A hospital and home-based exercise program to address functional decline in people following allogeneic stem cell transplantation

Efficacy of Pomalidomide on Motor Performance and Functional Abilities in Patients with Steroid Refractory Chronic Graft Versus Host Disease: A Randomized Clinical Study

Deficits in motor performance and functional abilities represent a severe complication for individuals with steroid refractory chronic graft versus host disease (cGVHD) and is associated with decreased survival and high morbidity. The objective of this study was to characterize the impact of pomalidomide on motor and functional outcomes in patients with cGVHD. Thirty-four adult patients with cGVHD were enrolled in a randomized and unblinded trial. Pomalidomide was administered orally at two dose levels: low (0.5 mg/d) or high (initial 0.5 mg/d, escalating 0.5 mg/d every 2 weeks to a maximum 2 mg/d). Efficacy was assessed primarily by the Activity Card Sort (ACS), 2 Minute Walk Test (2MWT), Medical Outcomes Study Short Form 36 (SF-36), Active Range of Motion (AROM), Disabilities of the Arm, Shoulder, and Hand (DASH), and Manual Abilities Measure 36 (MAM). Compared to baseline, the pooled sample of study participants at 6 months showed improvement in hand skills (MAM, P = .01), upper extremity (UE) function (DASH, P = .01), and health related quality of life (SF-36 Physical Component Summary score (PCS), P = .02). Though no statistically meaningful differences between the two dose groups were found, the low-dose group had greater improvements in AROM, walk distance, UE and hand function, and in the high-demand physical leisure and social subdomains of the ACS as compared to the high-dose group. Responders to pomalidomide performed better than nonresponders on most measures at the 6-month endpoint. The study suggests pomalidomide, at both dose levels, may improve several aspects of motor and functional abilities. However, further study is warranted to determine if the trends found in this study, are sustained over time in larger, and in more diverse cGVHD populations. The findings highlight the potential utility of administering functional and motor tests, such as the ACS, DASH, and MAM, to patients with cGVHD, to fully elucidate the efficacy of treatment options for persons with steroid refractory cGVHD.

Rehabilitation after bone marrow transplant compared with usual care to improve patient outcomes (REBOOT): protocol for a randomised controlled trial

BACKGROUND

Haematological cancer affects more than 1.3 million people around the world annually and accounted for almost 800,000 deaths globally in 2020. The number of patients with these cancers undergoing bone marrow transplant is increasing. Of note, this intensive treatment is associated with complex and multifactorial side effects, often impacting nutritional status, physical functioning and overall health-related quality of life. The primary aim of this study is to investigate the effectiveness of an eight-week multidisciplinary rehabilitation intervention compared with usual care on the physical function domain of the European Organisation for the Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-C30 version 3) in patients with haematological cancer following bone marrow transplant.

METHODS

This is a multisite, pragmatic two-arm parallel-group, randomised controlled trial (RCT) with stratified randomisation, powered for superiority, recruiting 170 participants at 30 days following either allogeneic or autologous bone marrow transplant (ACTRN12622001071718). Recruitment sites include three Australian university affiliated teaching hospitals. Participants are eligible if aged ≥ 18 years, treated for haematological cancer with allogeneic or autologous bone marrow transplant and can walk independently. The intervention group will receive eight weeks of twice weekly telehealth-based exercise classes, an initial and follow up dietetics consult, post exercise protein supplements, and a home-based physical activity program, all with embedded behaviour change strategies. The primary outcome is patient reported physical function measured using the EORTC QLQ-C30 version 3. Secondary outcomes include other domains of the EORTC QLQ-C30, fatigue, physical function, physical activity levels, frailty, body composition, sarcopenia and nutrition assessment. We will also undertake a health economic analysis alongside the trial and a process evaluation exploring intervention fidelity, causal mechanisms as well as contextual influences through qualitative enquiry.

DISCUSSION

The REBOOT trial will add RCT-evidence from a rigorously conducted, statistically powered multi-site trial to existing limited knowledge on the effects of multi-disciplinary rehabilitation for people with haematological cancer. If effectiveness is supported, then implementation of rehabilitation into care pathways for people having bone marrow transplant can be considered.

