Everyday life following hematopoietic stem cell transplantation: decline in physical symptoms within the first month and change-related predictors
Qual Life Res
Everyday life following hematopoietic stem cell transplantation: decline in physical symptoms within the first month and change- related predictors
Aleksandra Kroemeke 0 1 2
Małgorzata Sobczyk-Kruszelnicka 0 1 2
Zuzanna Kwissa-Gajewska 0 1 2
0 Department of Psychology, SWPS University of Social Sciences and Humanities , Warsaw , Poland
1 Maria Sklodowska-Curie-Oncology Center , Gliwice Branch, Gliwice , Poland
2 Department of Psychology, SWPS University of Social Sciences and Humanities , Chodakowska Street 19/31, 03-815 Warsaw , Poland
3 Aleksandra Kroemeke
Purpose Lower quality of life, especially in the physical domain (Physical-QOL), is common in patients after hematopoietic stem cell transplantation (HSCT). However, few studies explore changes in the Physical-QOL, i.e., physical symptoms, in everyday life of patients following HSCT. The present study addresses this gap by examining patient daily physical symptoms and their predictors in terms of demographic and clinical characteristics. Methods Physical symptoms were reported by 188 patients (56.9% men; aged 47.6 ± 13.4 years) for 28 consecutive days after post-HSCT hospital discharge. Multilevel modeling was used to investigate fixed and random effects for physical symptom changes over time. Results The results indicated that the initial level of physical symptoms (immediately after hospital discharge) systematically decreased over 28 days. Treatment toxicity (WHO scale; β = 0.09, p < .01) and baseline depressive symptoms (CES-D scale; β = 0.06, p < .01) were associated with the initial level of physical symptoms. Patients with more depressive symptoms before HSCT and with more adverse treatment effects presented with more physical symptoms immediately after hospital discharge. The type of transplant, diagnosis, and conditioning regimen differentiated the course of physical symptoms. Patients with leukemias and other myeloid neoplasms (β = 0.05, p < .01), after allogeneic HSCT (β = −0.06, p < .01), and with non-myeloablative conditioning (β = −0.09, p < .01) showed a significant lower decrease in symptoms over time. Patients with multiple myeloma presented with the most rapid improvement (β = −.03, p < .05). Conclusions The findings suggest a heterogeneous and rather positive response to HSCT. Treatment-related conditions occurred to be a significant predictor of the intensity of change in physical functioning after HSCT.
Physical symptoms; Hematopoietic stem cell transplantation; Intensive longitudinal study; Multilevel modeling
Although high dose-therapy (chemotherapy and
radiotherapy) and hematopoietic stem cell transplantation (HSCT)
lead to an improved long-term survival of patients treated
by these methods [
], such treatments have an impact on
the well-being of patients and the overall short- [
long-term quality of life [
]. The main treatment-related
side effects of HSCT include a wide range of physical
symptoms, such as loss of appetite, skin, eye and mouth problems,
trouble sleeping, or fatigue [
Adverse physical symptoms are common indicators of
the health-related quality of life (HRQOL) physical domain
]. Earlier studies suggest that poorer physical condition
is associated with diminished well-being of patients [
a lower psychological domain of HRQOL [
distress, anxiety and depression [
], and poorer health
prognosis and survival rates [
]. Physical functioning
of patients after HSCT is frequently the focus of studies.
Still little is known about the dynamics of changes in
physical symptoms or physical HRQOL over time after HSCT
and the determinants of these changes. The present study
addresses this gap.
