The Immediacy of Illness and Existential Crisis: Patients' lived experience of under-going allogeneic stem cell transplantation for haematological malignancy. A phenomenological study

Balancing risks and rewards: How hematologists discuss uncertainty in allogeneic hematopoietic cell transplantation outcomes

OBJECTIVE

Allogeneic hematopoietic cell transplant (alloHCT) offers many patients with blood cancers a chance of cure but carries risks. We characterized how hematologists discuss the high-risk, high-reward concept of alloHCT.

METHODS

Qualitative analysis of video-recorded virtual encounters of hematologists who routinely perform alloHCT with actors portraying an older man recently diagnosed with high-risk myelodysplastic syndrome.

RESULTS

Hematologists (n = 37) were a median age of 44 years, 65% male, and 68% white. They frequently used "teeter-totter" language that juxtaposed alloHCT's risks and rewards in a dynamic, quickly alternating fashion and communicated uncertainty in transplant outcomes. This dialogue oscillated between encouragement about alloHCT's potential for cure and caution about its risks and occurred within single speech turns and in exchanges between hematologist and patient. Fewer hematologists outlined their big-picture stance on transplant's risks and benefits early in the conversation. Meanwhile, hematologists varied in how they counseled patients to manage transplant-related uncertainty and consider treatment decision making.

CONCLUSION

Hematologists use "teeter-totter" language to express hope and concern, confidence and uncertainty, and encouragement and caution about the high-risk, high-reward nature of alloHCT.

PRACTICE IMPLICATIONS

Teeter-totter language may help frame big-picture content about alloHCT's risks and benefits that is essential for patient education and decision making.

Communication Strategies of Transplant Hematologists in High-Risk Decision-Making Conversations

PURPOSE

Shared decision making (SDM) is essential to empower patients with blood cancers to make goal-concordant decisions about allogeneic hematopoietic cell transplantation. This study characterizes communication strategies used by hematologists to discuss treatment options and facilitate SDM with patients in this high-risk, high-reward setting.

METHODS AND MATERIALS

We recruited US hematologists who routinely perform allogeneic hematopoietic cell transplant through email. Participants conducted up to an hour-long video-recorded encounter with an actor portraying a 67-year-old man with recently diagnosed high-risk myelodysplastic syndrome. We transcribed and qualitatively analyzed video-recorded data.

RESULTS

The mean age of participants (N = 37) was 44 years, 65% male, and 68% White. Many hematologists included similar key points in this initial consultation, although varied in how much detail they provided. Their discussion of treatment options included transplant and chemotherapy and less commonly supportive care or clinical trials. They often emphasized transplant's potential for cure, discussed transplant chronologically from pretransplant considerations through the post-transplant course, and outlined risks, complications, and major outcomes. Hematologists referred to several elements that formed the basis of treatment decision making. The strength of their treatment recommendations ranged from strong recommendations for transplant or chemotherapy to deferrals pending more information. Hematologists also varied in the extent to which they indicated the decision was physician-driven, patient-led, or shared.

CONCLUSION

The transplant decision-making discussion is complex. Identification of similar content areas used by hematologists can be used as the basis for a communication tool to help hematologists discuss allogeneic hematopoietic cell transplant with patients.

'The last bridge'- How patients experience the CAR T-cell therapy. A qualitative study

PURPOSE

CAR T-cell therapy gives patients new hope, who are diagnosed with relapsed or refractory B-cell lymphoma or B-cell leukaemia. To date, there is no scientific knowledge about the experiences of patients with CAR T-cell therapy, their process of treatment decision making or how they handle potential side effects. The study aims at deepening the understanding of the patient's experiences, indicating how to improve nursing care for this patient population.

METHOD

A qualitative study was carried out. Episodic guideline-based interviews were conducted with 14 patients who had received CAR T-cell therapy. The data analysis was performed according to the Grounded Theory. The study took place at a German university hospital.

RESULTS

Data analysis showed five sequential phases including the following concepts: 'living with cancer recurrence', 'deciding on CAR T-cell therapy', 'waiting for the reinfusion of the CAR T-cells', 'experiencing CAR T-cell therapy' and 'recovering and staying healthy'. The decision for CAR T-cell therapy was characterised by the lack of alternatives and uncertainty about the outcome and side effects.

CONCLUSIONS

Before, during and after CAR T-cell therapy, patients are faced with major challenges for which they need nursing support and guidance. These include preparation for CAR T-cell therapy, handling of side effects and preparation for discharge home.