TRIAL REGISTRATION

ACTRN12622001071718 prospectively registered 03/08/2022, last updated 08/03/2024.

Feasibility, safety, and adherence of home-based exercise interventions in people diagnosed with cancer: a systematic review

PURPOSE

This systematic review aims to evaluate the feasibility, safety, and adherence of home-based exercise interventions in people diagnosed with cancer. The primary research question is: Are home-based exercise interventions safe and feasible for people diagnosed with cancer?

METHODS

A comprehensive search of databases including PubMed, EMBASE, and Cochrane Library was conducted in January 2025, focusing on randomized controlled trials (RCTs) that involved home-based exercise interventions people diagnosed with cancer. Studies were included if they reported on safety, feasibility, and health-related outcomes. The Physiotherapy Evidence Database (PEDro) scale was used to assess study quality and risk of bias. Adverse events were categorized by severity, and feasibility which was determined based on recruitment, withdrawal, and adherence rates.

RESULTS

From 127 eligible studies involving 10,562 participants, the review found that home-based exercise interventions are generally safe, with less than 3.2% of participants experiencing exercise-related adverse events, most of which were minor. Feasibility was supported by an average recruitment rate of 50.1%, which was calculated as the proportion of eligible participants who consented to participate across the included studies. Additionally, the review found a withdrawal rate of 13.7%, and an adherence rate of 76.2%. However, significant variability in these rates were observed across the studies, highlighting the challenges in maintaining participant engagement.

CONCLUSIONS

Home-based exercise interventions are feasible and safe for people diagnosed with cancer, with minor adverse events being the most common. However, there is a need for standardized protocols in reporting adverse events and better strategies to improve recruitment and adherence.

IMPLICATIONS FOR CANCER SURVIVORS

These findings support the integration of home-based exercise into standard cancer care, offering a practical and safe option for enhancing the health and well-being of cancer survivors. However, the successful implementation of these programs may require additional support from exercise professionals within primary care or community settings to ensure appropriate guidance and adherence. Personalized exercise programs, developed by qualified exercise professionals such as physiotherapists or clinical exercise physiologists, and improved reporting standards are essential to optimizing these interventions.

Prevention of cancer-therapy related cardiac dysfunction

PURPOSE OF REVIEW

Introduction of modern cancer therapies has led to increased survival of affected patients. With this advantage, the incidence of cancer therapy-related cardiac dysfunction (CTRCD) has increased and reasonable prevention strategies become necessary. This review outlines the major approaches to limit development and progression of CTRCD.

RECENT FINDINGS

A broad range of cancer therapies can provoke CTRCD ranging from mild asymptomatic forms to severe heart failure. Profound cardiological assessment of cardiovascular comorbidities before initiation of cancer therapy allows identification of cancer patients at higher risk developing CTRCD which may also require closer surveillance. Cardioprotective adjustment of cancer therapy and initiation of cardioprotective medication and lifestyle optimization prior to anti-cancer treatment additionally limit the risk of CTRCD. During therapy, regular examination of cancer patients using high-sensitive cardiological diagnostic tools as three-dimensional (3D) echocardiography and global longitudinal strain (GLS) enables early detection of mild forms of CTRCD. This allows appropriate adjustment of cancer therapy and initiation of CTRCD treatment to prevent further progression to severe forms. Cardiological risk stratification before treatment initiation, cardioprotective interventions before and during cancer therapy, along with regular monitoring of treated cancer patients, can help prevent the development of CTRCD. This maintains the antitumor effects of cancer therapy while limiting cardiotoxic side effects resulting in improved quality of life and mortality of affected cancer patients.