The findings of previous studies indicate patient physical
condition improves with time when considering the
hospitalization period [
], first 14 days [
], 24 days [
100 days after HSCT . However, studies over long
periods of time indicate physical symptoms remain stable over a
] or 9-year follow-up period [
]. Several factors
are associated with better patient physical HRQOL
following HSCT including younger age [
8, 17, 18, 22
5, 8, 24, 25
], employment [
], lack of comorbidities [
], autologous (patient’s own stem cells) HSCT [
less-intensive previous therapy [
], lack of chronic
graftversus-host disease (GvHD; a medical complication
following HSCT) [
8, 9, 22
], and lack of depression [
predictors were identified in a recent meta-analysis
indicating a strong effect of chronic GvHD, and weak and
inconsistent findings of the remaining factors [
]. In one study,
younger age and not receiving systemic immunosuppression
was related to a decline in physical symptoms over 3 to 7+
years post-transplant among recipients of allogeneic (i.e.,
donor stem cells) HSCT [
]. Despite a number of important
advantages of these studies, their weakness is often a long
time period from HSCT and the examination of predictors of
physical HRQOL instead of predictors of changes in
symptoms or the growth curve of physical symptoms over time.
In fact, improvements in physical HRQOL and regression
of treatment-related side effects occur shortly after HSCT
4, 5, 17
]. Moreover, cross-sectional studies allow only a
determination of the variability between participants, but
not the intra-individual variability (within-person).
Longitudinal studies, on the other hand, rarely involve multiple
occasions and use advanced statistical methods that allow
characterizing within-person processes. Hence, the
following questions remain unanswered: what the trajectory is and
what is responsible for the dynamics of physical symptoms
over time after HSCT.
Therefore, the aim of this study was to (1) identify the
growth curve of physical symptoms in everyday life of
patients during the first month (28 days) after post-HSCT
hospital discharge, and (2) to determine the predictors and
moderators of changes in physical symptoms in terms of
demographic and clinical characteristics using a
sophisticated modeling technique. To our knowledge, this study is
the first to examine patterns of change in post-HSCT
physical symptoms in everyday life of patients immediately after
hospital discharge. The first month after hospital discharge
could be a challenging period—the patient is not given
allday care that was guaranteed in hospital settings and
complaints that were present during hospitalization may still
be present. However, systematic changes in the physical
condition of patients can be predicted. Thus, we expected
a decrease in physical symptom level over the study period.
The second aim was to evaluate whether demographics (age,
gender, education, employment, marital, and economic
status) and pre- and peri-HSCT clinical variables (primary
diagnosis, time since diagnosis, medical comorbidities,
type of transplant, conditioning regimen [preparatory
treatment to HSCT of various intensities, from lower- to
higherintensity], treatment toxicity, and baseline depression) help
to determine time changes of physical symptoms in patients.
Based on previous studies, we hypothesized that the above
factors could be related to the initial level of physical
symptoms and the symptom growth curve.
The inclusion criteria for the study were: (1) the first
autologous or allogeneic HSCT, (2) age ≥18 years, (3) no history
of other major disabling medical or psychiatric condition,
and (4) written informed consent. The recruitment occurred
in a single center after elective hospital admission for HSCT.
The research procedure consisted of two stages: (1)
baseline measurement (before conditioning regimen) in which
demographic and medical characteristics, as well as
patientreported depression were measured; and (2) daily evening
self-reported physical symptoms for 28 days starting from
the first day of hospital discharge. Following
recommendations for dyadic research [
], the format of the diary was
adjusted to the individual preferences of the participants,
namely: a traditional pen-and-paper form, an electronic
version sent to a provided email account, or a telephone
interview. This minimalizes the percentage of persons refusing
to participate in the study and will not impact the results of
a statistical analysis [
]. In this study, only paper (85.6%)
and email modes (14.4%) were chosen by the participants.
In the daily assessment, participants received a short text
message (SMS) every evening to remind them to fill in their
diary. Participation was voluntary. The study protocol was
approved by the Ethics Committee of the SWPS University
of Social Sciences and Humanities.
Daily somatic symptoms
Physical symptoms based on EORTC QOL-C30 symptom
], Larsen and Kasimatis [
physical symptoms scale, and additional symptoms related to
HSCT (e.g., altered taste, mouth or eye complaints) were
assessed for 28 consecutive days after hospital discharge
to obtain a representative account of daily health status of
patients after HSCT. The final scale consisted of a checklist
containing 21 symptoms self-assessed in the evenings. The
participants checked the symptoms they experienced
during each day, responding to the instruction: “Today I have
experienced the following symptoms (check all that apply).”
