Results Over one quarter (27.6%) of the total sample ( M age = 31.96, SD  = 5.33) - 31.9% of active treatment, and 21.8% in survivorship - reported at least one sexual health concern (i.e., sexual concern, loss of libido, pain with sex, and unprotected sex). The most frequently endorsed concerns differed between active treatments and survivorship. Both genders often endorsed general sexual concerns and loss of libido. Conclusion The literature on sexual concerns in the AYA population is sparse and inconclusive, especially accounting for gender and other types of concerns. The current study highlights the need for further examination between treatment status, psychosexual concerns, emotional distress, and demographic and clinical factors. Given the prevalence of sexual concerns in AYAs in active treatment and survivorship, providers should consider integrating assessment and discussion of these needs at onset of diagnosis and as part of monitoring.

Patient reported improvement in sexual health outcomes following care in a sexual health clinic for women with cancer

PURPOSE

Sexual health concerns are common among female cancer survivors. Few data exist regarding patient-reported outcomes following interventions in this population. We aimed to determine patient-reported adherence and impact of interventions provided in an academic specialty clinic for treatment of sexual health problems.

METHODS

A cross-sectional quality improvement survey regarding sexual problems, adherence with recommended therapies, and improvement following intervention was administered to all women seen at the Women's Integrative Sexual Health (WISH) program at the University of Wisconsin-Madison between November 2013 and July 2019. Descriptive and Kruskal-Wallis tests were used to explore differences between groups.

RESULTS

Two hundred twenty women (median age at first visit = 50 years, 53.1% breast cancer) were identified; N =113 surveys were completed (response rate = 49.6%). The most common presenting complaints were pain with intercourse (87.2%), vaginal dryness (85.3%), and low libido (82.6%). Menopausal women were more likely than premenopausal women to present with vaginal dryness (93.4% vs. 69.7%, p = .001) and pain with intercourse (93.4% vs. 76.5%, p = .02). Nearly all women adhered to recommendations for vaginal moisturizers/lubricants (96.9-100%) and vibrating vaginal wands (82.4-92.3%). A majority found recommended interventions helpful regardless of menopausal status or cancer type and reported persistent improvement. Nearly all women had improvement in understanding sexual health (92%) and would recommend the WISH program to others (91%).

CONCLUSION

Women with cancer report integrative sexual health care to address sexual problems that are helpful and result in long-term improvement. Patients are overall highly adherent to recommended therapies, and nearly all would recommend the program to others.

IMPLICATIONS FOR CANCER SURVIVORS

Dedicated care to address sexual health in women after cancer treatment improves patient-reported sexual health outcomes across all cancer types.

Partnership, sexuality, and fertility-related communication: findings from a register-based study among long-term hematological cancer survivors

PURPOSE

Even though the number of hematological cancer survivors suffering from long-term and late consequences of their disease is growing, knowledge about their situation regarding partnership, sexuality, and fertility-related communication is sparse to date.

METHODS

We recruited survivors of hematological malignancies (≥ 3 years after diagnosis) from two cancer registries in Germany. We applied validated instruments and study-specific items on satisfaction with partnership, sexual functioning, and fertility-related communication with physicians. We provided descriptive statistics and conducted multiple regression analyses to identify associations of the outcomes with patient factors and well-being (anxiety, depression, and quality of life).

RESULTS

Of 2001 eligible survivors, 922 (46%) participated. Fifty-seven percent were male, and the mean age was 64 years. Ninety percent and 60% reported to be satisfied with their partnership and sexual life, respectively. However, 81% and 86% reported being sexually impaired by physical or mental symptoms, respectively. Seventy-four percent of those with incomplete family planning had a fertility-related conversation with a physician. Female gender (p < .05, Beta =  - .09), older age (p < .01, Beta = .10), and chemotherapy (p < .01, Beta = .10) were associated with less sexual pleasure caused by physical impairment. Satisfaction with partnership (p < .001, Beta = .22), satisfaction with sexual life (p < .001, Beta = .28), and conversation about fertility (p < .05, Beta = .26) were associated with better quality of life.

CONCLUSION

Even though long-term survivors seem to be generally satisfied with their partnership and sexual life, they may suffer from specific impairments. Our findings need to be verified in longitudinal studies.