Implementation of Group-Based Exercise Programs in Physiotherapy: A Rapid Scoping Review

ABSTRACT

This review synthesized implementation literature on group-based exercise programs in physiotherapy. MEDLINE and Embase databases were searched for English and French articles published between 2000 and 2022. Through a two-step process (titles/abstracts and full text), two independent reviewers selected studies. The independent reviewers then extracted data and assessed study quality using the Mixed Methods Appraisal Tool. A total of 31 studies involving 4555 participants were included. Data on the group-based programs were extracted using the Consensus on Exercise Reporting Template and reported narratively. Implementation outcomes were reported narratively. The most frequently reported constructs pertained to feasibility and acceptability. Overall, the implementation of group-based programs appeared to be feasible, yielding high rates of adherence and attendance (between 36% and 91%), moderate-to-high completion rates (between 46% and 100%), low-to-moderate dropout rates (between 4.5% and 35.9%), and high satisfaction (satisfaction scores generally ranging above 7/10). The present findings also indicate a high acceptability for group-based physiotherapy exercise programs among patients. This review provided an overview of the literature on the implementation of group-based exercise programs in physiotherapy. In addition, it identified the need for more evidence on fidelity and costs. Future research should address these gaps to better inform healthcare stakeholders.

Family-Focused Facilitated Fitness: Feasibility and Acceptability of a Couple-Based Physical Activity Intervention for Hematopoietic Cell Transplant Recipients and Their Caregiving Partners

Reductions in physical activity (PA) are common among patients following hematopoietic cell transplantation, and a risk factor for poor physical functioning. PA among spouses/cohabiting partners, who frequently serve as the patient's primary caregiver, may also be reduced due to caregiving demands and limited bandwidth for self-care. In addition, the patient-caregiver relationship can be compromised, and communication patterns disrupted. All PA interventions in the hematopoietic cell transplantation setting have focused entirely on patients, ignoring an opportunity to synergistically engage and benefit the caregiver as well. We sought to test feasibility and acceptability of a couple-based intervention entitled Family-Focused Facilitated Fitness (FFFF), designed to improve PA as assessed by daily step counts among both patients undergoing hematopoietic cell transplantation and their caregivers. Guided by interdependence and communal coping perspectives, FFFF is an 8-week, remotely-delivered intervention that provides training in communication skills and joint problem-solving to help patients and caregivers support one another in PA. Participants are also given a Fitbit to track their steps and weekly individualized step prescription based on the 75th percentile ranked value of their last 7 recorded daily step counts. A priori benchmarks for feasibility and acceptability in this single-arm pilot were as follows: 50% of eligible couples would agree to participate, 70% of couples would attend all 8 sessions, 80% of participants would provide valid Fitbit wear data 4/7 days/ week, and among sessions reviewed for treatment fidelity, 85% of treatment protocol elements would be covered. Couples were recruited prior to transplant. Among 26 couples approached and deemed eligible, 17 enrolled (65% agreement) and completed baseline assessment. Three couples later withdrew after transplantation but prior to receiving the intervention, resulting in 14 couples commencing the intervention, on average 21 days post-transplant. Four couples subsequently discontinued due to medical complications (n = 3) or caregiver schedule (n = 1). Among the 10 couples who completed the intervention, the percentage of participants meeting our benchmark of valid Fitbit wear at least 4 days per week was 85% in week 1, 90% in weeks 2 to 7, and 80% in week 8. Treatment fidelity was 95% on average across 24 sessions reviewed (3 cases). Treatment satisfaction scores were uniformly high across multiple dimensions, with all means above 4 on the 1 to 5 scale. Daily step counts among those attending all 8 intervention sessions increased from 2249 ± 302 steps/day in week 1 to 4975 ± 1377 steps/day in week 8 among patients, and from 8676 ± 3760 steps/day in week 1 to 9838 ± 3723 steps/day in week 8 among caregivers. Qualitative feedback indicated perceived mental and physical health benefits of the program. Participants also offered suggestions for adaptations to accommodate medical setbacks and constraints. All a priori feasibility benchmarks were met or exceeded. Results offer promise for utility of the program to engage and leverage patient-caregiver dyads to increase PA following transplant. An investigation using a randomized controlled design will be necessary to adequately examine change over time relative to control and its possible impact on clinical and patient-reported outcomes.

A multimodal interdisciplinary rehabilitation programme (HAPPY) for patients undergoing allogeneic non-myeloablative haematopoietic stem cell transplantation: A feasibility study

PURPOSE

To evaluate the feasibility of the multimodal interdisciplinary rehabilitation programme HAPPY, targeting patients with haematological malignancy and undergoing allogeneic non-myeloablative haematopoietic stem cell transplantation (NMA-HSCT).