The list of symptoms was as follows: dyspnea, tightness in
chest, dizziness, nausea, vomiting, diarrhea, constipation,
skin rush, numbness/tingling, pain (headache, backache,
muscle soreness, other), dry/sore mouth and burning
sensation in the mouth, altered/loss of sense of taste, burning/dry
eyes, fatigue, trouble concentrating, insomnia, appetite loss,
cough/runny nose. The participants had an option to add
symptoms that were not included in the list. The narrative
responses were compared against the symptoms on the scale.
Symptoms that differed from the scaled items were added as
“other” (i.e., the 22nd symptom). The daily physical
symptoms score was calculated as the sum of experienced
symptoms (total daily score: 0–22).
Sociodemographic and clinical characteristics
Demographic data included age, gender, education, marital
status, subjective economic status, and employment. These
data were collected by self-report before HSCT. Clinical
data included diagnosis, time since diagnosis,
comorbidities (number of comorbidities co-occurring with primary
diagnosis), type of transplant, and conditioning. Clinical
data were abstracted from medical records. Treatment
toxicity was assessed by a physician using the World Health
Organization (WHO) standard toxicity scale [
] at the
end of hospitalization. The scale consists of 20 items (e.g.,
hemoglobin, leucocytes, creatinine, bilirubin, skin
reaction, infection, cardiac function) related to the functioning
of various organs and is assessed on a five-point scale from 0
(slight disturbance) to 4 (very high disturbance). Generally,
the higher the result, the greater the toxicity of treatment
(total score: 0–80). The internal consistency of the scale
was 0.70. Self-reported depressive symptoms were assessed
before HSCT with the 20-item Center for Epidemiological
Studies Depression Scale (CES-D) [
] on a four-point scale
from 0 (rarely or never) to 3 (often). The higher the result,
the greater the number of depressive symptoms (total score:
0–60). The internal consistency of the scale was 0.87.
We used an intensive longitudinal study procedure to test
the study hypotheses. The essence of this method is to carry
out more frequent (daily) measurements compared to
traditional longitudinal studies. This new analysis allows a
determination of the within-person change variability [
procedure also minimizes the retrospective character of the
data obtained during the study, which is typical of traditional
research design [
To identify the time course of somatic symptoms in
post-HSCT patients, multilevel modeling (MLM) was
conducted using IBM SPSS statistical package ver. 24. MLM
provides the best parameter estimates while
accommodating the hierarchical structure of the data (daily assessment
nested within individuals) [
]. An a priori power
analysis using G*Power  with the correction described by
] was conducted to determine the minimum sample
size required to detect small effect (f= 0.15) with α = 0.05
and power = .80. The minimum acceptable sample size was
determined to be N = 144 participants.
To test moderating effects of demographic and clinical
variables on within-patient variation in physical
symptoms across 28 diary days (level 1), between-person
predictors (level 2) were added to the model. All predictors
were grand-mean centered; dummy codes were created for
categorical variables [
]. To avoid multicollinearity,
potentially correlated predictors (type of transplant,
diagnosis, conditioning) were tested separately. First, the model
with all demographics and clinical variables was estimated
except the type of transplant, diagnosis, and conditioning.
A better fitting model was presented (model 1). Next, a
separate model for the type of transplant (model 2),
diagnosis (model 3 for leukemias and other myeloid neoplasms,
model 4 for multiple myeloma, model 5 for lymphomas),
and conditioning (model 6) were calculated with model 1
variables as covariates. Due to the percentage distribution
of the type of transplant and conditioning, a comparison
was made between patients with autoHSCT and the
remaining types of alloHSCT in total and between myeloablative
(MA; high-intensity) conditioning with non-myeloablative
(NMA; low-intensity) and reduced intensity conditioning
(RIC; intermediate-intensity) in total.
