Cognitive and psychosocial functioning of pediatric hematopoietic stem cell transplant patients: a prospective longitudinal study

Cognitive performance and mortality among patients receiving autologous hematopoietic stem cell transplant

OBJECTIVES

Patients undergoing autologous hematopoietic stem cell transplant (HCT) are at risk for death and remain understudied relative to those undergoing allogeneic HCT. Cognitive functioning may be a useful indicator of mortality risk. We examined cognition among patients who underwent autologous HCT and its relationship to mortality.

METHODS

Participants (N = 51; 11 patients deceased) completed tasks of processing speed, working memory, executive-mediated learning, and visual recall using the computerized CogState battery prior to HCT, 30 days post-autologous HCT, and 100 days post-autologous HCT.

RESULTS

Slower processing speed (HR = 3.00) and more errors on an executive-mediated visual learning task (HR = 2.78) prior to HCT were associated with an increased risk of death following HCT. Our sample size limited longitudinal analyses of whether cognitive change predicted survival, however descriptive cognitive data of the deceased versus living patient's performances over time suggested different patterns of performance across groups.

CONCLUSIONS

Pre-HCT cognition may have utility as an indicator of mortality risk following autologous HCT. More research is needed to examine whether cognitive changes after HCT could also predict mortality.

Evaluation of Children with Malignancies for Blood and Marrow Transplantation: A Report from the ASTCT Committee on Practice Guidelines

Evaluation of a candidate for hematopoietic cell transplantation (HCT) is a complex process with substantial intercenter variability. Although literature providing guidance for evaluating the eligibility of adults is well established, similar guidance for children is lacking. To address gaps between adult recommendations and the specific needs of children, we convened a panel of pediatric HCT experts from a wide geographic range of American Society of Transplantation and Cellular Therapy (ASTCT) member institutions to offer recommendations for pediatric-focused pre-HCT evaluation. In this report from the ASTCT Committee on Practice Guidelines, we present a practical framework for evaluating children with malignancies who are candidates for HCT. We also highlight key differences from adults and emphasize areas of unmet need that require additional research to delineate best practices.

ESTRO ACROP and SIOPE recommendations for myeloablative Total Body Irradiation in children

BACKGROUND AND PURPOSE

Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children.

MATERIAL AND METHODS

The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established.

RESULTS

Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3-4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III-IV evidence. Preferential TBI dose in children is 12-14.4 Gy in 1.6-2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies.

CONCLUSIONS

These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities.

Total Body Irradiation in Haematopoietic Stem Cell Transplantation for Paediatric Acute Lymphoblastic Leukaemia: Review of the Literature and Future Directions

Total body irradiation (TBI) has been a pivotal component of the conditioning regimen for allogeneic myeloablative haematopoietic stem cell transplantation (HSCT) in very-high-risk acute lymphoblastic leukaemia (ALL) for decades, especially in children and young adults. The myeloablative conditioning regimen has two aims: (1) to eradicate leukaemic cells, and (2) to prevent rejection of the graft through suppression of the recipient's immune system. Radiotherapy has the advantage of achieving an adequate dose effect in sanctuary sites and in areas with poor blood supply. However, radiotherapy is subject to radiobiological trade-offs between ALL cell destruction, immune and haematopoietic stem cell survival, and various adverse effects in normal tissue. To diminish toxicity, a shift from single-fraction to fractionated TBI has taken place. However, HSCT and TBI are still associated with multiple late sequelae, leaving room for improvement. This review discusses the past developments of TBI and considerations for dose, fractionation and dose-rate, as well as issues regarding TBI setup performance, limitations and possibilities for improvement. TBI is typically delivered using conventional irradiation techniques and centres have locally developed heterogeneous treatment methods and ways to achieve reduced doses in several organs. There are, however, limitations in options to shield organs at risk without compromising the anti-leukaemic and immunosuppressive effects of conventional TBI. Technological improvements in radiotherapy planning and delivery with highly conformal TBI or total marrow irradiation (TMI), and total marrow and lymphoid irradiation (TMLI) have opened the way to investigate the potential reduction of radiotherapy-related toxicities without jeopardising efficacy. The demonstration of the superiority of TBI compared with chemotherapy-only conditioning regimens for event-free and overall survival in the randomised For Omitting Radiation Under Majority age (FORUM) trial in children with high-risk ALL makes exploration of the optimal use of TBI delivery mandatory. Standardisation and comprehensive reporting of conventional TBI techniques as well as cooperation between radiotherapy centres may help to increase the ratio between treatment outcomes and toxicity, and future studies must determine potential added benefit of innovative conformal techniques to ultimately improve quality of life for paediatric ALL patients receiving TBI-conditioned HSCT.

A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia

Despite advances in haematopoietic stem cell transplant (HSCT) techniques, the risk of serious side effects and complications still exists. Neurological complications, both acute and long term, are common following HSCT and contribute to significant morbidity and mortality. The aetiology of neurotoxicity includes infections and a wide variety of non-infectious causes such as drug toxicities, metabolic abnormalities, irradiation, vascular and immunologic events and the leukaemia itself. The majority of the literature on this subject is focussed on adults. The impact of the combination of neurotoxic drugs given before and during HSCT, radiotherapy and neurological complications on the developing and vulnerable paediatric and adolescent brain remains unclear. Moreover, the age-related sensitivity of the nervous system to toxic insults is still being investigated. In this article, we review current evidence regarding neurotoxicity following HSCT for acute lymphoblastic leukaemia in childhood. We focus on acute and long-term impacts. Understanding the aetiology and long-term sequelae of neurological complications in children is particularly important in the current era of immunotherapy for acute lymphoblastic leukaemia (such as chimeric antigen receptor T cells and bi-specific T-cell engager antibodies), which have well-known and common neurological side effects and may represent a future treatment modality for at least a fraction of HSCT-recipients.

