Quality of life after chemotherapy or hematopoietic cell transplant in follicular lymphoma: what's next?

Quality of life (QOL) outcomes research in hematopoietic cell transplant (HCT) has begun to gain momentum in the last decade. Cross-sectional and longitudinal studies assessing QOL have been done from the pre-transplant phase through 10 years of follow-up in both allogeneic and autologous HCT settings [1 – 3]. Most studies assess QOL with multidimensional questionnaires such as the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire – C30 (EORTC QLQ-C30) or other instruments with varying degrees of relevance to specifi c HCT issues. In these surveys, physical, social and mental well-being have been assessed and reported. Common to most studies in survivors of HCT are the observations that approximately 75% of HCT recipients return to baseline physical function after 1 year; up to 90% return to full-time work by 3 years; and most experience transient or minimal psychological problems. In this issue of Leukemia and Lymphoma , Andresen and colleagues report a cross-sectional QOL analysis of longterm survivors of follicular lymphoma (FL) [4]. Th eir analysis compared three diff erent cohorts previously described in separate studies: upfront chemotherapy (R-CHOP; rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) and radiotherapy for follicular lymphoma (FL), high dose chemotherapy followed by autologous stem cell transplant (ASCT) for relapsed FL, and a healthy German control [5 – 7]. Although limited by diff erences in the case mix of patients, this study showed that, compared to a healthy German cohort, QOL is modestly decreased for all patients treated for FL. Th e HCT cohort was also found to have the worst QOL. Th e long-term impact of cytotoxic therapy and stem cell rescue on QOL cannot be understated and must be integrated into patient counseling. In addition, this study highlights general limitations common to most QOL studies in HCT. Th e subjectivity and relatively low rates of follow-through in patient self-reporting and diff erences in QOL expectations at various time points in the disease and treatment process all complicate objectivity. It is clear that eff orts must be made to improve the assessment of QOL of patients and fi nd more eff ective interventions to enhance recovery. In an attempt to improve the objectivity of QOL assessments and effi cacy of QOL interventions for HCT recipients there has been a shift from passive intervention (printed materials) to more active intervention (internet-based assessments and survivorship care resources). A number of randomized trials using internetbased health communication applications have shown benefi ts in health outcomes in patients without cancer [8]. More specifi c to HCT survivors is the work of Syrjala and colleagues [9]. Using multidisciplinary expertise, this group have developed an internet-based tool for assessing and promoting behaviors to improve QOL in HCT survivors. Th e web resource has proven accessible and will be tested in a multicenter randomized controlled trial with the goals of reducing post-transplant depression and distress and improving adherence to a preventive care plan for survivors of HCT. HCT is a complex and dynamic process with signifi cant physical, social and mental consequences. Th ese issues require a multidimensional and long-term care plan for the survivor. It is likely that internet and mobile device applications will play a key role in the future success of survivorship care models.