In all models, the restricted maximum likelihood (REML)
was used as the estimator. Goodness of fit for the models
was based on −2 Restricted log-likelihood ratio (−2LL),
the Akaike Information Criterion (AIC), and the Bayesian
Information Criterion (BIC). The first-order autoregressive
[AR(1)] covariance structure was used for the models, given
the common proximal autocorrelation in the daily data [
A total of 437 patients met the study criteria between
November 2014 and November 2016. Of the 437 eligible
patients, 238 gave their written informed consent and filled
in the baseline measurement questionnaire (1, stage). The
final sample included 188 participants who participated in
the daily study for at least 7 days (2, stage). Most
participants were in a stable relationship, had at least a secondary
education, were professionally inactive, and assessed their
economic status as average and underwent autologous HSCT
(autoHSCT) and myeloablative conditioning (high-intensity
conditioning; see Table 1).
Of the remaining 50 participants, 6 were disqualified
from HSCT, 16 died at the time of isolation, 28 resigned
from the daily assessment. Sample attrition analyses (using
binomial logistic regression) indicated that the daily study
completers and non-completers did not differ in terms of
sociodemographic (age, gender, education, marital status,
economic status, and employment), health-related variables
(diagnosis, time since diagnosis, comorbidities,
conditioning), or depressive symptoms at baseline, except treatment
toxicity (B = −0.06, SE = 0.02, p = .009, OR = .94), and type
of transplant (B = −1.34, SE = 0.33, p < .001, OR = .26).
Higher treatment toxicity according to the WHO Toxicity
Scale and allogeneic HSCT (alloHSCT) were associated
with an increased likelihood of belonging to the
Missing data analysis
The number of missing observations amounted to 9% (across
all days and participants; from 2.7% on day 1–13.3% on day
28), with 61% of fully completed diaries. There were no
significant associations between missing data and demographic
characteristics, clinical variables, daily physical symptoms,
and belonging to the paper or an email group. The data were
missing at random. MLM leads to unbiased estimates in that
]. The final analysis dataset consisted of 4780 daily
reports from 188 patients.
Growth curve of daily somatic symptoms
Descriptive statistics of daily physical symptoms are
presented in Table 2. The MLM analysis indicated that the
initial level of physical symptoms (intercept; immediately after
hospital discharge) was 4.3 unit on a 0–22 scale and showed
a 0.06 unit decrease over time (slope; 28 days; Cohen’s d
effect size = 1.28); −2LL = 15365.59, AIC = 155375.59,
BIC = 15407.95. Besides, there was evidence of
betweenperson (i.e., between subject) variability in both the intercept
(B = 6.40, SE = 0.02, p < .001) and slope (B = 0.01, SE = 0.00,
p < .001) of physical symptoms. The intraclass correlation
coefficient (ICC) was 0.72, also indicating between-person
differences in the physical symptoms.
Predictors of time course of daily somatic symptoms
Preliminary results of MLM indicated that only treatment
toxicity (B = 0.11, SE = 0.04, p = .008) and pre-HSCT
depressive symptoms (B = 0.05, SE = 0.02, p = .022) were
significantly associated with the intercept of physical
symptoms, but did not differentiate the slope of
physical symptoms (B = −0.01, SE = 0.00, p = .832; B = 0.00,
SE = 0.00, p = .819 for WHO and CES-D scale,
respectively). The remaining variables and their interactions
with time were not statistically significant. Final model
1 included treatment toxicity and depression, controlling
for the age, gender, and comorbidities. Patients with more
depressive symptoms before HSCT and with more adverse
treatment effects had more physical symptoms
immediately after hospital discharge. The results from MLM (final
models) examining associations between level two
variables as predictors of time course of physical symptoms
are given in Table 3.