Neurocognitive functioning in long-term survivors of pediatric hematopoietic cell transplantation

Survivors of pediatric hematopoietic cell transplantation (HCT) are at risk for impairment in cognitive and academic function. Most research to date has focused on the first years following transplant, and less is known about the long-term effects. We examined global and specific neurocognitive functioning in long-term (>5 years post HCT) survivors in comparison to both normative data and a sample of demographically similar healthy peers. A comprehensive battery of neurocognitive measures was obtained from 83 long-term survivors and 50 healthy comparisons. Analyses were conducted to assess for differences in neurocognitive functions between survivors, normative means, and healthy comparisons, and to examine the impact of medical and demographic variables on neurocognitive performance. Survivors' performance was within the Average range across most measures, although significantly lower than both test norms and healthy comparisons on several measures. Despite generally intact neurocognitive functioning in the survivor group as a whole, survivors who experienced graft-vs.-host disease demonstrated slower processing speed and weaker verbal learning. Use of total body irradiation was not associated with any performance-based measure of neurocognitive functioning. Although subgroups of patients may be at relatively higher risk of neurocognitive impairment, the long-term neurocognitive impact for most survivors is relatively small.

Cognitive and psychological outcomes of pediatric allogeneic hematopoietic stem cell transplantation survivors in a single center in China

To investigate the cognitive and psychological outcomes of pediatric allogeneic HSCT survivors in China.A total of 135 3 to 18 years old children and adolescents who underwent allo-HSCT and survived at least 3 months post-HSCT were recruited and completed the assessments. Cognitive and psychological functions were assessed via age-appropriate standardized measures. Clinical information was extracted from the medical records.Forty one 3 to 6 years old children completed Psychological Questionnaires for 3 to 6 years Children. The scores of 21(51.2%) children in cognitive development dimension, 18(43.9%) in motor development dimension, 16(39.0%) in language development and social development dimension, 15(36.6%) in emotion and will dimension and 14(34.1%) in living habits dimension were less than the standard. Fifty six 8 to 16 years old children and adolescents completed the Depression Self-rating Scale for Children and 9 (16.1%) of these met the criteria of depression. Sixty nine 7 to 16 years old children and adolescents completed the screening for Child Anxiety Related Disorders and 7 (10.1%) of these met the criteria of anxiety, especially social phobia and school phobia. Eighty nine 6 to 18 years old children and adolescents completed the Symptom Checklist-90 and 43.8% to 77.5% of these experienced mild symptoms like obsession-compulsion (77.5%), hostility (64%), and interpersonal sensitivity (60.7%). Children treated with total body irradiation (TBI) showed more cognitive impairments like motor deficits than those without TBI. Also older children and adolescents had more symptoms like psychoticism.These findings demonstrated cognitive and psychological late effects of pediatric allo-HSCT survivors in a single center in China and highlighted that the survivors conditioned with TBI had more cognitive impairments and older children and adolescents had more symptoms. Early intervention in these children and adolescents might minimize the cognitive losses and psychological effects.

Female Sex is Associated With Poor Health-related Quality of Life in Children at 12 Months Post-Hematopoietic Cell Transplantation

To study the factors associated with poorer health-related quality of life at 1-year post-allogeneic hematopoietic cell transplantation (alloHCT), a secondary analysis of a prospective feasibility study was performed. Pediatric Quality of Life Inventory questionnaires were collected in 76 children undergoing alloHCT at baseline (within 30 d before transplantation), day 100, 6 months, and 12 months posttransplantation. The global score improved post-HCT (baseline: 67.1, 12 mo: 76.6). Females (odds ratio, 6.5; 95% confidence interval, 1.002-42.17; P=0.04) and patients with low baseline scores (odds ratio, 7.2; 95% confidence interval, 1.07-48.63; P=0.04) had lower scores at 12 months post-HCT and suggest a target group for early interventions such as physical exercise, stress management, and cognitive behavior therapy.

Neurocognitive dysfunction in hematopoietic cell transplant recipients: expert review from the late effects and Quality of Life Working Committee of the CIBMTR and complications and Quality of Life Working Party of the EBMT

Hematopoietic cell transplantation (HCT) is a potentially curative treatment for children and adults with malignant and non-malignant diseases. Despite increasing survival rates, long-term morbidity following HCT is substantial. Neurocognitive dysfunction is a serious cause of morbidity, yet little is known about neurocognitive dysfunction following HCT. To address this gap, collaborative efforts of the Center for International Blood and Marrow Transplant Research and the European Society for Blood and Marrow Transplantation undertook an expert review of neurocognitive dysfunction following HCT. In this review, we define what constitutes neurocognitive dysfunction, characterize its risk factors and sequelae, describe tools and methods to assess neurocognitive function in HCT recipients, and discuss possible interventions for HCT patients with this condition. This review aims to help clinicians understand the scope of this health-related problem, highlight its impact on well-being of survivors, and to help determine factors that may improve identification of patients at risk for declines in cognitive functioning after HCT. In particular, we review strategies for preventing and treating neurocognitive dysfunction in HCT patients. Lastly, we highlight the need for well-designed studies to develop and test interventions aimed at preventing and improving neurocognitive dysfunction and its sequelae following HCT.

Neurocognitive Dysfunction in Hematopoietic Cell Transplant Recipients: Expert Review from the Late Effects and Quality of Life Working Committee of the Center for International Blood and Marrow Transplant Research and Complications and Quality of Life Working Party of the European Society for Blood and Marrow Transplantation

Hematopoietic cell transplantation (HCT) is a potentially curative treatment for children and adults with malignant and nonmalignant diseases. Despite increasing survival rates, long-term morbidity after HCT is substantial. Neurocognitive dysfunction is a serious cause of morbidity, yet little is known about neurocognitive dysfunction after HCT. To address this gap, collaborative efforts of the Center for International Blood and Marrow Transplant Research and the European Society for Blood and Marrow Transplantation undertook an expert review of neurocognitive dysfunction after HCT. In this review we define what constitutes neurocognitive dysfunction, characterize its risk factors and sequelae, describe tools and methods to assess neurocognitive function in HCT recipients, and discuss possible interventions for HCT patients with this condition. This review aims to help clinicians understand the scope of this health-related problem, highlight its impact on well-being of survivors, and help determine factors that may improve identification of patients at risk for declines in cognitive functioning after HCT. In particular, we review strategies for preventing and treating neurocognitive dysfunction in HCT patients. Finally, we highlight the need for well-designed studies to develop and test interventions aimed at preventing and improving neurocognitive dysfunction and its sequelae after HCT.

