Digital life coaching could be feasible for patients during stem cell transplantation
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Patients with multiple myeloma who receive high-dose chemotherapy followed by autologous stem cell transplantation may experience diminished quality of life due to acute life disruptions and symptom burden.
Digital life coaching (DLC), an intervention through which trained coaches provide personalized well-being-related support by phone and text messaging, has been shown to improve quality of life for these patients.
However, DLC has not yet been evaluated during the period immediately before or after autologous stem cell transplantation (ASCT), which may be marked by intensification of symptoms and 2-week hospitalizations.
“Several studies show that the acute rise in symptom burden — including anxiety, insomnia and more — during the acute peri-ASCT period can have lasting effects even after these immediate symptoms resolve,” Rahul Banerjee, MD, FACP, assistant professor in the division of medical oncology at University of Washington and assistant professor of the clinical research division at Fred Hutchinson Cancer Research Center, told Healio. “For example, previous work by our group has shown that prescriptions for potentially inappropriate medications in older patients, such as benzodiazepines, tend to persist once started in this acute period. Worsened quality of life during the acute peri-ASCT period is similarly associated with long-term quality-of-life deficits and post-traumatic stress disorder.”
Banerjee and colleagues conducted a pilot study investigating the use of DLC during the peri-ASCT period. He discussed the study’s findings, the challenge of providing DLC during this period and the potential utility of this intervention.
Healio: What factors may compromise quality of life in patients with multiple myeloma who undergo chemotherapy followed by ASCT?
Banerjee: High-dose chemotherapy followed by ASCT is, by definition, the most intensive regimen that we offer to patients with any type of cancer. Based on several decades of research, multiple myeloma is one of the few cancers where we still employ ASCT for front-line consolidation in all eligible patients — not just those with high-risk or relapsed disease. Most ASCT-related toxicities occur during the first few weeks following transplantation: mucositis, low blood counts, infections and more. However, the fatigue and decreased appetite associated with ASCT can persist for several weeks or months. Finally, the time and energy devoted to ASCT can take a large practical toll on patients and their caregivers. For example, the majority of nonretired patients with multiple myeloma do not return to work following ASCT. All of these factors can significantly impair quality of life for patients after transplantation.
Healio: Your study was different in that it involved offering DLC to these patients during the acute peri-ASCT period. Why did you take this approach?
Banerjee: We decided that investigating a novel supportive care strategy during the acute peri-ASCT time period was warranted. The challenge with such an approach, of course, is these patients are generally hospitalized and actively recovering from the acute symptoms associated with myeloablative chemotherapy. For this reason, we started with a pilot study to assess the feasibility of our intervention during this period.
Healio: How did you conduct this study?
Banerjee: Patients in our pilot study were provided with 3 months of digital access to a certified life coach employed by a company called Pack Health. This 3-month period began at Day 5 before ASCT, immediately before patients came to the hospital for chemotherapy, and extended through the 2-week hospitalization and subsequent recovery period. Of note, all of our patients underwent ASCT in California, while all of the coaches were based in Alabama —so this was 100% a digital intervention implemented through phone calls, text messages and mailed materials. Coaches attempted to set up at least one structured phone call per week, but the patient decided the cadence and topics of coaching, which could vary during the 3-month period.
Healio: What did you find?
Banerjee: Our primary endpoint was feasibility, which we defined as at least one bidirectional DLC conversation per 4 weeks over the 16-week study period. Of 15 enrolled patients, two dropped out of the study before being paired with a coach or undergoing transplantation. Another two patients showed ongoing bidirectional DLC conversations for the first three but not the final 4-week period, so 11 out of 15 patients (73%) met our criteria for DLC feasibility. We also assessed patient-reported outcomes of quality of life, emotional distress and sleep. Although the quality-of-life nadir occurred during count nadir after ASCT, as expected, we were surprised to see that distress was highest at baseline before ASCT rather than during count nadir.
Healio: Are there patients for whom DLC might not be appropriate during the acute peri-ASCT period?
Banerjee: Our pilot study enrolled only patients who owned personal cellphones and spoke English. Expanding the potential of DLC to reach a broader patient population is an important next step both for us and for the coaching company. We did discover during our pilot study that our DLC timeframe beginning at Day 5 before ASCT was suboptimal for two reasons: first, because patient distress was already quite high by this point; and second, because it meant that many of the initial patient-coach conversations were happening while patients were hospitalized. I think asking anyone to open up to a relative stranger while hospitalized is impractical, let alone for patients with cancer. For our subsequent studies, we have moved the start point to Day 10 or earlier. This might help patients and coaches to establish more of a bond before the ASCT hospitalization itself.
Healio: What are the potential implications of these findings?
Banerjee: Now that the feasibility of DLC has been established through this pilot study, the next step is to investigate its efficacy. As such, we’ve launched a randomized phase 2 study of DLC vs. usual care. I'm lucky to have received funding through an ASCO Conquer Cancer Foundation Young Investigator Award for this study of 60 patients, which just completed patient accrual last month. If this phase 2 study shows that DLC can improve patient-reported outcomes during the peri-ASCT period, I think its convenience to patients and ease of implementation across centers offer big advantages in terms of its adoptability. If DLC doesn't show any improvement against usual care, we may consider other directions for this type of intervention. Importantly, Healthtree Foundation recently launched a similar coaching program for patients with multiple myeloma, with one important difference: the coaches in this study are themselves patients with myeloma rather than certified coaching professionals. Both approaches have their pros and cons, and — as I'm sure each type of coaching background may work better or worse for individual patients — I hope that both succeed.
For more information:
Rahul Banerjee, MD, FACP, can be reached at University of Washington, Paul Allen Center AC101, 185 Stevens Way, Seattle, WA 98195; email: banerjee@cs.uw.edu.
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Banerjee R, et al. JMIR Form Res. 2022;doi:10.2196/33701.
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