BACKGROUND
Hematopoietic stem cell transplantation (HSCT) is standard treatment in recurrent lymphoma, with ~50 000 hematopoietic stem cell transplants performed annually worldwide.1 The 5-yr cancer-specific survival continues to improve,2 however, for many at high cost. At initial diagnosis, patients with lymphoma are treated with anthracycline-based chemotherapy protocols. With recurrence, HSCT is the only curative intervention involving peripheral stem cell collection, another high-dose chemotherapy, and then stem cell infusion. Stem cell engraftment requires prolonged recovery (4+ wk) during which patients are bedfast, critically ill with hemodynamic and major organ instability. In the short-term, decreased functional status and poor quality of life (QOL) are universal. In the longer-term, with organ toxicities, HSCT survivors develop cardiovascular risk factors at rates 7.0-15.9 times greater than their matched controls,3,4 with subsequent 5.6 times greater risk of cardiovascular disease (CVD) events including myocardial infarction, heart failure, and stroke.
Aerobic exercise improves overall QOL and facilitates physical recovery in HSCT populations. However, this single intervention cannot adequately address multiple CVD risk factors, nor influence future events. A recent position statement from the American Heart Association recommends an approach based on the cardiac rehabilitation (CR) model5 that has been beneficial in patients with early breast cancer.6 In addition to clinical exercise physiologists, CR commonly involves multidisciplinary teams (MDTs) of dieticians, social workers, pharmacists, nurse practitioners, and cardiologists synergistically promoting heart-healthy lifestyle and reducing CVD risk. We have previously shown that CR improves multiple physical metrics in HSCT.7 In brief, patients with recurrent lymphoma were sequentially referred to CR. Activity protocol testing was performed at three time points: before HSCT, 6 wk following HSCT, and 14 wk post-HSCT (Figure). After HSCT, CR was an 8-wk program of supervised moderate aerobic activities and light resistance training. At 14-wk testing, we observed significant improvements compared with baseline, concluding that with CR, HSCT survivors can meet or even surpass baseline functioning. However, in traditional CVD populations, participation in CR is often poor, influenced by multiple individual factors.8 Accordingly, we studied perspectives of HSCT patients with recurrent lymphoma who participated in this CR program.
METHOD
Following ethical approval from Health Research Ethics Board of Alberta ID#: CC-16-0503, patients were mailed an invitation letter. Ten interviews were conducted in a private setting and using interpretive description, three key themes were identified.
All procedures were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
RESULTS
PERCEPTIONS OF CV RISK AND PRIORITIES
Participants reported the immediate issues associated with HSCT were their main priority, rather than theoretical future risk of CVD. However, some expressed CR as a means to convey their appreciation:
I felt so committed to them, that was part of the reinforcement, part of the motivation. But it was a quid pro quo ... [the nurse practitioner] especially was really committed to me ... I would stand on my head for her and that team. Because they, well, they saved me.
Among those previously active, CR participation was a priority. In addition to exercise, patients could choose to attend via face-to-face interactions, written information, or group sessions. While some initially did not believe these sessions were useful, others reported benefits, especially where overlap of symptoms common to both CVD and HSCT occurred, such as energy conservation.
PERCEPTIONS OF CR ON HSCT RECOVERY
Much of participant reflections dealt with the debilitating treatment effects associated with HSCT. For many, returning to exercise exposed the marked decline from pre-HSCT status:
One thing that shocked me with the transplant is how weak I got. Once I had the transplant, and crashed, if you tried to tell me to exercise, I would have told you to piss off.
Observing their strength improving as the CR program progressed provided patients a tangible motivation to continue.
CR AS A COPING MECHANISM
As HSCT was a long and difficult experience for most, coping and success during recovery were multifactorial processes influenced by goal setting, positive attitude, and the CR program itself:
I had a goal for admitting one of my students to the bar the first week of July of that year. And so, I did everything humanly possible to get myself in shape ... I had to be fit-mentally and physically fit.
Remaining positive and maintaining hope through recovery were seen as instrumental:
As far as hope ... [sigh] attitude going in, or during ... the whole treatment and everything else, in my mind, makes a huge difference ... just in terms of believing that you're gonna get out the other side.
Here, CR team members were especially important. Participants felt they had an additional team beyond the HSCT treatment team supporting them during recovery and coaching them to future health.
DISCUSSION
Compared with all cancer survivors, those undergoing HSCT are likely the highest-risk group overall for concurrent and subsequent treatment-related cardiac events. A recent position statement from the American Heart Association recommends a risk-based cardio-oncology care delivery model based on CR programming.5 Oncology guidelines recommend evaluation and management of risk factors such as smoking, hypertension, diabetes, dyslipidemia, and obesity.9 However, oncology teams are rarely sufficiently experienced to provide this specialized support. To our knowledge, we are the first to describe both physiological and psychological experiences of high-risk patients with cancer referred to CR. Cancer-specific rehabilitation centers are few and only in major urban centers. Thus, CR represents an optimal service model available in many settings, including telehealth, to address the complex needs of high-risk cancer populations.5,9 A noteworthy finding was the powerful connection to both the HSCT oncology and CR MDTs. Both offered support during an extremely difficult time, aiding both emotional and physical recovery.
Approximately 18 million cancer survivors were expected in the United States by 2020,10 struggling daily with persistent debilitating symptoms and exponential CVD risk. Cardio-oncology is a field in relative infancy but with great opportunity to reduce morbidity and mortality. As survivors have diverse needs associated with initial diagnosis and subsequent treatments, supportive CVD care should be personalized according to the degree of symptoms and accumulating risk. CR MDT care represents the future health promotion model for high-dose and high-risk cancer survivors with their extensive knowledge of proven approaches. Cancer and cardiovascular MDTs are key to patient coping and survivorship and could provide complementary efforts in effective CVD risk reduction before, after HSCT, and lifelong.
Derek Rothe, MN, RN (NP Adult)
Kara Schick-Makaroff, PhD, RN
Alexander M. Clark, PhD, RN
Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta, Canada
Nanette Cox-Kennett, MN, RN (NP Adult)
Cross Cancer Institute, Edmonton, Alberta, Canada
Drammy O'Rourke, PhD, BS/MS, RN (NP)
Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta Canada
ACKNOWLEDGMENTS
This research was made possible with trainee awards (D.R.) from the following institutions: Elaine Antoniuk Graduate Nursing Scholarship; Maurice and Edna Minton Endowment Fund; Aplastic Anemia and Myelodysplasia Association of Canada Scholarship, Canadian Nurses Foundation; Dean's Discretionary Fund, University of Alberta; Liz Lemire Memorial Scholarship, Alberta Registered Nurses Education Trust.
REFERENCES