Quality of Life After Hematopoietic Stem Cell Transplantation in Pediatric Survivors: Comparison With Healthy Controls and Risk Factors

BACKGROUND

Hematopoietic stem cell transplantation has prolonged life for children with life-threatening diseases. Quality of life is an essential outcome for evaluating the long-term effects of transplantation.

OBJECTIVE

The aims of this study were to compare the quality of life of children posttransplantation to that of healthy peers and explore the variables associated with the quality of life of posttransplant children.

METHODS

A cross-sectional study was conducted with 43 pediatric transplantation survivors and 43 age- and sex-matched healthy peers.

RESULTS

The mean age of the transplant group was 12.06 years. The mean time since transplant was 3.73 years. After covariate adjustment, there was no difference between posttransplant and healthy children in each domain and overall quality of life, except for physical functioning where the posttransplant children had lower scores than did the healthy group. Chronic graft-versus-host disease was found to be the primary factor associated with poor posttransplant overall quality of life and emotional and social functioning. Sociodemographic variables, symptom distress, and caregiver depression were not correlated with posttransplant quality of life.

CONCLUSIONS

The quality of life of pediatric transplantation survivors was comparable to that of healthy peers.

IMPLICATIONS FOR PRACTICE

The finding that children after transplant may achieve quality of life similar to their healthy peers is important information for parents to consider as they consider treatment options. For those sick children who cannot regularly attend school, their emotional and social functioning should be closely monitored.

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.

Incidence and severity of crucial late effects after allogeneic HSCT for malignancy under the age of 3 years: TBI is what really matters

Younger children are considered to be more vulnerable to late effects (LE), which prompted us to study LE in patients after haematopoietic stem cell transplantation (HSCT) for a haematological malignancy before the age of 3. In this multicentre EBMT study, cumulative incidence (CI) and severity of endocrine LE, central nervous system complications and secondary malignancies at 5, 10, 15 and 20 years of follow-up were assessed. Risk factors (RF) like gender, diagnosis, age at and year of HSCT, TBI- or chemo-conditioning and GVHD were analysed. CI of any LE was 0.30, 0.52, 0.66 and 0.72 at 5, 10, 15 and 20 years after HSCT, respectively. In 25% of the patients, LE were severe at a median follow-up of 10.4 years. In multivariate analysis, only TBI was a RF for having any LE and for thyroid dysfunction and growth disturbance. Female gender was a RF for delayed pubertal development. Some more insight could be gained by descriptive analysis regarding the role of TBI and GVHD on the severity of LE. Although only five selected LE have been studied and median follow-up is relatively short, the incidence and severity of these LE are considerable but not different from what has been found in older children and TBI is the main RF.

Sleepiness, Fatigue, Behavioral Functioning, and Quality of Life in Survivors of Childhood Hematopoietic Stem Cell Transplant

OBJECTIVES

To examine subjective fatigue and sleepiness as predictors of functional outcomes in long-term pediatric hematopoietic stem cell transplant (HSCT) survivors.

METHODS

Participants included 76 survivors assessed 5-14 years post-HSCT. Self-report and parent-proxy (i.e., N = 38) measures of fatigue, excessive daytime sleepiness (EDS), emotional and behavioral functioning, executive functioning, and quality of life (QOL) were completed. Health-related correlates were obtained from medical records.

RESULTS

Survivors exhibited significant fatigue for self (M = 69.21 ± 20.14) and parent-proxy (M = 72.15 ± 20.79) report. EDS was endorsed for 20-33% of survivors, depending on the respondent. EDS was not significant for parent-proxy outcomes, but was associated with poorer self-reported QOL and internalizing problems (p < .0016). Fatigue was associated with poorer functioning across all domains (p's < .0016).

CONCLUSIONS

A substantial number of pediatric HSCT survivors exhibit sleepiness and fatigue. Fatigue is associated with statistically and clinically greater functional difficulties, highlighting the importance of examining sleep and fatigue and considering interventions to improve alertness.

Monitoring and Assessment of Neuropsychological Outcomes as a Standard of Care in Pediatric Oncology

Central nervous system cancers or exposure to CNS-directed therapies increase risk for neuropsychological deficits. There are no accepted guidelines for assessment of neuropsychological functioning in this population. A multifaceted literature search was conducted and relevant literature reviewed to inform the guidelines. Studies of neuropsychological outcomes are widely documented in the pediatric oncology literature. There is strong evidence of need for neuropsychological assessment, but insufficient evidence to guide the timing of assessment, nor to recommend specific interventions. Children with brain tumors and others at high risk for neuropsychological deficits should be monitored and assessed for neuropsychological deficits.

Alterations in Memory and Impact on Academic Outcomes in Children Following Allogeneic Hematopoietic Cell Transplantation

The prevalence of late effects following allogeneic hematopoietic cell transplantation (HCT), a curative treatment for pediatric leukemia, is high: 79% of HCT recipients experience chronic medical conditions. The few extant studies of cognitive late effects have focused on intelligence and are equivocal about HCT neurotoxicity. In an archival study of 30 children (mean transplant age = 6 years), we characterize neuropsychological predictors of academic outcomes. Mean intellectual and academic abilities were average, but evidenced extreme variability, particularly on measures of attention and memory: ∼25% of the sample exhibited borderline performance or lower. Medical predictors of outcome revealed paradoxically better memory associated with more severe acute graft-versus-host disease (GVHD) and associated with steroid treatment. Processing speed and memory accounted for 69% and 61% of variance in mathematics and reading outcomes, respectively. Thus, our findings revealed neurocognitive areas of vulnerability in processing speed and memory following HCT that contribute to subsequent academic difficulties.