METHOD

A single arm longitudinal design was applied to test the feasibility of the 6-month HAPPY programme, which consisted of motivational interviewing dialogues, individual supervised physical exercise training, relaxation exercises, nutritional counselling, and home assignments. The feasibility measures included acceptability, fidelity, exposure, practicability, and safety. Descriptive statistics were conducted.

RESULTS

From November 2018 to January 2020, thirty patients (mean age (SD) 64.1 (6.5)) were enrolled in HAPPY, of whom 18 patients completed the programme. Acceptance was 88%; attrition 40%; fidelity was 80%-100% for all HAPPY elements except phone calls; exposure of HAPPY elements at the hospital reflected individual differences but was acceptable, whereas exposure of HAPPY elements at home was low. Planning of HAPPY for the individual patient was time consuming, and patients were dependent of reminders and incites from the health care professionals.

CONCLUSION

Most elements of the rehabilitation programme HAPPY were feasible. Yet, HAPPY will benefit from further development and simplifications before an effectiveness study can be conducted, especially regarding improvement of the intervention elements supporting patients at home.

Effects of a physiotherapeutic protocol in cardiorespiratory, muscle strength, aerobic capacity and quality of life after hematopoietic stem cell transplantation

OBJECTIVE

To analyze the effects of hospital cardiorespiratory physical therapy protocol on the functional capacity and quality of life of patients submitted to hematopoietic stem cell transplantation (HSCT).

METHODS

From January to December 2019, bilateral dynamometry, Manovacuometry and Ventilometry, peak expiratory flow "Peak Flow", 6-min walk test (6MWT), SF-36 Quality of Life Questionnaire and Visual Analog Scale (VAS) were applied in patients who have undergone an allogeneic or autologous hematopoietic stem cell transplantation (HSCT), pre-conditioning (initial evaluation) and pre-discharge (final evaluation). The patients were submitted to an intervention protocol, consisting of aerobic training, muscle strengthening and respiratory muscle training, between the two assessments.

RESULTS

29 patients were enrolled in the study and 24 (83%) completed all procedure. Myeloablative and reduced intensity conditioning were performed in 89.6% and 10.4%, respectively; 17 (58%) patients have undergone an autologous HSCT; 10 (35%) identical related allogeneic HSCT, and 2 (7%) haploidentical allogeneic HSCT. The median number of interventions per patient was 3 (1-9). A decreasing in the right and left dynamometry (p  ≤ 0.0001 and 0.002, respectively) and, also in the distance covered in the 6MWT (p  = 0.004), was observed after HSCT. There was no significant difference in respiratory muscle strength, quality of life and fatigue sensation.

CONCLUSION

Cardiorespiratory rehabilitation can preserve functional capacity and quality of life.

Preventing the adverse cardiovascular consequences of allogeneic stem cell transplantation with a multi-faceted exercise intervention: the ALLO-Active trial protocol

BACKGROUND

Allogeneic stem cell transplantation (allo-SCT) is a potentially lifesaving treatment for high-risk hematological malignancy, but survivors experience markedly elevated rates of cardiovascular disease and associated functional impairment. Mounting evidence suggests regular exercise, combined with a reduction in sedentary time through replacement with light exercise may be a useful therapeutic strategy for the prevention of cardiovascular comorbidities. However, this type of intervention has yet to be evaluated in patients undergoing allo-SCT. The ALLO-Active study will evaluate the efficacy of a ~ 4 month multi-faceted exercise intervention, commenced upon admission for allo-SCT, to preserve peak oxygen uptake (VO2peak) and peak cardiac output, compared with usual care. The study will also evaluate the effect of the intervention on functional independence, quality of life, and symptoms of fatigue.

