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The long road to recovery

Researchers probe factors that contribute to length of readjustment to normal life after bone-marrow or stem-cell transplantation
For bone-marrow and stem-cell transplant patients, recovery for activities such as gardening, may take three to five years depending upon physical and emotional factors. Photo by Todd McNaught

A new study from the Clinical Research Division finds that it takes three to five years for a leukemia or lymphoma patient to fully recover from a bone-marrow or stem-cell transplant, the only known cure for the diseases. The study, published in the May 19 issue of The Journal of the American Medical Association, identified physical and emotional factors that affect the recovery process, which will help health-care providers improve long-term outcomes for all patients who undergo the procedure.

Among 319 transplant recipients, including a group of 94 survivors who had no cancer recurrence after five years, researchers found that physical recovery occurred earlier than psychological recovery or return to work. One fifth of patients had no major limitations after one year, a number that increased to nearly two thirds after five years. Among the survivors who remained free of cancer, 84 percent had returned to full-time work after five years.

Contrary to what was expected, the researchers found that patients who had experienced cancer treatments such as chemotherapy or radiation before undergoing transplant experienced a more rapid recovery from stress and depression, suggesting that they went into the transplant procedure with coping skills developed during earlier cancer therapy.

LTFU Program

The study was led by Dr. Karen Syrjala, head of the division's Biobehavioral Sciences group, a component of the center's Long-Term Follow-Up Program. The program conducts research on and provides care for transplant recipients to help them obtain the best medical outcome and quality of life during and after transplant.

"The good news is that most patients do very well in the long term," Syrjala said. "But an important message to get out to patients, their families and their physicians and nurses is that a transplant is not a process that is over when the patient goes home in three months or even in one year. We want to inform patients and their families that there is a physical and emotional process of adjustment that takes three to five years.

"It's common for family members of cancer patients to say, 'okay, we're going to put everything into this and then it will be over in a year.' There is a wish to move on. The patient has that wish too, but you have to go with the process."

Bone-marrow or stem-cell transplantation involves first destroying a patient's diseased bone marrow and immune system with high doses of radiation and chemotherapy. The marrow and immune systems are reconstituted with a transfusion of stem cells or marrow from a tissue-type matched donor or from the patient's own blood or marrow, which is extracted prior to the procedure. Over the last 30 years, cure rates for transplantation — a technique pioneered and perfected at Fred Hutchinson — have risen dramatically, exceeding 80 percent for some cancers. This growing long-term survivor population now makes it possible to conduct studies such as this one, Syrjala said.

Progress reports

To evaluate recovery in transplant survivors, Syrjala and colleagues measured physical, emotional and work functioning before the procedure, at 90 days post-transplant and at one, three and five years after the procedure. Patients completed four types of written surveys that addressed physical limitations, depression, and distress or worry associated with their treatment and complications.

The researchers found that recovery after transplant occurred gradually. At some point during treatment or recovery, 22 percent of the patients had symptoms consistent with clinical depression, while an additional 31 percent had mild depressive symptoms. Higher levels of depression, lower levels of physical function and less satisfaction with social support before transplant increased the risk of impaired physical and emotional recovery after the transplantation. Women had increased risk for depression, treatment-related distress and delayed return to full-time work.

Positive lessons

Conversely, previous cancer therapy before beginning transplant seemed to facilitate recovery from the psychological aspects of this intensive treatment.

"One of the positive things we learned from this study is that despite the fact that some patients have serious medical risk factors before transplant, if they survive, these have no real influence long term on how well they do," she said. "If a high-risk patient has concerns that the transplant procedure might not be worth it, this is encouraging information for them to hear."

Syrjala said that she and colleagues are now focusing on recovery in survivors five to 15 years post-transplant and on treating the physical and emotional limits they found during recovery.

Coauthors of the paper were Drs. Shelby Langer, Janet Abrams, Barry Storer, Jean Sanders, Mary Flowers and Paul Martin, all of the Clinical Research Division. The National Cancer Institute funded the study.

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