Determine the difficulties of home care in children following haematopoietic stem cell transplantation

The aim of this study was to determine the difficulties regarding the home care of children following haematopoietic stem cell transplantation (HSCT). The sample of the study includes the families of 73 children in a bone marrow transplant unit between 2010 and 2013, Turkey. Data were collected using a form included descriptive information and questions about the difficulties and complications of home care. Families were telephoned and problems they had encountered were recorded. Mann-Whitney U-test and the logistic regression analysis were used. The average age of the children was 10.65 ± 5.03 years, the average age was 8.89 ± 4.9 when HSCT was performed, and the average year after HSCT was 1.79 ± 0.74. 41.1% of the children underwent transplantation with diagnoses of anaemia. Primary physical problems that were found after discharge from the hospital were fever (43.8%), decreased appetite (37%), rash (34.2%) and pain (26%). Socially, 43.8% of families reported that their children had difficulties with school. Primary difficulties regarding care and follow-up were reported as skin care (34.2%) and catheter care (33.3%). In the post-transplantation period, it is important to provide information about potential problems and care to patients and families in order to increase the quality of life.

National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: V. The 2014 Ancillary Therapy and Supportive Care Working Group Report

The 2006 National Institutes of Health (NIH) Consensus paper presented recommendations by the Ancillary Therapy and Supportive Care Working Group to support clinical research trials in chronic graft-versus-host disease (GVHD). Topics covered in that inaugural effort included the prevention and management of infections and common complications of chronic GVHD, as well as recommendations for patient education and appropriate follow-up. Given the new literature that has emerged during the past 8 years, we made further organ-specific refinements to these guidelines. Minimum frequencies are suggested for monitoring key parameters relevant to chronic GVHD during systemic immunosuppressive therapy and, thereafter, referral to existing late effects consensus guidelines is advised. Using the framework of the prior consensus, the 2014 NIH recommendations are organized by organ or other relevant systems and graded according to the strength and quality of supporting evidence.

Health-related quality of life after allogeneic hematopoietic stem cell transplantation for sickle cell disease

Sickle cell disease (SCD) is a hereditary hemoglobinopathy that affects over 100,000 people in the United States. Patients with SCD are known to experience suboptimal health-related quality of life (HRQoL). In addition to the physical manifestations of SCD, psychological and social stress, along with academic difficulties, secondary to the chronicity of the disease and its complications often affect patients with SCD. Although medical therapy of SCD has improved, allogeneic hematopoietic cell transplantation (allo-HCT) remains the only curative therapy. The objective of this study was to measure HRQoL before and after allo-HCT by assessing physical, psychological, and social functioning in patients with SCD who have undergone reduced-toxicity conditioning (busulfan/fludarabine/alemtuzumab) followed by allo-HCT. Patients < 21 years of age undergoing allo-HCT (matched siblings and unrelated donors) for SCD and their primary caregiver were enrolled using either the English or Spanish version of the PedsQoL 4.0. Data were collected at 3 time points: before allo-HCT and on days 180 and 365 after allo-HCT. The change in HRQoL from baseline was assessed with unadjusted and adjusted mixed-effects models in which subjects were treated as random effects, and variance component structure was used. Seventeen patients and 23 primary caregivers were enrolled and reported a mean overall HRQoL of 66.05 (SD, 15.62) and 72.20 (SD, 15.50) at baseline, respectively. In the patient-reported analysis with adjusted mixed-effects models, the estimated improvements in overall HRQoL were 4.45 (SE, 4.98; P = .380) and 16.58 (SE, 5.06; P = .003) at 180 and 365 days, respectively, after allo-HCT. For parent-reported overall HRQoL, the estimated improvements were 1.57 (SE, 4.82; P = .747) and 9.28 (SE, 4.62; P = .053) at 180 and 365 days, respectively, after allo-HCT. Similar results were found across the physical, social, and emotional HRQoL domains with mixed-effects models after adjustment of demographic and medical variables. In addition to the alleviation of clinical manifestations of SCD, these patients demonstrated significant improvement in most aspects of HRQoL by 1 year after allo-HCT. These data represent the trajectory of HRQoL during the initial year of follow-up within this population and should be integrated into the decision-making process when considering allo-HCT in patients with SCD.

Cognitive outcome after pediatric stem-cell transplantation: impact of age and total-body irradiation

PURPOSE

To examine the influence of age and conditioning with total-body irradiation (TBI) on the trajectory of cognitive functioning after treatment with pediatric hematopoietic stem-cell transplantation (SCT).

PATIENTS AND METHODS

Pediatric patients who were scheduled to undergo a SCT were eligible for the study, with 315 patients completing a baseline assessment. Of these, 183 patients (58.1%) were alive at 1 year after SCT and completed additional assessments at 1, 3, and 5 years after SCT. Half of the long-term sample (52.1%) received TBI during conditioning. Cognitive functioning was assessed via age-appropriate standardized measures.

RESULTS

At baseline, there were no differences in intelligence quotient (IQ) based on age. At 5 years after SCT, the youngest patients (< 3 years old at baseline) who received TBI demonstrated a significantly lower IQ than those who did not receive TBI (P = .05). Longitudinal analyses (piecewise linear mixed-effects models with a knot at 1 year after SCT) revealed a significant impact of age and TBI over time. The youngest patients evidenced declines in cognitive functioning during the first year; however, patients who did not receive TBI largely recovered their functioning in subsequent years. In contrast, young patients who received TBI failed to recover the losses experienced during the first year after SCT, demonstrating stability in their functioning, but at a lower level.

