Stem Cell Transplantation: Survivors Concerns
D. Kathryn Tierney, RN, PhD and Ranjana Advani, MD
The long-term health issues faced by survivors following stem cell transplantation (SCT) result from a combination of factors. These factors include the underlying disease, treatment prior to SCT, the preparative regimen employed for SCT, and treatment of complications following SCT. The long-term health issues can also vary depending on the source of stem cells, which may be autologous (from the patient) or allogeneic (from a donor).
While SCT survivors may face a number of health problems post-transplant, most survivors move on to enjoy a healthy life with excellent quality of life. Health care providers can help those SCT survivors facing ongoing health problems with coping and adaptation by providing education, counseling and aggressively treating active health problems.
Common concerns for both autologous and allogeneic SCT survivors include fatigue, decreased physical stamina, anxiety about relapse, fear of secondary malignancies, infertility, premature menopause, and struggles to reintegrate into their lives. Reintegrating into their lives may mean renegotiating role responsibilities within the family, which were altered during treatment. Autologous SCT survivors do not usually return to work until about six months post-transplant and this may be a year or more for allogeneic SCT survivors. For some SCT survivors, this long delay before returning to work can pose significant financial hardship.
One unique long-term problem faced by allogeneic SCT survivors is chronic graft versus host disease (GVHD). Chronic GVHD is an immune reaction of the donor's cells against the recipient's tissues. The risk of developing chronic GVHD is dependent on the type of donor (related or unrelated), the degree of donor-recipient matching (complete or partial match), presence or absence of prior acute GVHD and infectious complications. Chronic GVHD can affect almost any body tissue, but the most common sites are the skin, eyes, mouth and liver. The mainstay of therapy for chronic GVHD is immunosuppressive medications. A key component of caring for individuals with chronic GVHD is the careful selection of antimicrobial agents to prevent infectious complications while patients are receiving immunosuppressive therapy.
A consensus panel composed of members of the American Society of Blood and Marrow Transplantation, the European Group for Blood and Marrow Transplantation and the Center for International Blood and Marrow Transplantation Research developed guidelines to assist primary care providers in the monitoring and care of SCT survivors. The guidelines also contain recommendations for SCT survivors to assist them understanding their long-term health care needs.
- The following is a summary of the recommendations of the consensus panel:
- Recommendations for blood testing to assess organ function include liver function tests, creatinine and BUN, thyroid function tests, endocrine evaluation of the hypothalamic-pituitary-gonadal axis and a complete blood count with differential to monitor for secondary malignancies.
Blood testing for evaluation of possible complications following SCT include serum ferritin and lipid panel.
Other testing should be performed as indicated based on prior evaluations, history and current symptoms such as chest radiography, pulmonary function testing, and bone density testing.
Psychological evaluation should include an assessment for emotional distress, relationship distress, sexual dysfunction and employment concerns.
The complete list of recommendations can be found at www.cibmtr.org/Publications/physicians_guidelines
SCT survivors should also be educated on healthy lifestyle choices such as avoiding tobacco use, limited intake of alcohol, use of sun screen, beginning the American Cancer Society recommendations for screening 5-10 years earlier than the general population and exercise. One resource for healthy living can be found at www.ahrg.gov/consumer. (For References- See Appendix)
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