A Theoretically Informed Critical Review of Research Applying the Concept of Liminality to Understand Experiences with Cancer: Implications for a New Oncological Agenda in Health Psychology

Liminality was described more than 20 years ago as a major category explaining how cancer is experienced. Since then, it has been widely used in the field of oncology research, particularly by those using qualitative methods to study patient experience. This body of work has great potential to illuminate the subjective dimensions of life and death with cancer. However, the review also reveals a tendency for sporadic and opportunistic applications of the concept of liminality. Rather than being developed in a systematic way, liminality theory is being recurrently 're-discovered' in relatively isolated studies, mostly within the realm of qualitative studies of 'patient experience'. This limits the capacity of this approach to influence oncological theory and practice. In providing a theoretically informed critical review of liminality literature in the field of oncology, this paper proposes ways of systematizing liminality research in line with a processual ontology. In so doing, it argues for a closer engagement with the source theory and data, and with more recent liminality theory, and it sketches the broad epistemological consequences and applications.

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.

Medication Adherence among Allogeneic Haematopoietic Stem Cell Transplant Recipients: A Systematic Review

Recipients of a haematopoietic stem cell transplantation (HSCT) may experience issues in medication adherence (MA) when discharged. The primary aim of this review was to describe the oral MA prevalence and the tools used to evaluate it among these patients; the secondary aims were to summarise factors affecting medication non-adherence (MNA), interventions promoting MA, and outcomes of MNA. A systematic review (PROSPERO no. CRD42022315298) was performed by searching the Cumulative Index of Nursing and Allied Health (CINAHL), Cochrane Library, Excerpta Medica dataBASE (EMBASE), PsycINFO, PubMed and Scopus databases, and grey literature up to May 2022 by including (a) adult recipients of allogeneic HSCT, taking oral medications up to 4 years after HSCT; (b) primary studies published in any year and written in any language; (c) with an experimental, quasi-experimental, observational, correlational, and cross-sectional design; and (d) with a low risk of bias. We provide a qualitative narrative synthesis of the extracted data. We included 14 studies with 1049 patients. The median prevalence of MA was 61.8% and it has not decreased over time (immunosuppressors 61.5% [range 31.3-88.8%] and non-immunosuppressors 65.2% [range 48-100%]). Subjective measures of MA have been used most frequently (78.6%) to date. Factors affecting MNA are younger age, higher psychosocial risk, distress, daily immunosuppressors, decreased concomitant therapies, and experiencing more side effects. Four studies reported findings about interventions, all led by pharmacists, with positive effects on MA. Two studies showed an association between MNA and chronic graft-versus-host disease. The variability in adherence rates suggests that the issues are relevant and should be carefully considered in daily practice. MNA has a multifactorial nature and thus requires multidisciplinary care models.

Medication adherence among allogeneic haematopoietic stem cell transplant recipients: a systematic review protocol

INTRODUCTION

Patients receiving a haematopoietic stem cell transplant (HSCT) are subjected to complex oral medications based on prophylactic and immunosuppressive treatments. Adherence to medication plays a role in survival, and medication non-adherence (MNA) is closely associated with graft-versus-host disease and other complications. The aim of this systematic review is to summarise the available evidence regarding prevalence rates of medication adherence, the risk factors of MNA, the effectiveness of interventions to increase medication adherence and the outcomes associated with MNA.

METHODS AND ANALYSIS

We designed a systematic review according to the Joanna Briggs Institute methodology. We will search the Cochrane Library and the CINAHL, EMBASE, MEDLINE via PubMed, PsycINFO and Scopus databases. We will include published and unpublished primary studies: (a) on humans, from inception until 10 May 2022; (b) written in any language; (c) experimental (randomised and non-randomised), observational (prospective, retrospective cohort and case-control), correlational, cross-sectional and longitudinal; and (d) with a low risk of bias, according to the quality assessment we perform. We will exclude secondary and qualitative studies, protocols, publications without original data, including paediatrics or related to autologous HSCT. The primary outcome will be the prevalence of oral medication adherence; the secondary outcomes will be the risk factors of MNA, the interventions aimed at increasing medication adherence and the outcomes of MNA. Two researchers will independently screen the eligible studies, then extract and describe the data. Disagreements will be resolved by a third researcher. We will provide a qualitative narrative synthesis of the findings.

ETHICS AND DISSEMINATION

Ethical approval is not required given that previously published studies will be used. We will disseminate the findings through conference presentations and publications in international peer-reviewed scientific journals.

