Physiologic Frailty in Nonelderly Hematopoietic Cell Transplantation Patients: Results From the Bone Marrow Transplant Survivor Study

Importance

Frailty results in decreased physiological reserve and diminished resistance to stressors; approximately 10% of those in the elderly population (those ≥65 years) are frail. High-intensity treatments and complications after hematopoietic cell transplantation (HCT) injure normal tissues and may increase the risk of frailty even among nongeriatric HCT patients.

Objective

To determine the prevalence of frailty in young adult HCT patients (18- to 64-year-olds) and siblings; and the impact of frailty on subsequent mortality in HCT survivors.

Design, Setting, and Participants

This cohort study, conducted in August 2015 examined 998 HCT survivors, who underwent transplant procedures between 1974 and 1998, who have survived at least 2 years after HCT, and 297 frequency-matched siblings. The study was performed at City of Hope or University of Minnesota with participants completing surveys at home or in the clinic. Hematopoietic cell transplantation survivors and siblings participating in the Bone Marrow Transplant Survivor Study (BMTSS) completed a frailty survey between February 13, 1999 and June 15, 2005 (median time since HCT: 7.9 years); HCT survivors were followed for subsequent mortality (median: 10.3 years from survey).

Main Outcomes and Measures

Prevalence and predictors of frailty; impact of frailty on subsequent mortality in HCT survivors. Frailty phenotype defined as exhibiting 3 or more of the following characteristics: clinically underweight, exhaustion, low energy expenditure, slow walking speed, and muscle weakness. The national Death Index, Social Security Death Index and medical records were used for mortality assessment as of December 21, 2011.

Results

The 998 HCT survivors were a mean (SD) of 42.5 (11.6) years of age, and the 297 matched siblings were 43.8 (10.9) years of age. The prevalence of frailty among young adult HCT patients exceeded 8%. The HCT survivors were 8.4 times more likely to be frail than their siblings (95% CI, 2.0-34.5; P = .003). Among HCT recipients, allogeneic HCT recipients with chronic graft-vs-host disease (GvHD) were at increased risk of frailty compared with autologous HCT (OR,15.02; 95% CI, 6.6-34.3; P < .001); resolved chronic GvHD (OR, 2.7; 95% CI, 1.1-6.9; P = .04). Cumulative incidence of subsequent all-cause mortality was 39.3% and 14.7% at 10 years for HCT recipients with and without frailty, respectively (P < .001). Frailty was associated with a 2.76-fold (95% CI, 1.7-4.4; P < .001) increased risk of subsequent mortality after adjusting for relevant prognosticators.

Conclusions and Relevance

The prevalence of frailty among young-adult HCT survivors approaches that seen in the elderly general population. Frail HCT survivors are at increased risk of subsequent mortality when compared with nonfrail survivors. This study identifies vulnerable populations needing close monitoring to anticipate and manage morbidity and prevent mortality.

Impact of Tailored Education on Awareness of Personal Risk for Therapy-Related Complications Among Childhood Cancer Survivors

Purpose

Survivors of childhood cancer carry a substantial burden of long-term morbidity; personal risk awareness is critical to ensure survivors' engagement in early detection/management of complications. The impact of education provided in survivorship clinics on survivors' understanding of their personal health risks is unclear.

Methods

Patients diagnosed with cancer at age 21 years or younger and at 2 or more years off therapy completed questionnaires about awareness of personal risk for therapy-related complications at T0 (first survivorship clinic visit) and at T1 to T5 (subsequent visits). After questionnaire completion at each clinic visit, survivors received education tailored to personal risk.

Results

A total of 369 survivors completed 1,248 visits (median, three visits; range, one to six visits). The median age at cancer diagnosis was 11 years (range, 0 to 21 years); the median age at T0 was 24 years (range, 5 to 57 years); 38% were white; 45% had leukemia; and 34% received hematopoietic cell transplantation. The cohort was at risk for a median of six (range, one to nine) complications. Awareness increased from 38.6% at T0 to 66.3% at T3. Generalized estimating equations (that adjusted for diagnosis, hematopoietic cell transplantation, race/ethnicity, and patient/parent education) showed significant gains in awareness from T0 to T1 (P < .001), T1 to T2 (P = .03), and T2 to T3 (P < .001) but no significant gain thereafter through T5 (P = .7). Predictors of low awareness included education less than a college degree (odds ratio [OR], 1.9; P = .02), longer time from diagnosis (OR, 1.03/year; P = .04), diagnosis of leukemia (OR, 2.1; P = .004), nonwhite race (OR, 2.8; P < .001), and risk for six or fewer complications (OR, 2.1; P = .002).

Conclusion

Risk-based education in a survivorship clinic significantly increases awareness of personal health risk through three sessions, with saturation thereafter. Vulnerable populations with minimal gain in awareness identified in this study could inform targeted interventions.