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Unemployment rates high among survivors of allogeneic transplant
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SALT LAKE CITY — Long-term survivors of childhood allogeneic hematopoietic stem cell transplantation have higher unemployment rates than the general U.S. population, according to study results presented at the BMT Tandem Meetings.
Survivors experienced increased risk for unemployment if transplant occurred in late adolescence, they received total body irradiation-based myeloablative conditioning or had poor performance status on the Lansky play-performance scale prior to cell transplant.
“Results of this study will increase awareness of clinicians regarding quality-of-life and employment outcomes among pediatric patients undergoing transplant for malignant and non-malignant conditions,” Neel S. Bhatt, MBBS, MPH, fellow in the department of pediatrics hematology/oncology/blood and marrow transplant at Medical College of Wisconsin, told HemOnc Today. “This study is just the first step toward learning about the impact of hematopoietic cell transplant on employment outcomes in this population.”
Employment status is associated with healthy recovery and quality of life among survivors of allogeneic HSCT.
Research surrounding employment outcomes of long-term survivors of childhood allogeneic HSCT and pre-HSCT risk factors associated with unemployment are scarce.
“Previously, our focus was mainly on how to improve survival after hematopoietic cell transplant. Now that the number of survivors is increasing, we are slowly learning about long-term complications,” Bhatt said. “Posttransplant employment status is an important marker of social and economic well-being of survivors and it needs to be studied in order to better characterize the quality of life posttransplant.”
Bhatt and colleagues evaluated records of 3,518 allogeneic HSCT recipients from the Center for International Blood and Marrow Transplant Research database. All survivors underwent transplant between 1985 and 2010, were aged younger than 18 years at the time of transplant (median age, 13), survived at least 1-year posttransplant and were aged older than 18 years at their most recent assessment.
Among the survivors, 42% were female, 66% were white, 61% received HSCT for malignant diseases and 50% received total body irradiation-based myeloablative conditioning regimens.
Researchers compared unemployment status rates of survivors with national employment data from the Bureau of Labor Statistics. Researchers used multivariable analysis to determine preallogeneic HSCT risk factors associated with unemployment. Analysis of risk factors included only survivors aged 18 to 27 years due to a limited number of events among survivors aged 28 to 32 years, the researchers noted.
The median follow-up time from HSCT was 11.6 years.
For full-time and part-time rates, researchers observed a steady increase in employment as age increased: 4% for 18 to 22 years; 29% for 23 to 27 years; and 41% for 28 to 32 years. The number of students steadily decreased as age increased: 58% for 18 to 22 years; 32% for 23 to 27 years; and 13% for 28 to 32 years.
Unemployment rates appeared stable over time but remained high in each age group: 37% for 18 to 22 years; 37% for 23 to 27 years; and 43% for 28 to 32 years. Unemployment rates appeared significantly higher than the general population between 1985 and 2017 (range: 3.8%-9.9%).
“The patient age at transplant was the most significant risk factor associated with higher unemployment rate,” Bhatt said. “We think children and adolescents are at higher risk for posttransplant complications as they undergo an intensive procedure during their formative years, although our findings are also likely reflective of the era of transplant.”
Longer-term follow-up data were available for patients transplanted in the 1980s and early 1990s. Bhatt noted the potential impact of previously used conditioning regimens, donor selection techniques and supportive care.
“Since the transplant process has significantly changed over time, it will be interesting to see if age continues to remain a significant factor in future studies,” Bhatt said. “Regardless, our study highlights the need for interventions for younger patients to allow them to follow their desired career path and achieve employment in adulthood.”
Other pre-HSCT factors associated with higher rate of unemployment included nonmalignant disease, bone marrow as a graft source and related donor type.
“With this study, we aim to understand the relationship between health-related quality of life and employment outcomes in this vulnerable population and learn about their ability to become productive members of society and whether they achieve their career goals,” Bhatt said.
Bhatt expects future studies to assess the following: longitudinal changes in quality of life and their impact on employment status and work performance posttransplant; to make changes in modifiable risk factors to prevent any effect on employment and quality of life; to identify an at-risk population; and design and implement vocational and interventions earlier in transplant course to prevent long-term declines in quality of life and subsequent financial toxicity.
“Next, we need to hear patients’ voices to know why they are unemployed, what their quality of life is and what could be done to help them,” Bhatt said. “Transplant also significantly affects several outcomes that are important to patients, including psychological, social-environmental, and health behavior aspects. We hope to see integration of quality of life and employment status as important treatment outcomes along with OS and DFS in transplant practice.” – by Melinda Stevens
Reference:
Bhatt NS, et al. Abstract 7. Presented at: BMT Tandem Meetings; Feb. 21-25, 2018; Salt Lake City.
Disclosures: Bhatt and the other authors report no relevant financial disclosures.