PROSPERO REGISTRATION NUMBER

CRD42022315298.

Healthcare-related correlates of preoperative psychological distress among a mixed surgical and cancer-specific sample

OBJECTIVE

Preoperative distress is commonly experienced by surgical patients and is associated with adverse health-related outcomes. Research suggests preoperative distress may be elevated among cancer surgery patients relative to other surgical groups and there appears to be greater recognition of the adverse impacts of distress for these patients. This study examined associations between preoperative distress and postoperative healthcare-related correlates (e.g., length of stay, re-hospitalization) among a large, mixed surgical sample, and separately among cancer surgery patients with active cancer.

METHODS

We analyzed secondary data from the Vascular Events In Non-cardiac Surgery Patients Cohort Evaluation (VISION) study - Mental Health Supplement (N = 997; n = 370 active cancer/cancer surgery). The Kessler 6-item Psychological Distress Scale assessed preoperative distress on the day of surgery. Multivariable regressions examined associations between distress and healthcare-related correlates. For significant relationships, we examined associations between anxiety and depressive subscales of distress with the correlates of interest.

RESULTS

Among the full surgical sample, after adjustment, preoperative distress was associated with a greater length of stay (b = 0.01, 95% CI [0.00-0.02], R² = 0.15, f² = 0.18) and increased odds of re-hospitalization (AOR = 1.07, 95%CI [1.01-1.13]). Results were comparable among cancer surgery patients (length of stay: b = 0.02, re-hospitalization: AOR = 1.11). Post-hoc analyses revealed associations between anxiety symptoms and re-hospitalization (AOR range: 1.13-1.26) and between depressive symptoms and length of hospital stay (b range: 0.02-0.04, R² range: 0.07-0.15, f² range: 0.07-0.18).

CONCLUSIONS

Findings suggest preoperative distress may be associated with greater postoperative healthcare needs. Results support the importance of screening for distress in the perioperative period.

Patient and Provider Perspectives on the Impacts of Unpredictability for Patient Sensemaking: Implications for Intervention Design

Patients facing situations with significant unpredictability are met with challenges to expectation formation and preparation. One such context with unpredictable clinical outcomes is bone marrow transplant (BMT) for patients with hematologic malignancies. To understand the experience of unpredictability and opportunities for intervention, semi-structured interviews with patients who had received BMT (n  =  7) and transplant providers (n  =  8) were conducted. Thematic analysis revealed conflict between the necessity of expectation formation and the unpredictability of transplant. Providers described a tension between adequately informing patients of potential risks of transplant and presenting so much information as to create unnecessary anxiety in patients. Patients described issues with outcome unpredictability (not knowing what particular complications they would experience) and temporal unpredictability (not knowing when complications would appear). Patients struggled to make sense of unexpected complications and resulting limitations post-BMT and plan for the future amid the nonlinear recovery timeline. The challenges of unpredictability warrant a support solution that enables patient sensemaking in their evolving illness journey and facilitates adaptation to new circumstances.

Response-An Extreme Ordeal: Writing Emotion in Qualitative Research

Responding to the stimulus afforded by Little et al.'s "Pragmatic pluralism: Mutual tolerance of contested understandings between orthodox and alternative practitioners in autologous stem cell transplantation," this paper explores how the norms of qualitative inquiry affect the representation of emotion in research reports. It describes a conflict between the construction of emotion in qualitative research accounts and its application to analysis and theorization, whose origins may lie in researchers' reticence when it comes to conveying or using the emotional features of data. The technical aspects of report writing that are associated with this conflict are explored via a deconstruction of Little et al.'s paper and a survey of the qualitative research methods literature. Writing to convey emotion and analysing to include author-constructed emotional context are neglected topics. Using data in Little et al.'s text, the paper demonstrates the importance of author-constructed emotional context to theory generation. The paper recommends the inclusion of emotional context as data in analysis and points to lessons Little et al.'s paper offers in the areas of narrative technique and reflexive practice.

Patients' reflections on undergoing non-myeloablative allogeneic haematopoietic stem cell transplantation and participating in a multimodal interdisciplinary rehabilitation programme: A qualitative study

PURPOSE

To explore participants' experiences and perspectives on the relevance and meaning of participating in the multimodal interdisciplinary rehabilitation programme named 'HAPPY', and the programme's influence on their handling of everyday life during and after non-myeloablative allogeneic haematopoietic stem cell transplantation.

