Effects and moderators of coping skills training on symptoms of depression and anxiety in patients with cancer: Aggregate data and individual patient data meta-analyses.

PURPOSE: This study evaluated the effects of coping skills training (CST) on symptoms of depression and anxiety in cancer patients, and investigated moderators of the effects. METHODS: Overall effects and intervention-related moderators were studied in meta-analyses of pooled aggregate data from 38 randomized controlled trials (RCTs). Patient-related moderators were examined using linear mixed-effect models with interaction tests on pooled individual patient data (n = 1953) from 15 of the RCTs. RESULTS: CST had a statistically significant but small effect on depression (g = -0.31,95% confidence interval (CI) = -0.40;-0.22) and anxiety (g = -0.32,95%CI = -0.41;-0.24) symptoms. Effects on depression symptoms were significantly larger for interventions delivered face-to-face (p = .003), led by a psychologist (p = .02) and targeted to patients with psychological distress (p = .002). Significantly larger reductions in anxiety symptoms were found in younger patients (pinteraction < 0.025), with the largest reductions in patients <50 years (ß = -0.31,95%CI = -0.44;-0.18) and no significant effects in patients ≥70 years. Effects of CST on depression (ß = -0.16,95%CI = -0.25;-0.07) and anxiety (ß = -0.24,95%CI = -0.33;-0.14) symptoms were significant in patients who received chemotherapy but not in patients who did not (pinteraction < 0.05). CONCLUSIONS: CST significantly reduced symptoms of depression and anxiety in cancer patients, and particularly when delivered face-to-face, provided by a psychologist, targeted to patients with psychological distress, and given to patients who were younger and received chemotherapy.

Effects and moderators of exercise on sleep in adults with cancer: Individual patient data and aggregated meta-analyses.

OBJECTIVES: To evaluate the effects of exercise interventions on sleep disturbances and sleep quality in patients with mixed cancer diagnoses, and identify demographic, clinical, and intervention-related moderators of these effects. METHODS: Individual patient data (IPD) and aggregated meta-analyses of randomized controlled trials (RCTs). Using data from the Predicting OptimaL cAncer RehabIlitation and Supportive care project, IPD of 2173 adults (mean age = 54.8) with cancer from 17 RCTs were analyzed. A complementary systematic search was conducted (until November 2018) to study the overall effects and test the representativeness of analyzed IPD. Effect sizes of exercise effects on self-reported sleep outcomes were calculated for all included RCTs. Linear mixed-effect models were used to evaluate the effects of exercise on post-intervention outcome values, adjusting for baseline values. Moderator effects were studied by testing interactions for demographic, clinical and intervention-related characteristics. RESULTS: For all 27 eligible RCTs from the updated search, exercise interventions significantly decreased sleep disturbances in adults with cancer (g = -0.09, 95% CI [-0.16; -0.02]). No significant effect was obtained for sleep quality. RCTs included in IPD analyses constituted a representative sample of the published literature. The intervention effects on sleep disturbances were not significantly moderated by any demographic, clinical, or intervention-related factor, nor by sleep disturbances. CONCLUSIONS: This meta-analysis provides some evidence that, compared to control conditions, exercise interventions may improve sleep disturbances, but not sleep quality, in cancer patients, although this effect is of a small magnitude. Among the investigated variables, none was found to significantly moderate the effect of exercise interventions on sleep disturbances.

Effects and moderators of psychosocial interventions on quality of life, and emotional and social function in patients with cancer: An individual patient data meta-analysis of 22 RCTs.

OBJECTIVE: This individual patient data (IPD) meta-analysis aimed to evaluate the effects of psychosocial interventions (PSI) on quality of life (QoL), emotional function (EF), and social function (SF) in patients with cancer, and to study moderator effects of demographic, clinical, personal, and intervention-related characteristics. METHODS: Relevant studies were identified via literature searches in 4 databases. We pooled IPD from 22 (n = 4217) of 61 eligible randomized controlled trials. Linear mixed-effect model analyses were used to study intervention effects on the post-intervention values of QoL, EF, and SF (z-scores), adjusting for baseline values, age, and cancer type. We studied moderator effects by testing interactions with the intervention for demographic, clinical, personal, and intervention-related characteristics, and conducted subsequent stratified analyses for significant moderator variables. RESULTS: PSI significantly improved QoL (ß = 0.14,95%CI = 0.06;0.21), EF (ß = 0.13,95%CI = 0.05;0.20), and SF (ß = 0.10,95%CI = 0.03;0.18). Significant differences in effects of different types of PSI were found, with largest effects of psychotherapy. The effects of coping skills training were moderated by age, treatment type, and targeted interventions. Effects of psychotherapy on EF may be moderated by cancer type, but these analyses were based on 2 randomized controlled trials with small sample sizes of some cancer types. CONCLUSIONS: PSI significantly improved QoL, EF, and SF, with small overall effects. However, the effects differed by several demographic, clinical, personal, and intervention-related characteristics. Our study highlights the beneficial effects of coping skills training in patients treated with chemotherapy, the importance of targeted interventions, and the need of developing interventions tailored to the specific needs of elderly patients.