Male-Specific Late Effects in Adult Hematopoietic Cell Transplantation Recipients: A Systematic Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

Male-specific late effects after hematopoietic cell transplantation (HCT) include genital chronic graft-versus-host disease (GVHD), hypogonadism, sexual dysfunction, infertility, and subsequent malignancies, such as prostate, penile, and testicular cancer. These effects may be closely intertwined and cause prolonged morbidity and decreased quality of life after HCT. Here we provide a systematic review of male-specific late effects in a collaboration among transplantation physicians, endocrinologists, urologists, dermatologists, and sexual health professionals through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. We used a systematic review methodology to summarize incidence, risk factors, screening, prevention, and treatment of these complications and provide consensus evidence-based recommendations for clinical practice and future research. Most of the evidence regarding male GVHD is still based on limited data, precluding strong therapeutic recommendations. Therefore, we recommend systematic screening for male genital GVHD regularly and reporting of cases to large registries to allow for a better understanding. Future research also should address treatment, given the little published evidence currently available. Male-specific endocrine consequences of HCT include hypogonadism, which also may affect bone health. Given the scanty evidence, current recommendations for hormone substitution and/or bone health treatment are based on similar principles as for the general population. Following HCT, sexual health decreases, and this topic should be addressed at regular intervals. Future studies should focus on interventional strategies to address sexual dysfunction. Infertility remains prevalent in patients having undergone myeloablative conditioning, warranting the offer of sperm preservation for all HCT candidates. Most studies on fertility rely on descriptive registry analysis and surveys, underscoring the importance of reporting post-HCT conception data to large registries. Although the quality of evidence is low, the development of cancer in male genital organs does not seem more prevalent in HCT recipients compared with the general population; however, subsequent malignancies in general seem to be more prevalent in males than in females, and special attention should be given to skin and oral mucosa. Male-specific late effects, which likely are more underreported than female-specific complications, should be systematically considered during the regular follow-up visits of male survivors who have undergone HCT. Care of patients with male-specific late effects warrants close collaboration between transplantation physicians and specialists from other involved disciplines. Future research should be directed toward better data collection on male-specific late effects and on studies about the interrelationships among these late effects, to allow the development of evidence-based effective management practices.

Male-specific late effects in adult hematopoietic cell transplantation recipients: a systematic review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation

Male-specific late effects after hematopoietic cell transplantation (HCT) include genital chronic graft-versus-host disease (GvHD), hypogonadism, sexual dysfunction, infertility, and subsequent malignancies. They may be closely intertwined and cause prolonged morbidity and decreased quality of life after HCT. We provide a systematic review of male-specific late effects in a collaboration between transplant physicians, endocrinologists, urologists, dermatologists, and sexual health professionals through the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research, and the Transplant Complications Working Party of the European Society of Blood and Marrow Transplantation. The systematic review summarizes incidence, risk factors, screening, prevention and treatment of these complications and provides consensus evidence-based recommendations for clinical practice and future research.

Sexual and Emotional Health after Allogeneic Hematopoietic Cell Transplantation: A Comprehensive Review and Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)

A person’s sexual and emotional life is greatly impacted after allogeneic hematopoietic stem cell transplantation (allo-HSCT). This topic is not addressed very much by patients and caregivers. Physical, endocrine and genital chronic graft versus host disease (cGVHD)-related disorders are multiple and intertwined with psychological disorders. The Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) has issued recommendations for a better gynecological monitoring of female recipients after allo-HCT. A patient booklet was also offered to patients in the form of questions and answers to facilitate discussions between patients and caregivers and to improve the management of sexual and emotional life after transplant.

Late follow-up of genital and ophthalmologic chronic graft-versus-host disease in females after allogeneic stem cell transplantation

INTRODUCTION

Genital chronic graft-versus-host disease (cGvHD) is a common late effect after allogeneic stem cell transplantation. In a previous cross-sectional study, prevalence, signs and symptoms of genital and extra-genital cGvHD were accounted for in a cohort of 42 women. Classifications of cGvHD were performed as per the National Institutes of Health (NIH) 2005 criteria. In this follow-up study on surviving women, the aim was to assess genital and extra-genital cGvHD status after long period of time. Our hypothesis was that signs and symptoms of cGvHD alleviate over time.

MATERIAL AND METHODS

All surviving women (n = 38) were re-examined by an ophthalmologist, a gynecologist and a hematologist. Signs and symptoms were classified according to the NIH 2014 criteria. Clinical scorings of affected organs were combined for estimating global score of cGvHD. To make possible comparisons between the two studies, data from the original study were re-classified as per the NIH 2014 criteria, and the four dead women were excluded. The same questionnaires were completed. Cervical smear, human papilloma virus test and vulvar photo-documentation were performed.

