Although previous research has shown that outpatient autologous hematopoietic cell transplantation (AHCT) is safe and feasible for patients with multiple myeloma (MM) – and could avoid the weeks of isolation and emotional distress associated with inpatient AHCT – results from a prospective cohort study of 140 patients suggest that there is no significant difference in quality of life (QOL) between the inpatient and outpatient settings. The findings were published in Biology of Blood and Marrow Transplantation.
“There is a general belief among transplant clinicians that patients experience the highest degree of distress while hospitalized for AHCT and [that outpatients] will generally have a better perception of well-being,” noted Massimo Martino, MD, from the Department of Hemato-Oncology and Radiotherapy at the Great Metropolitan Hospital in Reggio Calabria, Italy, and co-authors. The findings reported in this study, however, demonstrate that “the outpatient model of AHCT neither improves nor impairs global patient QOL, including physical and psychological status.”
The study included transplant-eligible patients with newly diagnosed MM receiving care at the Great Metropolitan Hospital between September 2012 and June 2016. Patients were excluded if they had Waldenström macroglobulinemia or immunoglobulin M MM, or disease that was refractory to induction chemotherapy.
Patients were invited to choose from two models of AHCT:
- early-discharge outpatient model (EDOM; n=64; median age = 57.14 years; range not provided)
- total-inpatient model (TIM; n=76; range = 56.9 years; range not provided)
Patients in the EDOM group were required to have access to a 24-hour caregiver, housing that was no more than a one-hour drive from the transplant center, and the capability of adequately performing (autonomously or under caregiver supervision) daily activities such as walking, eating, and personal hygiene.
All patients received bortezomib-based induction therapy in combination with corticosteroids with or without thalidomide in the outpatient setting. Conditioning therapy consisted of high-dose melphalan (220 mg/m2).
The researchers measured QOL with the self-administered Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT) at three timepoints: seven days prior to high-dose melphalan administration (baseline T1), seven days post-AHCT (T2), and 30 days post-AHCT (T3). FACT-BMT assesses QOL on several dimensions (including physical, emotional, functional, and social/family well-being); scores range from 0 to 148, with a higher score representing better QOL.
Differences in toxicity were “negligible” between the two AHCT approaches, the authors reported, except for episodes of fever and vomiting, which occurred more frequently in the TIM group than the EDOM group (p<0.05). Two patients (3.1%) in the EDOM group required rehospitalization because of fever. Treatment-related mortality was not reported.
At each time point, patients in the TIM cohort reported similar QOL scores than those in the EDOM cohort:
- T1: 86.05±15.54 vs. 85.62±14.51, respectively
- T2: 89.23±19.19 vs. 87.42±23.41
- T3: 87.96±13.6 vs. 83.98±20.2
The authors noted, “the global QOL of outpatients is not significantly different to that of inpatients during the whole period of transplantation.”
When the researchers compared QOL scores for specific domains of FACT-BMT, though, they observed statistically significant differences in physical and social/family well-being (see TABLE).
“Although outpatients do have higher levels of social/family well-being, these results are [offset] by the lower levels of physical well-being,” the researchers concluded.
At every timepoint, patients in the TIM group had higher physical QOL scores than patients in the EDOM group (7.67 vs. 5.89 for T1; 15.44 vs. 13.92 for T2; 12.96 vs. 8.84 for T3; p=0.0001). Physical well-being also appeared to differ between men and women (TIM = 11.7 vs. 12.28; EDOM = 8.97 vs. 10.92; p=0.027).
Mean scores on social/family-related QOL scales were higher for the EDOM group (22.92±13.29; 21.14±5.31; 21.64±4.58), compared with TIM (20.59±3.79; 19.52±5.12; 20.01±3.97; p=0.003).
The authors also observed similar patterns between inpatients and outpatients, wherein “both groups showed a relatively high QOL at [seven days post-AHCT], followed by a considerable decrease during the [30 days after] AHCT phase.” This pattern could be attributed to “the psychological relief of receiving transplantation, followed by the perception of increasing levels of general care provision and medical treatment,” they added.
“It is evident that good care provided by the caregivers and the support of the family positively influence the psychological dimensions of outpatients and affect the perception of their morbidity when they are in a home-based care modality,” the authors concluded.
The study is limited by its single-center, observational, non-randomized study design, as well as a narrow 30-day period of post-transplant follow-up.
The authors report no financial conflicts.
Martino M, Ciavarella S, De Summa S, et al. A comparative assessment of quality of life in multiple myeloma patients undergoing autologous stem cell transplantation through an outpatient and inpatient model. Biol Blood Marrow Transplant. 2017 October 12. [Epub ahead of print]