METHODS

Sixty adults with hematological malignancy scheduled for allo-SCT will be randomly assigned to usual care (n = 30) or the exercise and sedentary behaviour intervention (n = 30). Participants assigned to the intervention will complete a thrice weekly aerobic and progressive resistance training program and concomitantly aim to reduce daily sedentary time by 30 min with short, frequent, light-intensity exercise bouts. Participants will undergo testing prior to, immediately after inpatient discharge, and 12 weeks after discharge. To address aim 1, VO2peak and peak cardiac output (multiple primary outcomes, p < 0.025) will be assessed via cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, respectively. Secondary outcomes include functional independence (defined as VO2peak ≥ 18.mL.kg-1.min-1), quality of life, and fatigue (assessed via validated questionnaire). Exploratory outcomes will include indices of resting cardiac, vascular, and skeletal muscle structure and function, cardiovascular biomarkers, anxiety and depression, transplant outcomes (e.g., engraftment, graft-versus-host disease), and habitual physical activity, sedentary time, and sleep.

DISCUSSION

Multi-faceted exercise programs are a promising approach for ameliorating the cardiovascular consequences of allo-SCT. If this intervention proves to be effective, it will contribute to the development of evidence-based exercise guidelines for patients undergoing allo-SCT and assist with optimising the balance between acute cancer management and long-term health.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ID: 12619000741189 . Registered 17 May 2019.

Exercise in allogeneic bone marrow transplantation: a qualitative representation of the patient perspective

PURPOSE

Exercise is emerging as a vital aspect of care to alleviate the physical and psychosocial symptom burden associated with allogeneic bone marrow transplantation (BMT). Understanding the patient perspective regarding exercise is important to move towards implementation. This study aimed to characterise experiences and views regarding participation in an exercise program in adults receiving treatment for haematological disease with allogeneic BMT.

METHODS

Individual semi-structured interviews were conducted with 35 participants from either an early- or late-commencing supervised group-based exercise program. Using an inductive, conventional approach to qualitative content analysis data were independently analysed by two researchers.

RESULTS

Six major themes and 33 sub-themes were identified: this encompassed motivation, physical opportunity and capability to exercise; psychosocial effects of group-based exercise; experienced impact of participation in an exercise program; and intervention design considerations. Key barriers to exercise included symptom severity and fluctuating health and distance or difficult access to an exercise facility or equipment, whilst facilitators included encouragement from staff; peer support in the group-based setting; flexibility; education; and ability to measure change.

CONCLUSION

This study highlights the importance of a flexible approach to exercise with consideration of individual symptoms and preferences. The perceived psychological impact of exercise should not be underestimated; future exercise programs should be designed in partnership with patients, with consideration of group-based activities to reduce social isolation if this is feasible in the treatment context. Intervention design should also acknowledge the individual's physical and psychological capability, opportunity and automatic and reflective motivation to direct and sustain exercise behaviours following BMT.

People With Hematological Malignancies Treated With Bone Marrow Transplantation Have Improved Function, Quality of Life, and Fatigue Following Exercise Intervention: A Systematic Review and Meta-Analysis

OBJECTIVE

For people with hematological malignancies treated with bone marrow transplantation (BMT), this systematic review aimed to identify, evaluate, and synthesize the evidence examining the effect of exercise training on the outcomes of exercise capacity, health-related quality of life (HRQoL), and hospital length of stay (LOS) and to identify any difference in the effect on people treated with allogeneic versus autologous transplantation.

METHODS

Five electronic databases were systematically searched from inception to December 5, 2020. Prospective studies with a comparator group, with or without randomization, were included if they investigated the effects of an exercise intervention compared with usual care or another intervention in adults who had a hematological malignancy and were undergoing BMT. Primary outcomes of interest were functional exercise capacity and HRQoL; secondary outcomes included strength, fatigue, hospital LOS, and feasibility. Only randomized controlled trials were included in the meta-analyses. Risk of bias was evaluated using the Physiotherapy Evidence Database or Newcastle-Ottawa Scale; the quality of evidence for meta-analyses was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Twenty-four randomized controlled trials and 3 prospective nonrandomized experimental trials were included (n = 2432). There was moderate-quality evidence that exercise improves functional exercise capacity (mean difference [MD] = 29 m; 95% CI = 12.59 to 45.4), global HRQoL (MD = 3.38 points; 95% CI = 0.37 to 6.39), and fatigue (MD = 2.52 points; 95% CI = 0.42 to 4.63) and low-quality evidence for reduced hospital LOS (MD = 2.07 days; 95% CI = 0.43 to 3.72). These effects were more pronounced in recipients of allogeneic transplantation. No serious adverse events were associated directly with exercise in the included studies.