The model 2 parameters (moderator effect of type of
transplant: 1 = autoHSCT, 0 = alloHSCT, controlling for
the age, gender, comorbidities, treatment toxicity, and
pre-HSCT depression) showed that there were no group
differences in the initial level of physical symptoms. The
autoHSCT-by-day interaction indicated group differences
in time course of physical symptoms. AlloHSCT group
did not show physical symptom change over 28 days of
the study (non-significant 0.02 unit decrease), whereas
the autoHSCT group showed their 0.08 unit decrease over
time (see Fig. 1).
The result of model 3 examining the moderator effect
of leukemias and other myeloid neoplasms (1 = leukemias
group, 0 = other diseases), controlling for the age, gender,
comorbidities, treatment toxicity, and pre-HSCT depression,
indicated no group difference in the intercept of physical
symptoms. However, there was a significant
leukemiasby-day interaction i.e., patients with leukemias and other
myeloid neoplasms showed only a 0.02 unit decrease in
physical symptoms in time compared to other patients with
a significant 0.07 unit decrease (see Fig. 2).
The result of model 4 examining the moderator effect
of multiple myeloma (1 = MM, 0 = other diseases),
controlling for the age, gender, comorbidities, treatment toxicity,
and pre-HSCT depression, revealed significant group
differences in the growth curve of physical symptoms (see Fig. 3).
The decrease in physical symptoms over 28 days in the MM
group was stronger (0.08) than in non-MM group (0.05 unit
Finally, the result of model 6 examining the moderator
effect of conditioning (1 = MA, 0 = NMA + RIC), controlling
for the age, gender, comorbidities, treatment toxicity, and
pre-HSCT depression, indicating a significant difference in
the growth curve of physical symptoms between MA and
non-MA group (see Fig. 4). MA patients reported a 0.06
unit decrease in somatic symptoms over time, whereas in
non-MA patients, symptoms were stable over time
(nonsignificant 0.03 unit increase).
M (SD), range
20.96 (23.53), 3–180
0.99 (1.18), 0–6
18.44 (9.02), 10–91
14.89 (7.19), 10–91
27.98 (6.04), 17–45
18.09 (4.87), 0–37
16.51 (8.51), 3–42
MA—conditioning regimen that produces irreversible pancytopenia
and requires stem cell support; NMA—conditioning that produces
minimal pancytopenia and does not require stem cell support; RIC—
conditioning regimen that does not fulfill MA or NMA definition [
ALL acute lymphoblastic leukemia, AML acute myeloid leukemia,
CML chronic myelogenous leukemia, GvHD graft-versus-host disease
No moderator effect of lymphomas was found (see model
5). Besides, as it was expected, there was evidence of
autocorrelation in the level 1 residuals in all models.
Due to the lack of longitudinal research on the time course
of physical HRQOL in post-HSCT patients, the aim of this
study was to examine the time-based trajectory of their
physical symptoms over 28 days and trajectory determinants. The
findings revealed a significant systematic decrease in
physical symptoms in time, moderated by the type of disease,
transplant, and preparatory treatment (conditioning).
Immediately after hospital discharge patients reported on
average 4 out of 22 possible symptoms and their number
decreased in time. This indicates a relatively good physical
adaptation to HSCT as evidenced by few treatment-related
side effects and symptom resolution within the first month
after hospital discharge. Such results are consistent with
the current longitudinal studies conducted in a similar time
period and in the traditional mode [
]. The decline
in symptoms in the current study was clinically significant
as indicated by large effect size index. Significant
betweenperson differences were also noted for the initial level and
the time trend of physical symptoms. The range of the results
was 0–15 symptoms and was present for all 28 days.
