Hematopoietic stem cell transplantation and quality of life during the first year of treatment

ABSTRACT Objective: to evaluate the quality of life of adult patients with hematological cancer comparing Hematopoietic Stem Cell Transplantation modalities during the first year of treatment. Method: this is an observational and longitudinal research with 55 participants. Data collection was performed in six steps: before transplantation, pancytopenia, before hospital discharge, after 100, 180 and 360 days, in a reference hospital in Brazil for this treatment. The international instruments Quality of Life Questionnaire - Core 30 and Functional Assessment Cancer Therapy - Bone Marrow Transplantation were validated and translated into Portuguese (Brazil). Results: the mean age of participants was 36 years, 65% (n = 36) had leukemia diagnosis and 71% (n = 39) had undergone allogenic transplantation. In the Quality of Life Questionnarie - Core30 instrument, the pain symptom was significant between the first and second stages, and loss of appetite between the third and fourth stages, both in the allogenic group. In the Functional Assessment Cancer Therapy - Bone Marrow Transplantation, the functional well-being domain was significant between the third and fourth stages, also in the allogenic group. Conclusions: although the aggressiveness of treatment affects quality of life, patients consider it satisfactory after the first year. There are few significant differences between autologous and allogenic patients, and both groups have recovered in the course of the process.

The modalities of HSCT are denominated as autologous or autogenic and allogenic. They are determined according to the type of donor of hematopoietic stem cells (HSCs). In autologous HSCT, the HTCs are collected from the patient him/herself before the conditioning phase; they are basically stored and reinfused later. In allogenic HSCT, the HTCs come from a donor that may be related or not to the patient (14)(15)(16) .
Each HSCT modality has specificities, with preestablished protocols and chemotherapeutic regimens according to the disease, besides requiring care at different levels of complexity. The allogenic HSCT has some particularities in terms of variables to be controlled, as there is concern about the necessary compatibilities between donor and recipient. In addition, the fact that HSCs come from another person, relative or not, may increase the risk of complications, such as Graft versus Host Disease (GVHD), thus affecting multiple organ systems and implying changes in the domains of QoL (16)(17) .
However, both modalities have their own demands, and there are several factors, such as the existence of previous comorbidities associated or not with hematologic cancer, older age or not, diagnosis time, prognosis and even social conditions, among others that may interfere in the treatment, regardless of the type of transplantation performed.
During the therapeutic process, the patient undergoes some critical stages in which complications, besides putting their life at risk, can negatively affect their QoL, as symptoms that have a disabling potential may appear (16,18) . In addition to the physical complications, the patient may suffer with emotional and social changes during treatment. They may feel fear and anguish, and miss the family and friends, since social isolation is necessary in the early stages of treatment.
The QoL of patients worsens as the severity of the symptoms increases (19) . Knowing the specific changes in the QoL of the patient at each stage of the treatment enables the professionals involved in this context, especially the nurse, to establish an individualized and effective care plan, assisting the patient in facing their clinical condition, as well as aiming at a better survival.
In this sense, it is relevant to carry out studies focused on this theme.   (20) .
The FACT-BMT is divided into domains and its results are calculated as described in the FACIT Scoring Manual (21) .

Results
The sociodemographic characterization of the sample showed that the mean age was 36 years, 53% (n = 29) were male, 55% (n = 30) were married or declared stable union. Regarding education, 44% (n = 24) declared having completed high school and 64% (n = 35) declared themselves to be economically active.
The results expressed in Table 1

Discussion
HSCT is a complex and aggressive treatment, with a large number of variables that must be controlled so  (23) .
Despite the significant mortality rate, a significant proportion of patients survives after HSCT and demands Importantly, the place where the research was carried out is considered a world reference transplantation center also due to the amount of allogenic HSCTs that it performs annually. A study carried out in Spain evaluated the QoL of patients submitted to autologous and allogenic HSCT and revealed that the overall QoL is worse at two months compared to baseline; however, it improves at nine months after HSCT, confirming a positive evolution throughout the therapeutic process. This leads to conclude that the type of HSCT did not influence the QoL in the evaluated period. Nevertheless, a significant difference between the groups was observed in the physical scale (28) .
The physical function, personal performance and It is noteworthy that in the first months the patient suffers from the residual effects of drugs received, since the conditioning phase and many of these have side effects or adverse effects with potential to increase the symptoms, thus impacting the QoL.
As for the loss of appetite symptom, it was more intense in the autologous group only in the pre-HSCT stage; in all other stages, the means of the allogenic group were higher, with a significant difference between the groups after100 days (p = 0.031). National and international studies highlight the loss of appetite as one of the most present symptoms during HSCT; it has a substantial increase during hospitalization and remains a problem for up to six months after HSCT (4,8,19,30) . This symptom must be early detected by the care team in order to implement actions that prevent a possible malnutrition, which may compromise the health and the individually in all domains of QoL, as the results of this evaluation will serve as a basis for nursing to put in place effective interventions that will assist patients in coping with these symptoms (19) .

Conclusion
The diagnosis of hematologic cancer alone is already a stressful factor for the patient and his/her Rev. Latino-Am. Enfermagem 2018;26:e3065.
family. Besides this, the treatment to which they will be submitted has numerous risks, including death. The