RESULTS

Median time after original study was 8.4 (5.8-12) years and after transplant 14.5 (10-19.3) years. The prevalence of genital cGvHD was similar in the original (50%) and follow-up (58%) studies (p = 0.646) as well as extra-genital cGvHD. Systemic corticosteroid treatment of cGvHD was ongoing in 34% and 29%, respectively (p = 0.805). Ocular cGvHD was found in 24 of 37 examined women (65%) in the follow-up study. Genital cGvHD had disappeared in three women and developed in two women 5-12 and 9-17 years, respectively, after transplantation. The severity of global cGvHD changed over time in 14 women, but was the same on group level (p = 0.345). Atrophic mucous membranes as in estrogen deficiency were seen in 66%. Three women had human papilloma virus genotypes associated with the risk of developing cervical cancer.

CONCLUSIONS

Chronic GvHD did not alleviate over time. Allotransplanted women require early and continuous life-long contact with a gynecologist and an ophthalmologist for the detection of cGvHD. Specific attention should be given to the need for local estrogen and the risk of genital epithelial malignancies.

Biobehavioral Research and Hematopoietic Stem Cell Transplantation: Expert Review from the Biobehavioral Research Special Interest Group of the American Society for Transplantation and Cellular Therapy

Hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for many hematologic conditions. Despite advances in conditioning and supportive measures, however, there remain significant comorbidities that threaten survivorship. Adverse effects of stress-related biobehavioral processes-defined here as the interactions of behavioral, psychological, and socioenvironmental factors with biology-impact immune recovery and function and are particularly salient in the HCT context, given the importance of immune reconstitution for improved survivorship. However, biobehavioral processes have been underinvestigated in this vulnerable group compared with other cancer populations. Here the Biobehavioral Research Special Interest Group (SIG) of the American Society for Transplantation and Cellular Therapy provides an expert review to inform research directions explicating the biological correlates of behavioral symptoms and evaluate the impact of these on HCT outcomes. The goal of this expert review is to provide a foundation for advancing science that effectively integrates behavioral and biological processes to optimize quality of life and improve clinical outcomes for HCT recipients.

Use of Chronic Prescription Medications and Prevalence of Polypharmacy in Survivors of Childhood Cancer

BACKGROUND

As survivors of childhood cancer age, development of cancer treatment-related chronic health conditions often occur. This study aimed to describe the pattern of chronic prescription medication use and identify factors associated with polypharmacy among survivors of childhood cancer.

METHODS

This was a retrospective study conducted at the pediatric oncology long-term follow-up clinic in Hong Kong. Eligible subjects included survivors who were (1) diagnosed with cancer before 18 years old, (2) were at least 3 years post-cancer diagnosis and had completed treatment for at least 30 days, and (3) receiving long-term follow-up care at the study site between 2015 and 2018. Dispensing records of eligible survivors were reviewed to identify medications taken daily for ≥30 days or used on an "as needed" basis for ≥6 months cumulatively within the past 12-month period. Polypharmacy was defined as the concurrent use of ≥5 chronic medications. Multivariable log-binomial modeling was conducted to identify treatment and clinical factors associated with medication use pattern and polypharmacy.

RESULTS

This study included 625 survivors (mean current age = 17.9 years, standard deviation [SD] = 7.2 years) who were 9.2 [5.2] years post-treatment. Approximately one-third (n = 219, 35.0%) of survivors were prescribed at least one chronic medication. Frequently prescribed medication classes include systemic antihistamines (26.5%), sex hormones (19.2%), and thyroid replacement therapy (16.0%). Overall prevalence of polypharmacy was 5.3% (n = 33). A higher rate of polypharmacy was found in survivors of CNS tumors (13.6%) than in survivors of hematological malignancies (4.3%) and other solid tumors (5.3%) (P = .0051). Higher medication burden was also observed in survivors who had undergone cranial radiation (RR = 6.31; 95% CI = 2.75-14.49) or hematopoietic stem-cell transplantation (HSCT) (RR = 3.53; 95% CI = 1.59-7.83).

