Modified Psychosocial Assessment of Candidates for Transplantation Predicts Clinical Outcomes after Allogeneic Hematopoietic Stem Cell Transplantation

Introduction: The impact of psychosocial factors on the post-transplantation course and subsequent recovery has attracted attention in the field of organ transplantation and allogeneic hematopoietic stem cell transplantation (allo-HSCT). Therefore, evaluation indices have been developed to comprehensively assess psychosocial factors across the transplantation field, and their usefulness has been examined. One of the major psychosocial measures is known as Psychosocial Assessment of Candidates for Transplantation (PACT), and its usefulness has also been investigated in the field of allo-HSCT. However, initial findings showed that although some subscales of PACT were associated with overall survival (OS), the total assessment of PACT was not associated with it. Therefore, modified PACT (mPACT) was developed to evaluate psychosocial factors in patients with left ventricular assist device implantation. The subscales comprising mPACT have been reported to be prognostically relevant factors in allo-HSCT by themselves. Therefore, we hypothesized that mPACT, which improves the accuracy of the prognostic stratification of PACT, may be useful for allo-HSCT.

Methods: Of the 289 adult patients with hematological diseases who underwent allo-HSCT at the institutions enrolled in the present study between 2000 and 2023, the medical records of 250, for whom psychosocial items were fully interviewed or observed, were retrospectively analyzed, with a focus on medical records documented by nurses, psychologists, and psychiatrists.

Results: In the multivariate analysis, a higher mPACT total score correlated with longer OS (HR, 0.82; 95% CI, 0.76-0.89; p<0.01, for each 1-point increase), longer progression-free survival (PFS) (HR, 0.83; 95% CI, 0.77-0.90; p<0.01), and shorter non-relapse mortality (NRM) (HR, 0.81; 95% CI, 0.71-0.92; p<0.01). Since the cut-off value of the previously reported mPACT total score was 17 points, we divided patients into three groups with mPACT scores of 20, 19-17, and <17 points, which clearly stratified OS (< 17 vs. 17-19; p<0.01, < 17 vs. 20; p<0.01, 17-19 vs. 20; p<0.01), PFS (< 17 vs. 17-19; p=0.01, < 17 vs. 20; p<0.01, 17-19 vs. 20; p<0.01), and NRM (< 17 vs. 17-19; p<0.01, < 17 vs. 20; p<0.01, 17-19 vs. 20; p=0.08). We then examined whether the subscales comprising mPACT were associated with OS. The “Family and Support System Means” item was excluded from explanatory variables in subgroup analyses because there were no cases with reduced scores for that item. In the multivariate analysis, except for “Family and Support System Stability” and “Family and Support System Physical Ability/Availability”, all mPACT sub-items correlated with longer OS. The results obtained were as follows: “Family and Support System Stability” (HR, 0.70; 95% CI, 0.42-1.16; p=0.16, for each 1-point increase), “Family and Support System Physical Ability/Availability” (HR, 0.88; 95% CI, 0.58-1.35; p=0.56), “Patient Motivation” (HR, 0.71; 95% CI, 0.50-1.00; p=0.04), “Psychopathology/Personality Factors” (HR, 0.55; 95% CI, 0.40-0.75; p<0.01), “Cognition” (HR, 0.54; 95% CI, 0.41-0.72; p<0.01), “Independence in ADL” (HR, 0.66; 95% CI, 0.47-0.94; p=0.02), “Substance Abuse” (HR, 0.14; 95% CI, 0.05-0.40; p<0.01), “Knowledge and Education” (HR, 0.70; 95% CI, 0.52-0.96; p=0.03), and “Adherence with Medical Program” (HR, 0.68; 95% CI, 0.50-0.93; p=0.02).

Conclusions: In summary, mPACT, and its component subscales, predicted survival outcomes after allo-HSCT. This psychosocial measurement tool may improve transplantation outcomes by identifying patients with psychosocial vulnerabilities and by enabling targeted interventions to address critical issues.