CONCLUSION

Exercise is safe and improves outcomes, including functional exercise capacity, HRQoL, and hospital LOS in adults undergoing BMT.

IMPACT

The results of this systematic review support the implementation of exercise programs in adults undergoing BMT, particularly recipients of allogeneic transplantation.

Feasibility of early-commencing group-based exercise in allogeneic bone marrow transplantation: the BOOST study

Increasing evidence supports that individualised exercise is safe and beneficial for adults treated with allogeneic bone marrow transplantation (alloBMT), although this is not part of standard care and no research has investigated group-based interventions. This study aimed to determine safety, feasibility and exploratory effects of a supervised group-based inpatient and subsequent home-based exercise programme in alloBMT. This single-site prospective cohort study included consecutive adults treated with alloBMT for haematological disease. All participants received usual care in addition to the protocolised exercise programme pre-transplant until 60 days post transplant. The primary outcome was feasibility; secondary outcomes included exercise capacity, frailty, health-related quality of life and strength. Consent rate was 100% (n = 42); 83% (n = 35) completed all aspects of the intervention and outcome testing; of those, 83% (n = 29) attended ≥2 group-exercise sessions per week; no adverse events occurred. Emotional well-being significantly improved over time, which may highlight benefits of group-based intervention. Other outcomes significantly declined from pre-BMT to hospital discharge, with some improvement at 60 days post-BMT. Participants with early signs of frailty demonstrated the greatest decline in outcomes. Group-based exercise was safe and feasible; observations from this study highlight the importance of baseline identification of frailty to target intervention at those who need it most.

"This Graft-vs.-Host Disease Determines My Life. That's It."-A Qualitative Analysis of the Experiences and Needs of Allogenic Hematopoietic Stem Cells Transplantation Survivors in Germany

Background: Allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative treatment modality for many patients affected by hematologic malignancies. However, it can cause debilitating long-term effects. Understanding the impact of alloHSCT on all aspects of the patients' life is required for optimal survivorship management. Aim: To explore in-depth HSCT-survivors' experiences and needs post-transplant. Partners were included to provide further information on survivors' needs and how care could be improved in this area. Methods: We conducted semi-structured face-to-face and phone interviews with alloHSCT-survivors and their partners referred to a survivorship clinic in Germany. Theoretical sampling was used to recruit participants. Data were analyzed using framework analysis. Results: Thirty-two survivors (consent rate: 100%, response rate: 100%) and eighteen partners (consent rate: 84%, response rate: 72%) participated. Survivors were aged between 25 and 68 years (Median: 48, IQR: 25.3) and partners were aged between 26 and 64 years (Median: 54, IQR: 16, SD: 12.8). The themes emerging from the data involved survivors' needs included (i) the diversity of long-term treatment side-effects; and (ii) time post discharge as a dynamic process with individual peaks of burden. Survivors and their partners also suggested strategies for mitigating these unmet needs, i.e., (iii) transparent communication and patient empowerment; and (iv) improvement in continuity of care system and help with claiming social benefits as cornerstones of optimal survivorship care. Conclusion: To our knowledge, this is one of the first qualitative studies focused on the views of German alloHSCT-survivors on the long-term effects of alloHSCT and the first study integrating the view of their partners. Healthcare providers could better support survivors with managing their symptoms and adhering to their prescribed care by ensuring comprehensive, transparent communication that helps increase survivors' understanding and involvement in their care. Further efforts should be made to provide patient-centered, continuous survivorship care that involves additional support with navigating the healthcare and social service system. Intervention studies are required to test the effectiveness of the suggested strategies.