CONCLUSION

Although polypharmacy was observed in a minority of included survivors of childhood cancer, chronic medication use was common. Special attention should be paid to survivors of CNS tumors and survivors who have undergone HSCT or cranial radiation. These individuals should be monitored closely for drug-drug interactions and adverse health outcomes that may result from multiple chronic medications, particularly during hospitalization in an acute care setting.

Sexual Functioning in Long-Term Survivors of Hematopoietic Cell Transplantation

This investigation characterized sexual activity and sexual function in hematopoietic cell transplantation (HCT) survivors, compared them with norms, and examined factors associated with sexual dysfunction, with the goal of identifying targets for intervention to improve sexual health. Surviving adults from a large transplantation center were asked to complete an annual survey with a core of health questions and a module on sexual activity and function. Participants completed the Sexual Function Questionnaire, Cancer and Treatment Distress form, and Revised Dyadic Adjustment Scale. Clinical data were collected from the transplantation medical database. Multivariate logistic regressions identified factors associated with sexual activity and function. Participating survivors (n = 1742) were a mean of 11.9 years (range, .4 to 43.1 years) after HCT, mean age 57.6 years, and 53% male. Women were more likely than men to report being sexually inactive in the past year (39% versus 27%) and, among those sexually active, to report low sexual function (64% versus 32%). Male and female survivors reported lower rates of sexual activity and function than comparison norms (all P < .01). In regressions, factors associated with being sexually inactive included older age, having <4 years of college education, low performance status, and not being in a committed relationship. Additional factors for men included receipt of nonmyeloablative conditioning and not being employed or in school. Low sexual functioning for men and women was associated with low performance status, and, for women, a committed relationship of lower quality, while for men the association was with older age. Sexual dysfunction is common in both men and women after HCT, regardless of time since treatment. Survivors need routine evaluation and access to multimodal interventions.

Bone Health Management After Hematopoietic Cell Transplantation: An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy

Bone health disturbances commonly occur after hematopoietic cell transplantation (HCT) with loss of bone mineral density (BMD) and avascular necrosis (AVN) foremost among them. BMD loss is related to pretransplantation chemotherapy and radiation exposure and immunosuppressive therapy for graft-versus-host-disease (GVHD) and results from deficiencies in growth or gonadal hormones, disturbances in calcium and vitamin D homeostasis, as well as osteoblast and osteoclast dysfunction. Although the pathophysiology of AVN remains unclear, high-dose glucocorticoid exposure is the most frequent association. Various societal treatment guidelines for osteoporosis exist, but the focus is mainly on menopausal-associated osteoporosis. HCT survivors comprise a distinct population with unique comorbidities, making general approaches to bone health management inappropriate in some cases. To address a core set of 16 frequently asked questions (FAQs) relevant to bone health in HCT, the American Society of Transplant and Cellular Therapy Committee on Practice Guidelines convened a panel of experts in HCT, adult and pediatric endocrinology, orthopedics, and oral medicine. Owing to a lack of relevant prospective controlled clinical trials that specifically address bone health in HCT, the answers to the FAQs rely on evidence derived from retrospective HCT studies, results extrapolated from prospective studies in non-HCT settings, relevant societal guidelines, and expert panel opinion. Given the heterogenous comorbidities and needs of individual HCT recipients, answers to FAQs in this article should be considered general recommendations, with good medical practice and judgment ultimately dictating care of individual patients. Readers are referred to the Supplementary Material for answers to additional FAQs that did not make the core set.

Long-term Follow-up of Hematopoietic Stem Cell Transplant Survivors: A Focus on Screening, Monitoring, and Therapeutics

Annually, ~50,000 patients undergo hematopoietic stem cell transplantation (HCT) worldwide with almost 22,000 of these patients receiving HCT in the United States. HCT is a curative option for a wide range of hematologic malignancies, and advances in transplantation medicine have resulted in an increase in HCT survivors. It is anticipated that the number of HCT survivors will more than double from 242,000 in 2020 to ~500,000 in 2030. Survivors of HCT are at an increased risk of developing late complications due to exposure to chemotherapy and/or radiation in the pre-, peri-, and post-HCT phases and these cumulative exposures have the potential to damage normal tissue. This tissue damage leads to the early onset of chronic health conditions resulting in premature mortality in HCT survivors, who have a 15-year cumulative incidence of severe or life-threatening chronic health conditions exceeding 40%. Due to the significant burden of morbidity in HCT survivors and the delay in the development of long-term complications, this delicate patient population requires life-long monitoring due to the risk for neuropsychological, cardiac, pulmonary, renal, hepatic, ocular, skeletal, cardiac, endocrine, fertility, and sexual health complications, as well as secondary neoplasms. This review will focus on recent advances in screening, monitoring, and therapeutics for late-occurring or long-term complications in HCT survivors.