Since the group was heterogeneous in terms of physical
symptoms, we tested for the moderator responsible for this
variability. Significant independent predictors of the initial
level of physical symptoms were treatment toxicity and
baseline depression, after adjusting for the effects of age, gender,
The more toxic the treatment as measured by the WHO
scale, the more symptoms were reported by patients on
Daily physical symptoms were assessed using a self-assessed checklist containing 21 symptoms and the
“other” option (22nd symptom). The scores were calculated as the sum of experienced symptoms (total
daily score: 0–22)
Day 1 of the study. These important findings were not
previously reported in the literature. Moreover, a higher
initial level of physical symptoms was also related to higher
pre-HSCT depressive symptoms. Positive relationships
between these variables were observed in previous studies
13, 27, 28
]. One explanation for this effect is that
depression is associated with increased adverse symptom
] via pathophysiologic processes (e.g., increased
cytokine level or other inflammatory factors) [
Likewise, depression or depressive symptoms are related to
the increased perception and the focus on physical
]. Patients with elevated depressive symptoms
may be more “sensitive” to certain symptoms such as
pain or altered taste. Of note, our analyses were related to
baseline depressive symptoms. However, previous studies
reported that pre-HSCT depressive symptoms predicted
their level in post-HSCT period [
]. Therefore, it is
probable that patients with a larger number of depression
symptoms prior to HSCT experienced the increased level
of symptoms also in the further period. Finally, reported
physical symptoms may be a part of depressive mood.
Depressive patients may report more symptoms, such as
fatigue, lack of concentration, or sleep-related problems,
which may be connected to the patient mood and not to the
adverse effects of treatment. These findings have
significant clinical implications and highlight the two important
risk factors for a higher level of physical symptoms (or
lower physical HRQOL) at discharge: treatment toxicity
and baseline depression. They also identify a significance
for patient screening for mood disorders and the provision
of psychological care to patients with lowered mood as
early as prior to HSCT.
Interestingly, neither treatment toxicity nor baseline
depression determined the further course of symptoms in
time. Significant moderators of change were type of
disease, type of transplant, and conditioning regimen, after
controlling for the age, gender, comorbidities, treatment
toxicity, and baseline depression. Patients with autoHSCT,
MA conditioning, and with MM were characterized by a
significant higher decrease in symptoms over time. In turn,
patients with leukemias and other myeloid neoplasms
demonstrated a significantly lower decrease in symptoms over
time as compared to the remaining patients. A better
physical HRQOL among autoHSCT recipients as compared to
alloHSCT patients was reported in previous studies [
A novel finding in our study is a more rapid resolution of
adverse effects after autoHSCT, hence the improvement in
physical HRQOL in this patient group.
Patients with leukemias and other myeloid neoplasms
experienced lower decrease in treatment-related adverse
symptoms. Previous studies also reported poorer
functioning of patients with leukemias as compared to MM and
lymphoma patients [
]. Poorer functioning may be due to
immunosuppression, allogeneic transplant, and disease
connected with high-intensity treatment before HSCT.
Patients with MM experienced the most rapid
improvement in adverse physical symptoms. The similar result was
reported in another study [
]. Faster improvement in the
physical symptoms of patients with MM may be related
to the autologous type of transplant or MM itself. These
patients usually have several different (mainly pain-related)
complaints. Some complaints may resolve in the post-HSCT
period as a result of discontinuation of neurotoxic drug
Fixed effects, estimate (SE)
Intercept for Day 1 4.37 (0.24)***
Days, centered at −0.06 (0.01)***
Age 0.02 (0.01)
Gender (1 = female, −0.16 (0.34)
0 = male)
Comorbidity 0.20 (0.16)
Treatment toxicity 0.09 (0.03)**
Depressive symp- 0.06 (0.02)**
AutoHSCT × Days
Leukemias and other
Leukemias and other
neoplasms × Days
MM × Days
Lymphomas × Days
ing × Days
NMA + RIC
Random effects, estimate (SE)
Residual 1.60*** (0.05)***
Autocorrelation 0.51*** (0.02)***
Unstandardized estimates and standard errors (SE)
The interpretation of the MLM based on the example of model 2: (1) the intercept is the level of physical symptoms on Day 1 after hospital
discharge for the alloHSCT group, (2) the Days estimate is the change in physical symptoms in the alloHSCT group over 28 days of the study, (3)
the autoHSCT estimate is the difference in somatic symptoms (auto- minus alloHSCT) on Day 1, (4) the autoHSCT-by-day interaction is a
difference in somatic symptoms change between allo- and autoHSCT groups
NMA non-myeloablative conditioning, RIC reduced intensity conditioning, −2LL −2 restricted log-likelihood ratio, AIC the Akaike information
criterion, BIC the Bayesian information criterion
*p < .01, **p < .01, ***p < .001
Patients with lymphomas were similar to patients with
leukemias, other myeloid neoplasms, and MM in terms of
the level and time course of physical symptoms. Our
findings highlight the difference in adverse symptom change
among and between various disease groups and awareness
about the diversity of recovery of patients which can
prevent stereotyping and routine approaches to their physical
Somewhat surprisingly, our results show conditioning
regimen associated with higher toxicity (MA) [
resulted in a more rapid decrease in symptoms over time.