CONCLUSION

Our findings clarify the relationship between TBI and age on cognitive outcomes in pediatric SCT survivors. Young patients who receive TBI may benefit from early intervention efforts to minimize cognitive losses during the first year after SCT and to maximize potential recovery.

Early treatment is associated with improved cognition in Hurler syndrome

OBJECTIVE

Hurler syndrome is the most clinically severe form of an autosomal recessive lysosomal disorder characterized by the deficiency of α-L-iduronidase. The resulting accumulation of glycosaminoglycans causes progressive multisystem deterioration, resulting in death in childhood. Umbilical cord blood transplantation from unrelated donors has been previously shown to improve neurological outcomes of children <2 years of age and prolong life. The purpose of this article is to determine whether age at transplantation can predict cognitive outcomes.

METHODS

Between June 1997 and February 2013, 31 patients with Hurler syndrome underwent umbilical cord blood transplantation and were evaluated at baseline and every 6 to 12 months thereafter. All 31 patients underwent complete neurodevelopmental evaluation (median follow-up = 7.3 years, range = 2-21.7) and a median of 7.0 evaluations (range = 3-18).

RESULTS

Younger age at transplantation was associated with improved cognitive function (p = 0.001), receptive and expressive language (p = 0.004 and p = 0.01), and adaptive behavior (p = 0.03).

INTERPRETATION

Early age at transplantation is a strong predictor of cognitive, language, and adaptive behavior outcomes. Children younger than 9 months at the time of transplant showed normal cognitive development. Our results demonstrate that early diagnosis is necessary for optimal outcomes and support the need for newborn screening, because most patients are not identified at this young age.

Randomized clinical trial of therapeutic music video intervention for resilience outcomes in adolescents/young adults undergoing hematopoietic stem cell transplant: a report from the Children's Oncology Group

BACKGROUND

To reduce the risk of adjustment problems associated with hematopoietic stem cell transplant (HSCT) for adolescents/young adults (AYAs), we examined efficacy of a therapeutic music video (TMV) intervention delivered during the acute phase of HSCT to: 1) increase protective factors of spiritual perspective, social integration, family environment, courageous coping, and hope-derived meaning; 2) decrease risk factors of illness-related distress and defensive coping; and 3) increase outcomes of self-transcendence and resilience.

METHODS

This was a multisite randomized, controlled trial (COG-ANUR0631) conducted at 8 Children's Oncology Group sites involving 113 AYAs aged 11-24 years undergoing myeloablative HSCT. Participants, randomized to the TMV or low-dose control (audiobooks) group, completed 6 sessions over 3 weeks with a board-certified music therapist. Variables were based on Haase's Resilience in Illness Model (RIM). Participants completed measures related to latent variables of illness-related distress, social integration, spiritual perspective, family environment, coping, hope-derived meaning, and resilience at baseline (T1), postintervention (T2), and 100 days posttransplant (T3).

RESULTS

At T2, the TMV group reported significantly better courageous coping (Effect Size [ES], 0.505; P = .030). At T3, the TMV group reported significantly better social integration (ES, 0.543; P = .028) and family environment (ES, 0.663; P = .008), as well as moderate nonsignificant effect sizes for spiritual perspective (ES, 0.450; P = .071) and self-transcendence (ES, 0.424; P = .088).

CONCLUSIONS

The TMV intervention improves positive health outcomes of courageous coping, social integration, and family environment during a high-risk cancer treatment. We recommend the TMV be examined in a broader population of AYAs with high-risk cancers.

Measuring symptoms as a critical component of drug development and evaluation in hematological diseases

With the rapid development of new therapies for patients with hematological malignancies, there is an increasing need for patient report of symptom status during all phases of drug testing. The patient's perspective on new treatments reflects treatment tolerability as well as symptom benefit, and may assist patients and clinicians in choosing treatments. Inclusion of patient-reported outcomes, more common in solid-tumor than hematological trials, provides early information about symptoms to guide decisions about appropriate dosing and supportive care needs. We provide a historical overview of the use of patient-reported outcomes and symptom assessment in solid-tumor and hematological drug development, and offer recommendations about methodological issues in the monitoring of symptoms in the drug development process in hematological clinical trials.

Psychosocial adjustment and quality of life of children after hematopoietic stem cell transplantation in South Korea

The purpose of this study was to describe the psychosocial adjustment and health-related quality of life (HRQoL) in children who received hematopoietic stem cell transplantation (HSCT) and to examine the relationship of children's characteristics with psychosocial adjustment and HRQoL in South Korea. Participants were 53 children who survived at least 100 days after HSCT, whose current age ranged from 5 to 17 years and their primary caregivers, mostly mothers. Parents completed the Korean version of Child Behavior Check List and Child Health Questionnaire 50-item parent-report version. Children with HSCT had significantly lower scores on the total scale for behavior problems and on most subscales than a normative sample, t = 2.09 to -4.75, P = .043 to <.001. Compared with the Taiwanese sample, scores in physical and psychosocial QoL (except bodily pain, mental health, and behavior) were significantly lower in children with HSCT, t = -2.91 to -9.84, P =.005 to <.001. Time since HSCT seemed to influence the physical (F = 8.61, P = .001) and psychosocial QoL (F = 3.98, P = .025) subscales. Social competence (r = .48, P = .001) and behavioral problems (r = -.37, P = .006) were associated with psychosocial QoL but not with physical QoL. After HSCT, children could benefit from psychological support to promote their adaptation to daily life and improve their QoL.

Reviewing the follow-up care of pediatric patients' status post-hematopoietic stem cell transplantation for the primary care pediatrician

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a treatment modality for many oncologic as well as non-oncologic disorders. Although the side effects of different chemotherapy regimens have been well studied by several oncology consortiums, limited data is available regarding the late adverse effects of HSCT. Furthermore, pediatric-focused post-HSCT follow-up guidelines for primary care pediatricians do not exist.

OBJECTIVE

To provide a summary of the most common late adverse effects of HSCT and give the primary care pediatrician guidance and evidence-based information for the screening and management of this patient population.