Liraglutide and cardiovascular outcomes in adults with overweight or obesity: A post hoc analysis from SCALE randomized controlled trials.

The cardiovascular safety of liraglutide, a glucagon-like peptide-1 receptor agonist approved for weight management at a dose of 3.0 mg, was evaluated post hoc using data from 5908 participants in 5 randomized, double-blind, placebo-controlled clinical trials. Participants were randomized to liraglutide or a comparator group (placebo or orlistat). The objective was to evaluate whether cardiovascular risk was increased with liraglutide treatment. The primary composite outcome of this time-to-event analysis was the first occurrence of cardiovascular death, nonfatal myocardial infarction or nonfatal stroke. These cardiovascular events were adjudicated prospectively for three of the trials and retrospectively for two trials by an event adjudication committee. The primary outcome was analyzed using a Cox proportional hazards model, stratified by trial. With liraglutide 3.0 mg, 8 participants had positively adjudicated cardiovascular events (1.54 events/1000 person-years) compared to 10 participants in the comparators group (3.65 events/1000 person-years). The hazard ratio for liraglutide 3.0 mg compared to comparators was 0.42 (95% confidence interval, 0.17-1.08). In this analysis, liraglutide 3.0 mg treatment was not associated with excess cardiovascular risk. However, the wide confidence intervals and retrospective adjudication of events in two of the trials are limitations of the analysis.

A systematic review and meta-analysis of changes in cognitive functioning in adults undergoing hematopoietic cell transplantation.

Evidence is mixed regarding the effects of hematopoietic cell transplantation (HCT) on changes in cognitive functioning among adults. Meta-analysis, which is designed to help reconcile conflicting findings, has not yet been conducted on studies of adults receiving HCT. To fill this gap, the current study provides a systematic review and meta-analysis of cognitive functioning in adults receiving HCT. A search of PubMed, PsycInfo, CINAHL, and Cochrane Library yielded 732 abstracts, which were independently evaluated by pairs of raters. Seventeen studies were systematically reviewed; 11 were retained for meta-analysis. There was agreement that cognitive impairments are evident for a subset of patients before HCT. Meta-analytical findings of 404 patients revealed no significant changes in cognitive functioning pre- to post HCT (P-values >0.05). Age, time since transplant and TBI were not associated with changes in cognitive functioning. Patients who received autologous transplants were more likely to demonstrate improvements in attention (P=0.004). The systematic review identified several limitations of existing literature, including small, clinically heterogeneous samples. Large, cooperative group studies are needed to address these design limitations. Nevertheless, results from the current meta-analysis suggest that cognitive functioning does not significantly change following HCT.

Characteristics and correlates of cognitive functioning following bone marrow transplantation.

Patients who undergo bone marrow transplantation (BMT) often report cognitive problems following treatment. This study used cognitive tests and a self-report measure of subjective cognitive complaints to determine (1) the rate of objective cognitive impairment in a sample of 65 BMT patients, and (2) the correspondence of patients' cognitive complaints to their actual cognitive performance. At 6 months following BMT, patients were assessed in seven cognitive domains--attention, verbal learning, verbal memory, visual memory, simple executive function, complex executive function, and psychomotor speed. Cognitive complaints were likewise assessed. In all, 51% had at least mild impairment (-1 standard deviation (s.d.) below published norms) in one or more cognitive domains, with 28% demonstrating moderate-to-severe impairment (-2 s.d.). Older patients and patients with lower IQ were more likely to score in the impaired range on objective cognitive tests, with males and the less educated showing trends toward scores in the impaired range. Younger patients made significantly more cognitive complaints. Total cognitive complaints were unrelated to average cognitive performance, and complaints in specific cognitive domains were largely unrelated to objective performance on corresponding domains. Findings suggest that patients who complain about their cognitive performance following BMT differ from those who experience actual deficits.

Pilot study of a home-based aerobic exercise program for sedentary cancer survivors treated with hematopoietic stem cell transplantation.

