Oncology Nurses Must Understand the Later Effects of HSCT To Provide Adequate Survivorship Care

Stephany L. Rodriguez, RN, MS, NP

As the number of transplant patient survivors continue to grow world-wide, providing adequate long-term care for this population has surfaced as a problem, according to Stephany L. Rodriguez, RN, MS, NP. Furthermore, chronic graft-vs-host-disease (cGVHD) continues to present a challenge for patients and there is a score of other later adverse effects which require knowledgeable follow-up care as well.¹

“Transplant survivors have unique long-term health needs requiring knowledgeable follow-up care,” Rodriguez said, in a presentation during the 2022 Oncology Nursing Society Bridge. “Multidisciplinary and multispecialty collaboration remains critical.”

Rodriguez is a nurse practitioner at the University of California San Francisco. In her presentation at the ONS Bridge, “Survivorship After Stem Cell Transplant: Chronic Graft-vs-Host-Disease and Long-Term Follow-up Care,” she said, “Nobody tells patients what could possibly happen, they [often] have no idea how bad or how hard this could be.”

What Is Hematopoietic Stem Cell Transplant?

Hematopoietic stem cell transplant (HCT) is a procedure in which a patient receives healthy stem cells to replace damaged stem cells. Prior to undergoing HCT, a patient will receive conditioning treatment. Conditioning treatment may include high doses of chemotherapy, and sometimes radiation therapy, to prepare the body for transplantation. Following transplant, the new stem cells will travel to the bone marrow and begin the process of forming new, healthy blood cells (including white blood cells, red blood cells, and platelets). This process is called engraftment.

There are 2 types of transplantation that a patient may receive. The first is autologous transplantation, which uses a patient’s own cells to replace damaged cells after high intensity chemotherapy. This method relies on chemosensitivity. Patients who are most likely to receive this type of transplant include patients with myeloma, non-Hodgkin’s lymphoma, and Hodgkin’s lymphoma.

Patients may also receive allogeneic transplantation, which uses stem cells from a matching donor. These donated cells suppress the disease and restore the patient’s immune system. Patients who are most likely to undergo allogeneic transplantation include those with acute leukemia, myelodysplastic syndromes, myeloproliferative neoplasms, chronic myeloid leukemia, and chronic lymphocytic leukemia bone marrow failure disorders.

Long-Term Follow-Up of Transplant Survivors

According to Rodriguez, there is good news when it comes to transplant: there are now more stem cell transplant survivors than ever before. Further, with more than 60,000 HCTs performed annually, there is the potential for there to be more than 500,000 HCT survivors by 2030.

The challenge, therefore, remains in providing optimal care to survivors, both in transplant centers, and throughout community care. Late effects of transplant can affect morbidity, mortality, working status, and quality of life. Unfortunately, the life expectancy for 5-year transplant survivors is approximately 30% lower than the general population.² In addition, nearly80% of survivors will have or more late effect at 5 years post-transplant.

Many nurses may be familiar with GVHD for patients undergoing transplant; however, according to Rodriquez, there are a host of later effects that many patients are not prepared for.

These key later-effects can range from infections, secondary cancer, heart, and pulmonary problems and extend across endocrine and metabolic issues, bone health complications, sexuality or infertility issues, iron overload, “chemo-brain”, fatigue, cramps, sleep disturbances, as well as mental and emotional effects.

The rate of late fatal infections at 2 years after transplant are 55% for bacterial infections, 18% for fungal, 16% for viral, and 11% for multiple (P < .001).3

In terms of prevention, prophylaxis may be appropriate. Treatment options include include the following: antifungals (Azoles), antivirals (acyclovir), trimethoprim/sulfamethoxazole (Bactrim), atovaquone, dapsone, and antibacterial agents such as penicillin or evusheld. Rodriquez noted that there may be some questions regarding when to start vaccinations in the setting of transplant. COVID-19 and influenza vaccination should begin at 3 months, and other routine vaccinations may start at 6 months.

Undergoing transplant can also increase the risk of secondary malignancies. Patients undergoing HCST are a 3-fold higher risk of another cancer.4 Patients should keep routine cancer screenings to monitor any potential secondary malignancies.

Bone Health

Unfortunately, approximately 20% of transplant survivors will develop osteoporosis after 2 years. They are also at risk of compression fractures, especially in their spine or hip. Women are at greater risk than men. Additional risk factors include age, vitamin D insufficiency, GVHD, low sex hormones, and a sedentary lifestyle.

To help survivors maintain long-term bone health, they should be screened for their vitamin D levels and bone density. If concerns about a patient’s bone health should arise, the patient should be encouraged towards exercise, calcium and vitamin D supplements, bisphosphonates, and hormone replacement therapy.

Another possible complication is severe avascular necrosis. Risk factors may include steroids use and radiation and can be detected through an MRI. Treatment options include orthopedics. Patient undergoing transplant should be monitored for severe pain and join fractures, in particular at the hips and knees.

General Health

Many patients will experience fatigue. Paradoxically, exercise represents one of the best remedies to chronic fatigue, Rodriguez noted. However, strategic naps, reduced workloads, and treatments for underlying medical causes and pain are also important.

Other treatment strategies for general health issues include cognitive behavior therapy and sleep hygiene can be effective for sleep disturbances. Hydration and tonic water can help with cramping. For liver toxicities, patients should be advised to avoid alcohol and improve diet and exercise. Phlebotomy may be necessary for iron overload, and physical therapy or foot care can help with symptoms of neuropathy.

Patients are also at an increased of developing kidney problems; they should have their urine proteins periodically checked. They will require annual eye exams to screen for premature cataracts and dry eye syndrome (which can be managed with eyedrops and sunglasses). They will need to have regular dental exams and to understand that they may develop dry mouth and cavities, which may lead to later complications.

In addition, transplant may result in endocrine complications, such as low thyroid or diabetes, and mental health challenges. Patients may also experience brain fog and face short-term memory loss, slow thinking, word-finding difficulty, impaired learning, and executive function. It can take up to 5 years for these symptoms to improve, and patients may require cognitive rehabilitation, methylphenidate, and modafinil.

References

1. Rodriguez SL. Survivorship after stem cell transplant chronic graft vs host disease and long-term follow-up. Presented at: ONS Bridge; Sept 13-15, 2022; Virtual.
2. Martin PJ, Counts GW Jr, Appelbaum FR, et al. Life expectancy in patients surviving more than 5 years after hematopoietic cell transplantation. J Clin Oncol. 2010;28(6):1011-1016. doi:10.1200/JCO.2009.25.6693
3. Norkin M, Shaw BE, Brazauskas R, et al. Characteristics of late fatal infections after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2019;25(2):362-368. doi:10.1016/j.bbmt.2018.09.031
4. Kolb HJ, Socié G, Duell T, et al. Malignant neoplasms in long-term survivors of bone marrow transplantation. Late Effects Working Party of the European Cooperative Group for Blood and Marrow Transplantation and the European Late Effect Project Group. Ann Intern Med. 1999;131(10):738-744. doi:10.7326/0003-4819-131-10-199911160