METHOD

A qualitative interview study using Thorne's interpretive description methodology. A semi-structured interview guide and the analysis were inspired by symbolic interactionism. From April to July 2020, individual interviews were conducted with 24 patients who had participated in HAPPY while undergoing non-myeloablative haematopoietic stem cell transplantation.

RESULTS

HAPPY contributed to the patients' knowledge building on the basis of three themes: Social Solidarity and Comparison, Processing Mind and Body, and Balancing Disease and Life. HAPPY supported the participants in maintaining their physical functioning and induced a perception of empowerment. Moreover, HAPPY supported patients in their efforts to familiarise themselves with their changed life conditions after the stem cell transplantation.

CONCLUSION

Our findings showed that participation in HAPPY empowered patients to manage and cope with the stresses of everyday life and restore balance in their lives whilst undergoing treatment and confronting their cancer diagnosis. The findings underline the importance of elements of peer support and continuous support and facilitation from the specialist team, and the possibility to rethink the use of online technology to support and ensure a balance between disease and life and to minimise hospital visits.

Health-related quality of life and physical functioning in patients participating in a rehabilitation programme, undergoing non-myeloablative allogeneic haematopoietic stem cell transplantation: Outcomes from a single arm longitudinal study

OBJECTIVE

This study aims to report HRQOL, patient activation and physical functioning of haematological patients, participating in a 6-month multimodal interdisciplinary rehabilitation programme HAPPY, when undergoing non-myeloablative allogeneic haematopoietic stem cell transplantation (NMA-HSCT).

METHODS

A prospective single-arm longitudinal design. Outcomes were collected as part of a feasibility study and included: HRQOL (EORTC QLQ-C30), patient activation measure (PAM), cardiorespiratory capacity (VO_2peak ), leg extensor power, lean body mass, measured pre-NMA-HSCT at 3-, 6- and 12-month follow-up.

RESULTS

Thirty (mean age (SD) 64.1 (6.5)) out of 34 patients participated and 18 completed HAPPY. Outcome measures showed large individual differences of decline and improvement during follow-up. Patients rated HRQOL as good (median 70.8; range 33.3-100). Fatigue, dyspnoea, insomnia and appetite loss mainly remained or worsened. PAM stayed in the upper half of range (median 55.6; range 20.5-84.8) with a trend towards improvement at 12-month follow-up. Physical functioning scores were low [i.e. baseline VO_2peak , men median 1.5 L/min range (1.0-2.9), women 1.0 L/min (0.8-1.4), leg extensor power men 2.1 Watt/kg range (1.3-3.8), women 1.7 Watt/kg (1.3-2.4), lean body mass men 19.5% (17.6-24.9) and women 17.8% (15.3-21.7)].

CONCLUSION

The sustained low level of physical functioning and symptoms 12-month after NMA-HSCT emphasise the need for pre-rehabilitation and long-lasting rehabilitation support in this frail patient group.

What is known about palliative care in adult patients with allogeneic stem cell transplantation (allo-SCT)?

Patients undergoing allogeneic stem cell transplantation (allo-SCT) are given a real chance of cure, but at the same time are confronted with a considerable risk of mortality and of severe long-term impediments. This narrative, non-systematic literature review aims to describe the supportive and palliative care needs of allo-SCT recipients, including long-term survivors or those relapsing or dying after transplantation. It also evaluates the feasibility and effectivity of integrating palliative care early in transplant procedures. In this appraisal of available literature, the main findings relate to symptoms like fatigue and psychological distress, which appear to be very common in the whole allo-SCT trajectory and might even persist many years post-transplantation. Chronic GvHD has a major negative impact on quality of life. Overall, there is a paucity of research on further issues in the context of allo-SCT, like the distress related to the frequently unpredictable post-transplant trajectory and prognosis, as well as the end-of-life phase. First randomized controlled results support the effectiveness of early integration of specialized palliative care expertise into transplant algorithms. Barriers to this implementation are discussed.

Factors influencing the perception of protective isolation in patients undergoing haematopoietic stem cell transplantation: A multicentre prospective study

OBJECTIVES

To identify which factors can influence the patients' perception of protective isolation following Haematopoietic Stem Cell Transplantation (HSCT).

METHODS

This is a prospective study conducted in 10 Italian centres, members of the Italian Group of stem cell transplant (GITMO). Patients' perception of protective isolation was assessed using the ISOLA scale between 7 and 9 days post-transplant. Statistical linear regression analysis was performed.