DESIGN

The literature was searched using PubMed using keywords, including pediatric bone marrow transplant, hematopoietic stem cell transplant guidelines, pediatric bone marrow transplant guidelines, and pediatric bone marrow transplant immunizations. The most relevant articles out of the hundreds of results were reviewed.

RESULTS

Based on 9 review articles from the Pediatric Clinics of North America and 3 articles from the Biology of Blood and Marrow Transplant Journal as well as their original references, a summary of the most common late adverse effects after HSCT was constructed. Pediatric HSCT patients have a high incidence of late adverse effects, with 93% of survivors having at least 1 late adverse effect after 7 years of follow-up.

CONCLUSION

Late adverse effects after pediatric HSCT are common and require close screening and monitoring, which can be done by the primary care provider along with the oncologist.

A multimethod assessment of psychosocial functioning and late effects in survivors of childhood cancer and hematopoietic cell transplant

Previous research in childhood cancer and hematopoietic cell transplant (HCT) survivorship has relied on the use of standardized questionnaires that assess symptoms of psychological functioning but do not sufficiently capture the cancer survivorship experience. Study aims are to quantitatively and qualitatively assess the psychosocial functioning of pediatric cancer and HCT survivors seen in a multidisciplinary survivorship clinic, determine survivorship concerns, and assess potential demographic and medical correlates of psychosocial outcomes. Data were collected using a retrospective chart review of a parent-report questionnaire of the child's psychological functioning, responses to a semistructured interview that qualitatively assessed adjustment to life after treatment, and documented medical late effects. Results indicated the majority of survivors had healthy psychological adjustment based upon a parent-report questionnaire. However, nearly 72% of survivors reported 1 or more survivorship concerns during the interview, with the primary concerns being current and future health or physical functioning, including the possibility of cancer recurrence. A content analysis of the interview responses indicated HCT survivors had more school or cognitive functioning concerns compared with survivors who did not have an HCT. Further research should use survivorship-specific measures to better identify survivors at risk and determine the impact of late effects on their quality of life.

Health-related quality of life (HRQoL): the impact of medical and demographic variables upon pediatric recipients of hematopoietic stem cell transplantation

BACKGROUND

The trajectory of Heath-Related Quality of Life (HRQoL) in pediatric recipients who have undergone hematopoietic stem cell transplantation (HSCT), as well as the demographic and medical factors that predict HRQoL, has lagged behind the adult research.

METHODS

A prospective longitudinal study of HRQoL in pediatric HSCT recipients was conducted with 95 patients at the Columbia University Medical Center between 2002 and 2009. Both children and parents completed the PedsQL 4.0 prior to HSCT and at days 100, 180, and 365-post-HSCT.

RESULTS

The majority of patients and their parents reported linear improvements in HRQoL in the first year post-transplant; however, a portion of patients were in the at-risk group at each time point. Latent growth modeling was utilized to examine demographic and medical factors that predicted initial HRQoL and its trajectory. Older age at transplant significant predicted lowered HRQoL at baseline for self- and parent-report. Female gender significantly impacted lowered self-reported physical HRQoL over time. Ethnicity was a significant predictor of HRQoL at baseline and over time for self- and parent-report, with African-American children reporting the highest HRQoL; whereas, the worst decline in psychosocial HRQoL was often reported by parents and children of Asian descent.

CONCLUSION

This research identifies the significant impact of ethnicity upon HRQoL following pediatric HSCT. It is likely that an individual's pre-morbid experiences and expectations, particularly with regard to culture, behaviors, and values, influence the parent and child's perceptions and expectations of the HSCT process.

NCI, NHLBI/PBMTC First International Conference on Late Effects after Pediatric Hematopoietic Cell Transplantation: health-related quality of life, functional, and neurocognitive outcomes

The purpose of this manuscript is to summarize issues relevant to health-related quality of life (HRQL), physical function, and neurocognitive function for survivors of pediatric hematopoietic stem cell transplantation (HCT). The physiologic and psychological demands of HCT and its sequelae have the potential to substantially alter HRQL. When compared with research on adult HCT recipients, research in pediatric HRQL following HCT has lagged considerably. Initially, this lag was because of limited validated questionnaires, small numbers of affected patients, and a general lack of salience for the topic relative to traditional endpoints, such as transplant-related toxicity and potential mortality. The percentage of childhood HCT survivors with physical disability ranges from 7% to 17% in studies where the outcome was based on clinician or self-report measures, to over 40% in studies where the outcome was based on a directly measured physical performance task. Direct and comprehensive measures of physical performance may help further clarify the proportion of individuals who have subclinical problems amenable to intervention before apparent functional loss becomes a problem. There is a need to include longer term survivors in such an assessment. In terms of neurocognitive function, the majority of reports demonstrate relatively good function in survivors. However, it is clear that little or no data on outcomes beyond 5 years posttransplant have been obtained, and clinicians working with this population remain concerned regarding the cognitive functions of these survivors. Research focused on these domains should attempt to better understand the prevalence of the problem using child self-report and direct measurements of function, standardize measurement methods, and tools across trials, obtain longer term evaluations and begin to consider interventional trials.

Health-related quality of life of hematopoietic stem cell transplant childhood survivors: state of the science

The notion of health-related quality of life (HRQoL) holds unique significance in the treatment of patients who have undergone hematopoietic stem cell transplantation (HSCT). Not only is transplant procedure inevitably associated with immediate and late medical effects along with high mortality and morbidity rates, but it can also significantly affect the HRQoL for the patient and family. This review of literature will assist advanced practice nurses and pediatric oncology nurses in distinguishing and targeting interventions for patients and families who are at high risk of encountering distress during and following HSCT. It provides information on the assessment of pre-HSCT variables to identify patient subgroups in need of more aggressive supportive care to improve HRQoL during transplant. Furthermore, it serves as a guideline for developing interventional strategies and the role of the advanced practice nurse and pediatric oncology nurse caring for the patient throughout and following transplant.

