Pre-Transplant Psychosocial Assessment and Outcomes of Allogeneic Hematopoietic Cell Transplantation in Adults

Patients under consideration for allogeneic hematopoietic cell transplantation (HCT) undergo comprehensive evaluation, including psychosocial assessment, to evaluate their candidacy for transplant. Psychosocial factors such as presence of availability of a consistent care-partner, mental health needs, psychological issues such as depression and severe anxiety, and compliance can impact risks of toxicity and adverse outcomes including survival. However, instruments to objectively characterize psychosocial status in this population are generally lacking. Our group has previously assessed the Psychosocial Assessment of Candidates for Transplant (PACT) scale, originally developed for solid organ transplant recipients, to screen for psychosocial risk factors in allogeneic HCT patients (Foster et al, BMT, 2009). The PACT captures information in four domains (social support, psychological health, lifestyle factors, and patients understanding of the transplant process). The overall impression of the patient's suitability for transplantation is assigned a final PACT score ranging from 0 (poor candidate) to 4 (excellent candidate). We conducted a retrospective cohort study of 404 adult allogeneic HCT recipients (median age 50 [range, 18-73] years) between 2003 and 2014 at our institution to evaluate the association of PACT scale with other baseline clinical and sociodemographic factors and quality of life (QOL) prior to HCT, and its association with HCT outcomes. Patients were predominantly male (54%), White (89%), had acute leukemia/MDS (77%), had unrelated donor (55%), and received myeloablative regimens (78%). Based on ZIP code of residence, median annual household income for our cohort was $49,159 and 80% resided in Rural Urban Commuting Area designated urban area. Final PACT rating was poor/borderline (0-1) in 21 (5%), acceptable (2) in 87 (22%), good (3) in 177 (44%), and excellent (4) in 119 (29%) recipients. Significantly higher PACT ratings were observed in patients who were White (P=0.004), had higher household income (p=0.019), higher Karnofsky performance score (P=0.011), and low risk HCT-Comorbidity Index score (P=0.007). Final PACT rating was weakly correlated with the pre-HCT FACT BMT total QOL score (R=0.22), including its subdomains. A trend towards more days alive and outside the hospital in the first 100 days post-HCT was seen in patients with higher final PACT score (median 58, 65, 66, and 70 days for scores 0-1, 2, 3, and 4) in both univariable (P=0.07) and multivariable (P=0.09) analysis. At 1-year after HCT, cumulative incidence of non-relapse mortality for patients with PACT score 0-1 was 33%, for score 2 was 24%, for score 3 was 27% and score 4 was 16%. The 1-year overall survival probability for the four groups was 57%, 60%, 59% and 67%, respectively. In multivariable analysis that adjusted for patient and disease characteristics (including race/ethnicity, household income, place of residence and pre-HCT QOL), final PACT rating was associated with non-relapse mortality (HR 0.82 per point increase [95% CI, 0.69-0.98], P=0.03), but not with overall survival (HR 0.91 [95% CI, 0.79-1.05], P=0.18). There was no association between final PACT rating and neutrophil or platelet engraftment, acute or chronic graft-versus-host disease, or relapse. In conclusion the PACT scale provides prognostic information for NRM independent of clinical and other sociodemographic factors as an indicator of psychosocial adjustment post-HCT. The PACT scale can serve as a useful tool for screening adult patients for psychosocial risk factors prior to allogeneic HCT and may identify patients who need additional social support and resources to minimize risks of mortality after transplantation.