Psychosocial Factors in Decision-Making of Patient Eligibility for Allogeneic Bone Marrow Transplantation.

Oncologists specializing in bone marrow transplants (BMT) make daily decisions about appropriate medical candidates for allogeneic BMT based on clinical criteria. It is not clear how, and if, patient eligibility decisions are made based on psychosocial criteria. Although setting limits of patient eligibility based on psychosocial criteria has been researched in solid organ transplantation, data is sparse in BMT. This report focuses on physician responses to a psychosocial survey. An IRB approved survey was mailed to members of the ASBMT (North America) mailing list. Of 704 members, 663 were deemed viable respondents: excluded were non-physician members and physicians specializing in research or not working with allogeneic BMT patients. These surveys were mailed in April 2004. As of 7/6/04, 253 surveys were returned, representing a 38% response rate. Average age of responders was 47 years. Average number of years experience in BMT was 14, with a range of 2–39 years. 17 case vignettes were presented. These vignettes asked whether or not it was appropriate to proceed with allo BMT (assuming an appropriate donor was available) based on a specific psychosocial problem. In virtually every case vignette, at least 10% of respondents stated they would not proceed with allogeneic BMT based on the issues raised in the vignette. In seven case vignettes, the majority of respondents stated that they would recommend not proceeding with BMT. The general theme/construct of these 7 vignettes appears to be ability to comply with treatment plans. Specifically, the following were case vignettes in which the majority of respondents recommended not to proceed with transplant: no caregiver available to assist with the patient post-transplant (do not proceed = 70%); the patient is actively alcoholic (do not proceed = 62%); the patient is non-compliant (do not proceed = 75%); the patient is currently suicidal (do not proceed = 84%); the patient is currently using addictive illicit drugs (do not proceed = 73%); the patient has mild dementia (do not proceed = 55%); the patient cannot pay for the transplant (do not proceed = 52%). Conversely, the following case vignettes were less worrisome to the survey respondents, and in general represented surmountable psychosocial and/or clinical issues. These vignettes included; a history of prior suicidal attempts although not currently suicidal (proceed with transplant = 86%); controlled schizophrenia (proceed with transplant = 83%); daily marijuana use (proceed with transplant = 82%); smokes tobacco (proceed with transplant = 79%); morbid obesity (proceed with transplant = 71%); major depression (proceed with transplant = 84%). These findings underline the importance of post-transplant longitudinal care in determining the ultimate success of an allogeneic BMT, and underscore their importance in patient eligibility decision-making. These findings also illustrate that psychosocial variables play a significant role in determining patient eligibility for allogeneic BMT and that there is no clear-cut consensus on this topic, highlighting the need for ongoing clinical research.