Psychological effects of hematopoietic SCT on pediatric patients, siblings and parents: a review

Although hematopoietic SCT (HSCT) has become standard therapy for many life-threatening disorders of childhood, there is little research on the psychosocial ramifications of HSCT on patients, siblings and parents. Pediatric patients experience numerous psychological reactions throughout hospitalization, the procedure and recovery process: anxiety, depression, behavioral and social problems, and post-traumatic stress reactions. Similarly, sibling donors are at risk of developing emotional disturbances such as post-traumatic stress reactions, anxiety and low self-esteem. Parental distress, anxiety and depression levels are often increased as a result of their child undergoing the HSCT process. The distress and anxiety may be even greater for parents whose healthy child also becomes part of the HSCT process through donating their marrow. Thus, it is critical to develop interventions for pediatric patients and their families. There is, however, minimal research of interventions aimed at decreasing distress and improving emotional and psychosocial functioning for children undergoing HSCT, siblings and parents. Cognitive-behavioral interventions are the most researched treatment approaches for children with cancer and chronic illness and these are promising in improving emotional distress, compliance with treatment and behavioral problems associated with HSCT. Appropriate arenas in which pediatric patient interventions may focus include social skills and emotional well-being. Familial interventions that aim to enhance protective factors, improve communication, and decrease parental anxiety and depression are crucial, and cancer-specific interventions may serve as a template for the development of HSCT-specific interventions.

The burden of cure: long-term side effects following hematopoietic stem cell transplantation (HSCT) in children

Children who survive hematopoietic stem cell transplantation (HSCT) are at risk for an inordinate number of long-term side effects. Late effects can be secondary to the underlying diagnosis for which the transplant is performed, prior treatment of the disease, the transplant preparative regimen, treatment of the complications of transplant, and immunologic interactions between the graft and the host. This article describes the risks and manifestations of the most commonly reported late effects in survivors of pediatric HSCT.

The quality of life of adult survivors of childhood hematopoietic cell transplant

Survival rates after myeloablative hematopoietic cell transplantation (HCT) in childhood have improved. We conducted a cross-sectional study evaluating the quality of life (QOL) of 214 adult survivors of a childhood HCT compared with controls using standardized self-report measures with strong psychometric properties to evaluate physical function, psychological function and cognitive symptoms. From these results we conducted a multivariate analysis of risk factors. This analysis for physical functioning showed poorer function among myeloid disease survivors compared with patients with all other diagnoses (P=0.02), men functioned better than women (P=0.05) and those >18 years after transplant functioned more poorly than those <18 years after transplant (P=0.05). Psychological functioning showed that those who received more therapy and females were more likely to be depressed (P=0.03) and (P=0.005). Perceived cognitive symptoms showed that female survivors had more symptoms than male survivors (P=0.01), and those receiving more preceding therapy compared with those with less preceding therapy (P=0.001) or cranial irradiation compared with those without cranial irradiation (P=0.002) had more perceived cognitive symptoms. Overall, these data indicate that the majority of adult survivors of a childhood transplant are functioning well, but some have problems that need to be addressed.

Behavioral, social, and educational outcomes after pediatric stem cell transplantation and related factors

BACKGROUND

The purpose of the current study was to investigate longitudinally children's behavioral and social competence outcomes up to 2 years after pediatric stem cell transplantation (SCT) and related factors.

METHODS

Ninety-nine mothers and 24 youths completed standardized questionnaires (Child Behavior Checklist [CBCL] and Youth Self-Report [YSR]) pre-SCT, and 12 and 24 months after SCT; 26 teachers completed Teacher Report Form (TRF) at 24 months. Information regarding clinical (eg, diagnosis, cranial radiation, graft vs host disease [GVHD]), child (eg, age, sex, physical health), and familial (eg, maternal age, education, distress) factors was also obtained.

RESULTS

Linear mixed regression models with compound covariance structure followed by adjusted pairwise analyses yielded significant improvements from pre-SCT to 1 and 2 years after SCT in total scores; in externalizing and internalizing scores from pre-SCT to 2 years after SCT; and in total competence from pre-SCT to 1 year after SCT. Child's physical health, maternal age, and depression were found to be significantly associated with the total, internalizing, and externalizing CBCL scores, whereas GVHD, mother's age, and time since diagnosis were associated with CBCL competence scores. Diagnosis, cranial radiation, GVHD, child's physical health, and maternal age and education were associated with YSR total behavioral and competence scores. Finally, total TRF scores were associated with time since diagnosis; TRF educational and adaptability scores were associated with maternal education, age, and distress.

CONCLUSIONS

Clinical, personal, and familial factors must be considered to understand the psychosocial outcomes of these survivors up to 2 years after SCT. This study has important implications for psychosocial interventions for this population.

Longitudinal health-related quality of life outcomes and related factors after pediatric SCT

Our purpose was to investigate longitudinally health-related quality of life (HRQOL) outcomes and related factors up to 2 years post-pediatric SCT. A total of 99 mothers of patients, aged 1.5-17 years, completed two standardized HRQOL questionnaires, generic and disease specific (DS), about the child, and reported on their own symptoms of depression and family function pre-SCT, 12 and 24 months post-SCT. Clinical (diagnosis, radiation), child (age) and family (maternal depression) information was also obtained. Significant improvement in physical and psychosocial HRQOL from pre-SCT to 1 or 2 years post-SCT was reported. Survivors of ALL were reported to have poorer physical and psychosocial HRQOL than survivors of solid tumors on the DS measure. Maternal depression was negatively associated with physical and psychosocial HRQOL. Maternal education (higher) at pre-SCT predicted improvements in physical domains 2 years post-SCT; mother's age (older) and child's age (younger) also predicted improvements of physical and emotional HRQOL. We conclude that survivors of pediatric SCT improved physical and psychosocial HRQOL by 1 and 2 years post-SCT. Older survivors whose mothers are younger and distressed, with lower education at SCT have compromised HRQOL compared to other survivors. This study has important implications for the care of SCT survivors and their families.