Next-Generation Implementation of Chimeric Antigen Receptor T-Cell Therapy Using Digital Health

Chimeric antigen receptor T-cell (CAR-T) therapy is a paradigm-shifting immunotherapy modality in oncology; however, unique toxicities such as cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome limit its ability to be implemented more widely in the outpatient setting or at smaller-volume centers. Three operational challenges with CAR-T therapy include the following: (1) the logistics of toxicity monitoring, ie, with frequent vital sign checks and neurologic assessments; (2) the specialized knowledge required for toxicity management, particularly with regard to CRS and immune effector cell-associated neurotoxicity syndrome; and (3) the need for high-quality symptomatic and supportive care during this intensive period. In this review, we explore potential niches for digital innovations that can improve the implementation of CAR-T therapy in each of these domains. These tools include patient-facing technologies and provider-facing platforms: for example, wearable devices and mobile health apps to screen for fevers and encephalopathy, electronic patient-reported outcome assessments-based workflows to assist with symptom management, machine learning algorithms to predict emerging CRS in real time, clinical decision support systems to assist with toxicity management, and digital coaching to help maintain wellness. Televisits, which have grown in prominence since the novel coronavirus pandemic, will continue to play a key role in the monitoring and management of CAR-T-related toxicities as well. Limitations of these strategies include the need to ensure care equity and stakeholder buy-in, both operationally and financially. Nevertheless, once developed and validated, the next-generation implementation of CAR-T therapy using these digital tools may improve both its safety and accessibility.

Role of Physical Activity and Cardiac Rehabilitation in Patients Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation (HSCT) is a standard treatment for several malignancies, and >50,000 HSCT are performed annually worldwide. As survival after HSCT improves, cardiovascular disease and associated risk factors have gained importance as a significant cause of morbidity and mortality in this cohort. In this article, we detail the risk factors for cardiovascular disease and their impact in patients undergoing HSCT. Additionally, we critically review the data on the impact of physical exercise in patients undergoing HSCT. Although limited by significant heterogeneity in methodologies, small sample sizes, attrition, and lack of long-term cardiovascular follow-up, most of these studies reinforce the beneficial effects of physical activity and exercise in this patient population. Cardiac rehabilitation (CR) is a structured exercise and lifestyle modification program that is typically instituted in patients who experience acute cardiovascular events. We review the data on CR in the oncologic and nononcologic populations with an aim of building a framework for use of CR in HSCT patients.

Motor ability, function, and health-related quality of life as correlates of symptom burden in patients with sclerotic chronic graft-versus-host disease receiving imatinib mesylate

PURPOSE

To explore improvement in motor ability, function, health-related quality of life (HRQOL), and symptom severity in patients with sclerotic chronic graft-versus-host disease (ScGVHD) in response to treatment as well as the relationship among changes on such measures.

METHODS

This study was a secondary analysis of data from 13 individuals with severe ScGVHD enrolled in a clinical trial evaluating the efficacy of imatinib mesylate (clinicaltrials.gov identifier: NCT00702689). Self-reported, clinician-reported, and performance-based indicators of motor ability, function, HRQOL, and symptom severity were assessed at baseline and 6 months following the administration of imatinib mesylate.

RESULTS

Participants did not show statistically significant improvement on any measures over time. Approximately one-third of patients displayed clinically significant improvement on measures of motor ability (palmar pinch strength, dominant hand, 30.8%), functioning (Manual Ability Measure-36, 41.7%), HRQOL (Short Form 36 [SF-36] Mental Component Summary, 33.3%), and symptom severity (Lee Symptom Scale, 38.5%). Improvement in cGVHD symptom burden was correlated with improvement in function (Assessment of Motor and Process Skills [AMPS] and Disabilities of the Arm, Shoulder, and Hand [DASH] scores) and HRQOL (SF-36 Physical Component Summary scores).

CONCLUSIONS

Findings suggest the potential utility of administering patient-reported and performance-based functional measures, such as the DASH and the AMPS, to patients with cGVHD. By understanding the functional consequences of ScGVHD, interdisciplinary teams of health care providers, including rehabilitation professionals, can work to improve long-term outcomes.

Factors associated with muscle function in patients with hematologic malignancies undergoing chemotherapy

PURPOSE

Muscle dysfunction such as loss of muscle mass and decreased muscle strength is often observed in patients with hematologic malignancies. However, specific factors associated with muscle function have not been identified. The purpose of this study was to identify significant factors affecting muscle function in patients with hematologic malignancies.