Association between sexuality knowledge and sexual dysfunction in hematopoietic stem cell transplantation patients and their partners

OBJECTIVE

To evaluate the association of sexual knowledge with sexual desire, sexual activity, and sexual satisfaction in hematopoietic stem cell transplantation (HSCT) patients and partners, and their willingness to participate in sexual education.

METHODS

This is a multi-center survey. Patients were eligible if they had received HSCT. Patients' current sexual partners were invited to the study unless they had limitations on sexual activity. Sexual desire, activity and satisfaction was assessed using the Sexual Activity Questionnaire. Sexual knowledge, experience of information seeking, sexual counseling or education, and willingness of participate in sexual education were assessed using questionnaire.

RESULTS

Of 151 participants, 61.8 % had experience of receiving counseling about their sexual issues after HSCT. Compared to the lower sexual knowledge group, participants with higher sexual knowledge reported to be 1.91 times more sexually active with 3.04 times higher sexual desire. Among the participants, 79.4 % of participants had the willingness to receive sexual education after HSCT and preferred to receive sexual education from sexual education specialists CONCLUSIONS: Higher sexual knowledge was associated with higher sexual desire, sexual activity, and sexual satisfaction.

PRACTICE IMPLICATIONS

Sexual education should be provided to patients and their partners after HCST by trained experts for HSCT patient's sexual life.

[Sexual and emotional life after allogeneic hematopoietic stem cell transplant: Guidelines and patient booklet from the Francophone Society of Bone marrow Transplant and Cellular therapy (SFGM-TC)]

The Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) organises annual workshops in an attempt to harmonise clinical practices among different francophone transplantation centres. The SFGM-TC harmonisation workshops aim at establishing practical guidelines, on the one hand, from data from the literature and international recommendations and, on the other hand, by consensus in the absence of formally proven data. The sexual and emotional life of allogeneic hematopoietic stem cells transplanted (HSCT) patients is often very impacted and remains a subject relatively little addressed by patients and caregivers. This article is an update from a previous workshop and is accompanied by a patient booklet, which will be included in the post allograft follow-up workbook published by the SFGM-TC. The purpose of these two documents is to facilitate discussions between patients and caregivers on the subject and to present proposals for follow-up and tools to better manage the sexual and emotional life of allotransplanted patients.

Optimal Delivery of Follow-Up Care After Allogeneic Hematopoietic Stem-Cell Transplant: Improving Patient Outcomes with a Multidisciplinary Approach

The increasing indications for allogeneic stem-cell transplant in patients with hematologic malignancies and non-malignant diseases combined with improved clinical outcomes have contributed to increase the number of long-term survivors. However, survivors are at increased risk of developing a unique set of complications and late effects, besides graft-versus-host disease and disease relapse. In this setting, the management capacity of a single health-care provider can easily be overwhelmed. Thus, to provide appropriate survivorship care, a multidisciplinary approach for the long-term follow-up is essential. This review aims at summarizing the most relevant information that a health-care provider should know to establish a follow-up care plan, in the light of individual exposures and risk factors, that includes all organ systems and considers the psychological burden of these patients.

Recommended patient information sheet on the impact of haematopoietic cell transplantation on sexual functioning and sexuality

Sexual concerns are common after haematopoietic cell transplantation (HCT). Exposure to total body irradiation (TBI), alkylating agent and graft versus host disease (GvHD) can all affect sexual function, leading to problems in sexual desire, arousal and the orgasm phase of the sexual response cycle. In high-risk haematological malignancies, such as acute leukaemia and myelodysplastic syndromes, HCT often offers the highest chance for long-term survival. In addition, these haematological diseases and HCT can have an impact on body image, self-esteem, (sexual) relationship and psychosocial factors, all of which are able to affect sexuality and sexual function. Five years post HCT, 80% of the female survivors and 46% of the male survivors report sexual dysfunction.