Neuropsychological outcome in very young hematopoietic SCT recipients in relation to pretransplant conditioning

Stem cell transplantation involves conditioning with TBI and/or intensive chemotherapy, which may cause long-term neuropsychological deficits, particularly in children treated at a very young age. The aim of this study was to investigate whether very young children who receive chemotherapy-based conditioning only (BUCY) may have a more favorable neuropsychological outcome than children conditioned with TBI-CY. Twenty-two children who underwent allogeneic SCT at 0.4-3.6 years of age were subject to an extensive neuropsychological assessment at an average of 6.5 years post-therapy. The test results of 10 children exposed to BU were compared to the results of 12 children who had received TBI. Ten of them had received single-dose TBI, whereas two had received fractionated TBI. The BU group performed at age level on verbal measures, but tended to score below age level in the executive and visuo-spatial domains (P<0.01). By comparison, children treated with TBI had more pervasive neuropsychological impairments, including motor deficits (P<0.01) and varying degrees of perceptual (P<0.05), executive and cognitive (P<0.05) problems. In conclusion, children transplanted at a very young age had a more favorable neuropsychological development if conditioned with BUCY than if conditioned with single-dose TBI-CY.

Cognitive and Academic Consequences of Stem-Cell Transplantation in Children

Purpose

To describe cognitive and academic outcomes in survivors after pediatric stem-cell transplantation (SCT) through 5-years post-SCT.

Patients and Methods

A battery of neurocognitive measures were administered before admission and at 1, 3, and 5 years post-SCT for 268 patients who underwent SCT; the study sample is comprised of 158 patients who survived and were evaluated at 1-year post-SCT. Random coefficient models were generated to depict change over time, and to test differences in slope and intercept for medical and demographic predictor variables.

Results

In the cohort as a whole, no significant changes were seen in global intelligence quotient and academic achievement. Despite the overall stability, some significant differences in slopes were found based on diagnosis, type of transplantation, use of total-body irradiation (TBI), and presence of graft-versus-host disease (GVHD). However, these differences were small, and of limited clinical significance. In comparison, differences as a function of socioeconomic status (SES) were much larger. SES was a significant determinant of all cognitive and academic outcomes, and the effect size generally dwarfed that of other significant predictor variables. Age, which had previously been identified as an important determinant of outcome, was not significantly predictive of outcome in this cohort.

Conclusion

The procedure of SCT entails minimal risk of late cognitive and academic sequelae. Subgroups of patients are at relatively higher risk: patients undergoing unrelated donor transplantation, receiving TBI, and those who experience GVHD. However, these differences are small relative to differences in premorbid functioning, particularly those associated with SES.

Using Q-methodology to understand perceived fatigue reported by adolescents with cancer

Although fatigue is an unpleasant symptom commonly experienced by pediatric oncology patients, it also tends to be under-recognized and under-treated. A conceptual understanding of how patients perceive fatigue is beneficial for better identification and treatment planning. The purpose of this study was to understand how adolescents with cancer perceive their fatigue and to explore potential factors influencing their perceptions by using Q-methodology. The sample included 15 patients (ages 12-18 years) from the Chicago metropolitan area who were receiving cancer treatment. All participants completed a 37-statement Q-sort task. Data were analyzed by using PQMethod computer software. Results identified three descriptors of perceived fatigues reported by adolescents: energy and related capacity for physical functioning, psychosocial effects, and anemia-specific concerns. Appropriate referral for patients with the latter two descriptors of fatigue was recommended.

Health-related quality of life of pediatric patients receiving allogeneic stem cell or bone marrow transplantation: results of a longitudinal, multi-center study

The results of a 5-year longitudinal prospective study about the health-related quality of life (HRQL) of pediatric patients receiving allogeneic bone marrow or stem cell transplantation (BMT) are described. The patients' HRQL was assessed twice before, and five times after BMT, the end point being 1 year after BMT. For the measurement of HRQL, standardized questionnaires were completed by patients, parents and physicians. The final sample consisted of 68 patients aged 4-18 years, of which 19 were lost in the course of the study owing to relapse, transplant rejection and/or death. The worst HRQL was seen shortly after transplant and HRQL thereafter improved steadily, although the improvement was not always linear and not all patients drew benefit from this average positive evolution. Compromised emotional functioning, a high level of worry and reduced communication during the acute phase of treatment had a negative impact on HRQL 1 year after BMT. Nausea and pain during the acute phase of treatment did not have an effect on later HRQL. The interobserver agreement of HRQL reports between parents and their children was moderate to good, and generally better than child-physician and parent-physician agreement.

Quality of life of children following bone marrow transplantation: critical review of the research literature

Children's quality of life (QOL) following bone marrow transplant (BMT) is an important but poorly understood concept. The aim of this paper is to critically review all research study designs to determine the QOL of childhood BMT recipients and to identify implications for research, practice and theory. The studies' methodological quality was evaluated separately by two investigators according to a set of formal criteria modified from Hoodin and Weber (Psychosomatics 44 (2003) 181). The review yielded one retrospective, one cross-sectional, six descriptive surveys and two prospective longitudinal study designs. The studies included 568 childhood BMT recipients ranging from 0.8 to 33 years. Only one study used a generic and disease-specific, psychometrically sound, QOL measure. Timing of assessments ranged from pre-BMT to 21 years following BMT. Due to the poor methodological quality, rendering conclusions across the studies was challenging. While the available evidence seems to suggest children experience good QOL following BMT, several studies found BMT to have a negative impact on various aspects of QOL. These results appear to be influenced by timing and type of measurements undertaken. Ultimately, there is a need for larger, more methodologically rigorous trials using prospective longitudinal study designs with pre- and post-measures to examine all QOL domains in children.