METHODS

This was a cross-sectional, observational study. Eighty-eight inpatients with hematologic malignancies undergoing chemotherapy were recruited. Participants were evaluated for muscle thickness and isometric knee extensor strength as indicators of muscle function, physical activity, physical symptoms, psychological distress, and self-efficacy at the start date of rehabilitation. Multiple regression analysis with muscle function as the dependent variable and clinical information and other evaluation items as explanatory variables was performed.

RESULTS

Lymphocyte count, the geriatric nutritional risk index, and physical activity were significant factors associated with muscle thickness, while physical activity and self-efficacy were significant factors associated with isometric knee extensor strength.

CONCLUSIONS

Nutritional status, physical activity, and self-efficacy were significant factors associated with muscle function in patients with hematologic malignancies. Rehabilitation intervention focusing on improving physical activity and nutritional status should be considered necessary for enhancing muscle function in patients with hematologic malignancies.

Transplant Energize Me Patient Outcome (TEMPO): A Quality Improvement Project that Maintains Functional Mobility in Pediatric Patients Admitted for Allogeneic Hematopoietic Cell Transplantation

Allogeneic hematopoietic cell transplantation (HCT) remains the definite cure for many pediatric hematologic diseases but causes profound deconditioning, which impairs daily physical functioning and may lead to further health complications. The Transplant Energize Me Patient Outcome (TEMPO) project is a standard-of-care, quality improvement (QI) project whose primary objective is to maintain physical functional mobility and strength throughout admission for pediatric allogeneic HCT patients. Specifically, TEMPO incorporates individualized and developmentally appropriate exercises and activities that are administered by a multidisciplinary team, who objectively measure and record a patient's physical stamina at predetermined frequencies. Discipline-specific metrics at admission, at weekly intervals, at discharge, and at 100 days after graft infusion (D100) are recorded in templated flowsheets in the electronic medical record. As a secondary objective, resource utilization as measured by length of stay, duration of parenteral feeds and narcotics, readmission by D100, and infections was compared between TEMPO and historical control (pre-TEMPO) allogeneic HCT patients. TEMPO participation maintained physical endurance and functional strength throughout hospitalization, an effect that was significantly sustained or improved at D100. Resource utilization did not significantly differ between patient cohorts. Taken together, the TEMPO QI Project maintains physical functional mobility, strength, and endurance, thereby decreasing physical deconditioning in pediatric allogeneic HCT patients, an effect that is objectively sustained at D100.

Cardiac Complications in the Adult Bone Marrow Transplant Patient

PURPOSE OF REVIEW

Due to advancements in oncologic treatment strategies and techniques, the number of survivors who have undergone hematopoetic stem cell transplant (HCT) continues to increase in the United States; this number is projected to reach 502,000 by the year 2030. There is significant interest within the field of cardio-oncology to identify cardiotoxicity and cardiovascular disease in the HCT population. Epidemiologic studies analyzing both short- and long-term cardiovascular effects, risk stratification modeling, cardioprotective strategies, and expert consensus documents for cardiotoxicity surveillance recommendations are reviewed.

RECENT FINDINGS

Patients who have undergone HCT are at increased risk of cardiovascular events and mortality compared to matched controls. The type of cardiotoxicity and the incidence rates vary based on specific therapeutic regimens and pre-existing cardiovascular risk factors. Life-threatening cardiotoxicity can present during HCT as acute heart failure, arrhythmias, pericardial tamponade, or cardiac arrest; or it can present late after treatment as cardiomyopathy, ischemic heart disease, vascular disease, stroke, or comorbid conditions, such as hypertension and diabetes mellitus that are associated with cardiac events. HCT is associated with excess cardiovascular risk partially due to exposure to cardiotoxic chemotherapy and radiation, as well as indirect and direct detrimental effects on cardiovascular reserve. This review discusses the epidemiology and the known cardiotoxic effects of historical chemoradiation agents in addition to newer targeted therapies. Recent expert consensus statements from cardiology and hematology/oncology societies are reviewed in regard to risk stratification of the cancer patient based on the type of treatments. Finally, gaps in knowledge are identified with proposed avenues of research that will allow for more accurate risk assessment, prediction, and potential treatment of the HCT patient in attenuating the risk of developing both short- and long-term cardiovascular comorbidities.