Comparably, Andersson et al. [
] found a faster increase
in the physical symptoms in alloHSCT recipients who had
undergone RIC compared to MA conditioning; however, the
timeframe of both studies does not allow the comparison
between them. When interpreting the obtained results,
attention should also be given to the interactions of the mentioned
clinical characteristics. Among MA patients, the
predominant patients were those after autoHSCT (73%), diagnosed
with MM (31%) and lymphomas (44%). Of note, autoHSCT
model was the best-fitting model (see Table 3 AIC and BIC
Fig. 1 Spaghetti plot of
average (thick) and patient-specific
(thin) time courses of somatic
symptoms for alloHSCT (left)
and autoHSCT (right) groups
Fig. 2 Spaghetti plot of
average (thick) and patient-specific
(thin) time courses of somatic
symptoms for other diseases
(left) and leukemias and other
myeloid neoplasms (right)
Our study has a number of limitations. First, significant
disproportions in the number of members in the compared
groups (MA vs. non-MA) could have introduced bias into
our results. One of the remaining factors such as type of
transplant may be the cause of the MA effect. The issue of
MA-related long-term adverse symptoms requires further
investigation. Second, there were a disproportionate
number of patients who received autoHSCT in the study group.
Hence, larger groups of patients with different conditioning
regimen and type of transplant should be enrolled in future
Fig. 3 Spaghetti plot of
average (thick) and patient-specific
(thin) time courses of somatic
symptoms for other diseases
(left) and multiple myeloma
studies. Third, depressive symptoms were not controlled
on a daily basis, which could have the interpretative
significance. Fourth, depressive symptoms were based on
selfreport assessments rather than clinical diagnosis. Finally, we
tested only the moderator effect of demographic and clinical
factors on the initial level at discharge and the time course
of physical symptoms.
Due to the heterogeneity of the group, it would also be
reasonable to examine whether it is possible to identify in the
study group the patient subgroups with the similar baseline
Fig. 4 Spaghetti plot of
average (thick) and patient-specific
(thin) time courses of somatic
non-myeloablative (NMA) + reduced intensity
(RIC) (left) and
myeloablative (MA) conditioning (right)
level and trajectory of symptoms in time, in accordance with
the person-centered approach [
]. Despite the limitations,
the current study is the first to use an intensive
longitudinal approach to examine changes in physical symptoms or
physical HRQOL over the first month following HSCT. The
findings highlight the heterogeneity of the growth curve of
physical symptoms and the manner in which several clinical
factors are associated with the change in symptoms,
indicating the practical implications of these results.
Funding This study was founded by the National Science Centre,
Poland, Grant No. 2013/10/E/HS6/00189, to A.K.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and consistent with
the 1964 Helsinki declaration and its later amendments, or comparable
Informed consent Informed consent was obtained from each
individual participants included in the study.
Open Access This article is distributed under the terms of the
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(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
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