RESULTS

The participants were 182 adult patients receiving autologous (48%) or allogeneic (52%) HSCT in protective isolation. Male sex (β = .152), education level (β = -.245), double room (β = .186), satisfaction with visiting hours (β = -.174) and emotional support from nurses (β = -.169) were independently associated with isolation-related suffering. Significant predictors of the relationship with oneself included body temperature (β = -.179), fatigue (β = -.192) and emotional support from nurses (β = -.292). Factors independently associated with the relationship with others were education (β = -.230), chemotherapy cycles (β = -.218), pain (β = .150) and satisfaction with visiting hours (β = -.162).

CONCLUSION

Healthcare providers should pay greater attention in caring for those patients who are at risk for a negative isolation experience. Nurses should provide emotional support.

The experiences and needs of primary family caregivers of patients with multiple myeloma: A qualitative analysis

BACKGROUND

Family caregivers play a key role in the lives of patients with multiple myeloma. However, very little is known about the impact that the disease (its diagnosis, course and prognosis) has on the main family caregiver.

AIM

To achieve a deeper understanding of the lived experience of individuals who are the primary caregiver of a relative with multiple myeloma and to shed light on their needs.

DESIGN

Interpretative phenomenological study.

SETTING AND PARTICIPANTS

A total of 12 individuals who were the main family caregivers of a relative with multiple myeloma who was under outpatient follow-up at a cancer unit in Barcelona were recruited via purposive sampling until data saturation was reached. In semi-structured in-depth interviews, participants described their experiences of caring for their relative with multiple myeloma. Interviews were recorded, transcribed and analysed using ATLAS.ti v7.2. The seven steps proposed by Colaizzi were used for data analysis, and the relationships among emerging themes were examined.

FINDINGS

Four main themes emerged: (a) a new life, adapting to the disease, (b) commitment to the patient, (c) the emotional sphere and (d) experiences in relation to the care and support received. The analysis also revealed a core overarching theme: uncertainty.

CONCLUSION

Primary family caregivers experienced intense uncertainty, and they described a strong need to air their feelings. Specific practical initiatives, targeting both health-related and logistical aspects of care, need to be developed in order to support family caregivers of myeloma patients.

Experiences of newly diagnosed cancer patients in confronting the finitudes of life: a qualitative systematic review protocol

REVIEW QUESTION

What is the experience of newly diagnosed patients with cancer when facing the finitude of life and undergoing initial anti-cancer treatment?

Patients' experiences of different care settings and a new life situation after allogeneic haematopoietic stem cell transplantation

Over the past 20 years, considerable healthcare resources have shifted from an inpatient to an outpatient setting. To be in an outpatient setting or at home after allogeneic haematopoietic stem cell transplantation (allo-HSCT) has been shown to be medically safe and beneficial to the patient. In this study we describe patients' experiences of different care settings (hospital or home) and a new life situation during the acute post-transplant phase after HSCT. Semi-structured interviews were conducted with 15 patients (six women and nine men) 29-120 days after HSCT. An inductive qualitative content analysis was performed to analyse the data. The analysis resulted in four categories: To be in a safe place, To have a supportive network, My way of taking control, and My uncertain return to normality. The findings showed that patients undergoing HSCT felt medically safe regardless of the care setting. The importance of a supportive network (i.e. the healthcare team, family and friends) was evident for all patients. Both emotional and problem-focused strategies were used to cope with an uncertain future. Being at home had some positive advantages, including freedom, having the potential for more physical activity, and being with family members. The study highlights some key areas thought to provide more personalised care after HSCT.

Medication Adherence in Hematopoietic Stem Cell Transplantation: A Review of the Literature

Adherence to oral medications has been repeatedly shown to fall below the recommended 80% to 95% in pediatric and adult cancer populations. The purpose of this review is to report the state of the science about oral medication adherence during the acute phase of hematopoietic stem cell transplantation across the lifespan. An exhaustive search of the literature yielded 5 records for inclusion in the review. Two studies examined adherence in pediatrics, 2 in adults, and 1 included both pediatric and adult patients. Three studies were descriptive and 2 were interventional in design. The rate of adherence to oral medications ranged from 33% to 94.7%. Adherence decreased over time in all studies except in 1 pharmacist-led intervention study. Different methods were used to measure adherence, but most relied on self-report. Further research is needed in medication adherence in hematopoietic stem cell transplantation to better understand facilitators, barriers, and relationships to health outcomes.