It has been shown that these patients cope better after having discussed sexual health. While healthcare providers (HCPs) have the responsibility to address sexual issues, it has been demonstrated that 48%–82% HCT recipients reported not having discussed sexual issues with their HCPs and that only one-third of the HCPs routinely discussed sexual issues with their patients. HCPs describe a lack of knowledge and being uncomfortable with the topic as the most important reasons for not addressing sexual functioning. Even so, it would help >90% HCPs if the patient initiated discussing sexual issues. However, to empower patients addressing sexual issues, adequate comprehensive patient information is needed. In an effort to better meet the patients’ need, a patient information sheet: ‘Information for patients undergoing Hematopoietic Cell Transplantation: the impact of the disease and treatment on sexual function and sexuality’, has been created.

In this review, we describe what is known about the impact of HCT on sexual function and briefly the management of sexual problems.

A Practical Guide to Gynecologic and Reproductive Health in Women Undergoing Hematopoietic Stem Cell Transplant

Optimum care of female transplant recipients requires gynecologic care at several stages through the allogeneic hematopoietic stem cell transplantation (HCT) process. Sex-based considerations in women post-HCT span gynecologic sequelae of transplant along with assessment and maintenance of optimal sexual and gynecologic health. Pre-HCT, managing menstruation and abnormal uterine or genital bleeding, considering fertility preservation, and assessing for sexually transmitted infections, including human papillomavirus (HPV)-related disease and cervical cancer, enhance women's health. While inpatient during transplant when women are thrombocytopenic, menstrual bleeding requires suppression. Whenever graft-versus-host disease (GVHD) is assessed, screening for genital GVHD merits consideration. After the first 100 days, periodic assessments include obtaining a menstrual history, assessing ovarian function, and reviewing current hormonal use and contraindications to hormonal methods. Regular assessment for primary ovarian insufficiency, dyspareunia, and intimacy guides provision of contraception and hormone replacement options. As part of ongoing screening for genital GVHD and HPV-related disease, including sexually transmitted infections, periodic pelvic examinations are performed. Once successful long-term survival is achieved, planning for fertility may be considered. This article offers a comprehensive approach to these aspects of gynecologic care of patients throughout the trajectory of HCT and beyond into survivorship. We review the effects of HCT treatment on sexual health, ovarian function, and resulting menstrual changes and fertility challenges. Identification, treatment, and prevention of subsequent malignancies, including breast cancer, are discussed, with a focus on regular assessment of genital HPV disease and GVHD in long-term follow-up.

Sexuality after hematopoietic stem cell transplantation: A mixed methods study

PURPOSE

This study examined patients' experiences of sexuality following hematopoietic stem cell transplantation. A secondary aim of the study was to explore healthcare provider-patient communication about sexuality.

METHODS

A mixed methods design was employed with an embedded qualitative-quantitative approach whereby the quantitative data were used to supplement the qualitative results. Participants (8 male and 3 female) participated in semi-structured interviews and also completed the FACT-BMT questionnaire.

RESULTS

Qualitative themes that emerged included: changes in sexual function (such as with desire and arousal), changes in relation to self (such as with body image, sexual identity), changes in relation to others (such as with current relationships, starting new relationships, fear of exposure to 'germs') and the experience of discussing sexual health concerns with healthcare providers. Quantitative data from the FACT-BMT revealed that participants reported low satisfaction with their sex life but remained interested in sex. The majority of participants reported dissatisfaction with the appearance of their body and most were not concerned about fertility.

CONCLUSION

This study documents the physical and psychosocial sexual health concerns reported in male and female recipients of HSCT. Concerns were present even for those many years post-HSCT. Implications include suggestions for healthcare providers regarding patient education and assessment of sexual health changes in patients throughout the HSCT trajectory and continuing well into survivorship.

Beyond maximum grade: modernising the assessment and reporting of adverse events in haematological malignancies

Tremendous progress in treatment and outcomes has been achieved across the whole range of haematological malignancies in the past two decades. Although cure rates for aggressive malignancies have increased, nowhere has progress been more impactful than in the management of typically incurable forms of haematological cancer. Population-based data have shown that 5-year survival for patients with chronic myelogenous and chronic lymphocytic leukaemia, indolent B-cell lymphomas, and multiple myeloma has improved markedly. This improvement is a result of substantial changes in disease management strategies in these malignancies. Several haematological malignancies are now chronic diseases that are treated with continuously administered therapies that have unique side-effects over time. In this Commission, an international panel of clinicians, clinical investigators, methodologists, regulators, and patient advocates representing a broad range of academic and clinical cancer expertise examine adverse events in haematological malignancies. The issues pertaining to assessment of adverse events examined here are relevant to a range of malignancies and have been, to date, underexplored in the context of haematology. The aim of this Commission is to improve toxicity assessment in clinical trials in haematological malignancies by critically examining the current process of adverse event assessment, highlighting the need to incorporate patient-reported outcomes, addressing issues unique to stem-cell transplantation and survivorship, appraising challenges in regulatory approval, and evaluating toxicity in real-world patients. We have identified a range of priority issues in these areas and defined potential solutions to challenges associated with adverse event assessment in the current treatment landscape of haematological malignancies.

