Abstract
Psychosocial factors in patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) have long been recognized as important health determinants contributing to disparities in survival and transplant outcomes. Studies looking at the relationship between socioeconomic status (SES), race, and ethnicity have shown conflicting data on HSCT survival. A previous analysis at our center from 2003-2017 demonstrated that patients with high-risk psychosocial variables noted lower overall survival rates related to their pre-transplant score on the Transplant Evaluation Rating Scale (TERS). To address this challenge, our center implemented a three-step intervention for outpatient transplant recipients: 1) systemic pre-transplant screening with a requirement that majority of transplant physicians (3-MD sign off) sign off for high risk psychosocial factors, allowing time for interventions to improve risk factors, 2) pre-transplant mandatory caregiver contracts and education, and 3) drug/nicotine testing and allotted time for documentation of improved patient compliance. This study analyzes the impact of these protocols on HSCT outcomes among different psychosocial risk groups.
To assess the effects of psychosocial factors on allogeneic HSCT outcomes we analyzed 867 consecutive patients who received their first allogeneic HSCT at our center between 2014 and 2023. Disease and transplant related data were collected from our database where it was prospectively entered. In addition to transplant, disease and clinical related variables, we examined marital status, education level, smoking history, race, median house income, insurance status and TERS score. The psychosocial risks within the TERS score included but were not limited to psychiatric diagnosis, history of substance abuse or smoking, family/social support and overall compliance.
Patient characteristics included median age of 55 (range 18, 80), race (65% white,21% black, 9% Hispanic, and 5% Asian), marital status (69% married, 31% single), smoking history (39% current/previous, 61% never), HCT-CI (37% 0-2, 63% ≥3), and TERS risk (71% low, 23% moderate, and 6% high). Prior psychiatric diagnosis was documented in 27% of patients. 3-MD sign off (45% of patients) was required for 52 patients with psychological reasons and 425 for non-psychological reasons. Median follow up for survivors was 72 (20, 136) months.
Univariate analysis showed that in addition to older age, high disease risk (DRI), HCT-CI ≥3 and female donor-male recipient, patients with smoking history, single marital status and needing 3-MD sign off were all associated with worse OS. Smoking history, HCT-CI ≥3, history of psychiatric diagnosis and older age were associated with worsened NRM.
Multivariable Cox models were built for overall survival (OS), disease-free survival (DFS), relapses, and non-relapse mortality (NRM). Analysis showed that psychosocial factors were not significant independent predictors of adverse outcomes; however, smoking was associated with worsened OS (HR 1.23; CI 0.99-1.54) and DFS (HR = 1.25; CI: 1.01-1.54; p = 0.041). HCT-CI was found to be significantly correlated with OS (HR = 1.32; CI: 1.04-1.68; p = 0.023) and NRM (HR = 1.56; CI: 1.10-2.21; p = 0.014).
Results show that the implementation of our three-step intervention decreased the impact of psychosocial factors on HSCT outcomes. There was also no difference in overall outcome based on socioeconomic status, insurance status, education level, race or ethnicity. These results suggest that psychological and psychosocial interventions can effectively reduce the risk level of patients previously considered high-risk and historically perform poorly with allogeneic transplantation.