Resolution of Hematocolpos in Adolescents Affected with Graft vs Host Disease

BACKGROUND

Bone marrow transplantation is a lifesaving procedure for a range of serious benign or malignant hematological conditions. A proportion of patients, however, will develop graft vs host disease (GVHD), acute or chronic, with serious long-term sequalae.

CASES

We present 2 cases of hematocolpos that developed in adolescence because of vaginal synechiae due to GVHD. The condition was initially asymptomatic, resolved spontaneously at first and recurred. In 1 girl blunt lysis of the adhesions was performed with the patient under general anesthesia, followed thereafter by local hydrocortisone and estriol treatment.

SUMMARY AND CONCLUSION

Genital symptoms might not be readily reported by adolescents after bone marrow transplantation. Physicians should be aware of possible late effects of GVHD on genitalia, inquire about symptoms, and be acquainted with addressing complications, such as vaginal obstruction.

Vaginal development and sexual functioning in young women after stem cell transplantation, chemotherapy, and/or radiotherapy for childhood hematological diseases

To study vaginal development and sexual functioning in young women after childhood hemopoietic stem cell transplantation (HSCT) and radio/chemotherapy. Observational case-control study on 30 young sexually active women survived after HSCT and/or radio/chemotherapy for childhood malignancies or hematologic diseases and 48 controls matched for age. Female Sexual Function Index was lower (median 24.05, IQR = 17.30-28.30 vs. 29.00, IQR = 25.30-31.40, p = 0.001), Female Sexual Distress Scale higher (median 16.00, IQR = 8.00-23.00 vs. 2.00, IQR = 0.00-4.00, p < 0.001), vaginal length shorter (mean difference = 21.1 mm; 95% CI = 19.3-23, p < .001) and vaginal maturation index worst in cases than in controls. Subjects treated by irradiation before HSCT had lower FSFI (median 21.85, IQR = 9.60-31.10 vs. 24.90, IQR = 17.30-28.30) and shorter vaginal length (median 45.55, IQR = 42.60-45.80 vs. 50.10, IQR = 45.30-52.90) compared to those who had not received conditioning treatment (p-values = 0.004 and p = 0.05, respectively). Compared to untreated subjects, women receiving hormonal replacement therapy had higher overall FSFI (p = 0.02), lower FSDS (0.04), and better VMI. Gonadotoxic therapies have adverse effects on vaginal development, sexual functioning, and distress in young females. Hormonal replacement therapy should be shortly considered after main gonodatoxic treatments to improve vaginal and sex health.

Sexual health in patients with hematological malignancies: a neglected issue

Current evidence, although limited, outlines that sexual dysfunction may represent a prominent part of the symptom burden experienced by the patients with hematologic malignancies (HM). However, despite their presumed negative effects on quality of life (QoL), sexual health is not typically considered in the QoL assessment of HM patients. In addition, very few studies have been conducted in this area. Therefore, it would be important to further investigate how newer drugs developed in recent years for patients with HM, including targeted therapies and impact on sexual health, and how this influence overall patients' QoL outcomes.

Satisfaction with sexual activity and sexual dysfunction in hematopoietic stem cell transplantation survivors and their partners: a couple study

Sexual dysfunction is a common long-term complication of hematopoietic stem cell transplantation (HSCT). We assessed the extent to which HSCT survivors and their partners agree on the importance of and satisfaction with sexual activity and causes of sexual dysfunction, using a cross-sectional survey. Ratings of the importance of sexual activity were significantly higher in survivors than those of partners (2.57 vs. 2.14, P < 0.01). More survivors (48.4%) tried to discuss about sexuality with their partners than partners themselves (23.1%, P < 0.01). Male survivors were more likely to be sexually active than female survivors (odds ratio [OR] 5.04, 95% CI 1.85, 13.74). While 23.3 and 38% of male survivors and partners reported "rejection of partners" as a cause of sexual dysfunction, only 13.3% and none of female partners and survivors pointed this as a cause of sexual dysfunction respectively. There was poor concordance between survivors and partners in attitudes toward sexuality, satisfaction with sexual activity, and causes of sexual dysfunction. Couples who considered adequate sexual activity important were more likely to be sexually active than those who did not (OR 5.53, 95% CI 1.18, 25.89). Our study highlights the need for providing information and counselling about sexuality both to survivors and partners.

Long-term follow-up of endocrine function among young children with newly diagnosed malignant central nervous system tumors treated with irradiation-avoiding regimens

BACKGROUND

The adverse effects of irradiation on endocrine function among patients with pediatric brain tumor are well documented. Intensive induction chemotherapy followed by marrow-ablative chemotherapy with autologous hematopoietic cell rescue (AuHCR) without central nervous system (CNS) irradiation has demonstrated efficacy in a proportion of very young children with some malignant CNS tumors. This study assessed the long-term endocrine function of young children following chemotherapy-only treatment regimens.

PROCEDURES

A retrospective chart review was performed on 99 patients under 6 years of age with malignant brain tumors newly diagnosed between May 1991 and October 2010 treated with irradiation-avoiding strategies. Thirty patients survived post-AuHCR without cranial irradiation for a mean of 8.1 years (range 3.0-22.25 years). The patient cohort included 18 males and 12 females (mean age at AuHCR of 2.5 years, range 0.8-5.1 years).

RESULTS

All 30 surviving patients had documented normal age-related thyroid function, insulin-like growth factor binding protein 3 (IGF-BP3), prolactin, testosterone, and estradiol levels. Insulin-like growth factor 1 age-related levels were abnormal in one child with normal height. Ninety-seven percent of patients had normal cortisol levels, while follicle-stimulating hormone and LH levels among females were normal in 83% and 92%, respectively, and in 100% of males. Growth charts demonstrated age-associated growth within 2 standard deviations of the mean in 67% of patients. Of 10 patients (33%) with short stature, 6 had proportional diminutions in both height and weight.

CONCLUSIONS

These findings demonstrate that the use of relatively brief, intensive chemotherapy regimens including marrow-ablative chemotherapy with AuHCR results in fewer endocrine sequelae than treatment schemes utilizing CNS irradiation.

National Institutes of Health Hematopoietic Cell Transplantation Late Effects Initiative: The Patient-Centered Outcomes Working Group Report

In 2015, the National Institutes of Health convened six working groups to address the research needs and best practices for late effects of hematopoietic stem cell transplantation survivors. The Patient-Centered Outcomes Working Group, charged with summarizing the HRQOL evidence base, used a scoping review approach to efficiently survey the large body of literature in adult and pediatric HCT survivors over 1 year after transplantation. The goals of this paper are to (1) summarize the current literature describing patient-centered outcomes in survivors, including the various dimensions of health-related quality of life affected by HCT, and describe interventions tested to improve these outcomes; (2) highlight areas with sufficient evidence allowing for integration into standard practice; (3) address methodological issues that restrict progress in this field; (4) identify major gaps to guide future research; and (5) specify priority research recommendations. Patient-centered outcomes were summarized within physical, psychological, social, and environmental domains, as well as for adherence to treatment, and health behaviors. Interventions to improve outcomes were evaluated for evidence of efficacy, although few interventions have been tested in long-term HCT survivors. Methodologic issues defined included lack of consistency in the selection of patient-centered outcome measures, along with the absence of a standard for timing, frequency, and mode of administration. Recommendations for HCT survivorship care included integration of annual screening of patient-centered outcomes, use of evidence-based practice guidelines, and provision of treatment summaries and survivorship care plans after HCT. Three priority research recommendations included the following: (1) design and test risk-targeted interventions with dose-intensity modulation matching the needs of HCT survivors with priority domains, including sexual dysfunction, fatigue, sleep disruption, nonadherence to medications and recommended health care, health behaviors including physical inactivity and healthy eating, and psychological dysfunction, with particular consideration of novel technologies to reach HCT survivors distant from their transplantation centers; (2) design a consensus-based methodologic framework for outcomes evaluation; and (3) evaluate and compare existing practices for integrating patient-centered outcome screening and interventions across HCT survivorship programs.