We report a pilot study of a home-based aerobic exercise program in a group of 17 adult hematopoietic stem cell transplant (HSCT) recipients. Participants had received no cancer treatment for at least 6 months and reported leisure time physical activity less than 20 min per day and fewer than three times a week during the previous month. Following baseline assessments of aerobic fitness, fatigue symptoms, and quality of life, participants were placed on home-based aerobic exercise programs consisting of 20-40 min of activity in the target heart rate zone (40-60% predicted heart rate reserve) delivered in three to five sessions per week for 12 weeks. Subjects were supplied with electronic heart rate monitors and we encouraged program adherence using weekly telephone contacts and exercise diaries. In all, 32 of the 42 qualified candidates consented (acceptance=76%). Of these, 17 kept appointments for baseline assessments, four did not complete the study (attrition=46%), and no exercise-related adverse events were reported. Scores on measures of aerobic fitness, fatigue severity, and physical well-being improved (signed ranks test; P<0.05) during program participation. Our findings suggest that individually prescribed, home-based aerobic exercise is an acceptable, safe, and potentially effective intervention for improving physical functioning and fatigue in sedentary HSCT recipients.

Collision-induced dissociation of glycero phospholipids using electrospray ion-trap mass spectrometry.

Characterisation of phospholipids was achieved using collision-induced dissociation (CID) with an ion-trap mass spectrometer. The product ions were compared with those obtained with a triple quadrupole mass spectrometer. In the negative ion mode the product ions were mainly sn-1 and sn-2 lyso-phospholipids with neutral loss of ketene in combination with neutral loss of the polar head group. Less abundant product ions were sn-1 and sn-2 carboxylate anions. CID using a triple quadrupole mass spectrometer, however, gave primarily the sn-1 and sn-2 carboxylate anions together with lyso-phosphatidic acid with neutral loss of water. For the ion trap a charge-remote-type mechanism is proposed for formation of the lyso-phospholipid product ions by loss of alpha-hydrogen on the fatty acid moiety, electron rearrangement and neutral loss of ketene. A second mechanism involves nucleophilic attack of the phosphate oxygen on the sn-1 and sn-2 glycerol backbone to form carboxylate anions with neutral loss of cyclo lyso-phospholipids. CID (MS(3) and MS(4)) of the lyso-phospholipids using the ion-trap gave the same carboxylate anions as those obtained with a triple quadrupole instrument where multiple collisions in the collision cell are expected to occur. The data demonstrate that phospholipid species determination can be performed by using LC/MS(n) with an ion-trap mass spectrometer with detection of the lyso-phospholipid anions. The ion-trap showed no loss in sensitivity in full scan MS(n) compared to multiple reaction monitoring data acquisition. In combination with on-line liquid chromatography this feature makes the ion-trap useful in the scanning modes for rapid screening of low concentrations of phospholipid species in biological samples as recently described (Uran S, Larsen A, Jacobsen PB, Skotland T. J. Chromatogr. B 2001; 758: 265).

Progress in understanding fatigue associated with breast cancer treatment.

Fatigue is one of the most common and distressing symptoms reported by cancer patients. This article reviews research that has examined the extent to which breast cancer patients experience fatigue during and following completion of chemotherapy and radiotherapy. The article also addresses methodological issues in the study of fatigue as well as the current status of efforts to prevent or relieve fatigue associated with breast cancer treatment.

Sexual functioning in breast cancer survivors.

BACKGROUND: A growing body of evidence suggests that sexual dysfunction may be among the more common and distressing symptoms experienced by breast cancer survivors. METHODS: This report reviews studies in which sexual functioning in breast cancer survivors has been investigated. Included are reports on the prevalence and nature of sexual difficulties, the relationship between specific breast cancer treatments and sexual difficulties, and the treatment of sexual dysfunction following completion of breast cancer treatment. RESULTS: A review of the literature suggests a wide range of rates for the prevalence of sexual problems in breast cancer survivors. Factors that may affect prevalence rates include the methods used to determine prevalence and the demographic and medical characteristics of the patients studied. With regard to treatment effects, evidence suggests that breast cancer patients who undergo chemotherapy are at high risk for sexual dysfunction after treatment. In contrast, there is little evidence of a link between type of surgical treatment (eg, lumpectomy vs mastectomy) or treatment with tamoxifen and sexual functioning outcomes. CONCLUSIONS: A growing body of evidence suggests that sexual problems can be a long-term side effect of breast cancer treatment. Oncology professionals should initiate communication about sexual difficulties, perform comprehensive assessments, and educate and counsel patients about the management of these difficulties.

Analysis of phospholipid species in human blood using normal-phase liquid chromatography coupled with electrospray ionization ion-trap tandem mass spectrometry.

A narrow-bore normal-phase high-performance liquid chromatography (HPLC) method was developed for separation of phospholipid classes in human blood. The separation was obtained using an HPLC diol column and a gradient of chloroform and methanol with 0.1% formic acid, titrated to pH 5.3 with ammonia and added 0.05% triethylamine. The HPLC system was coupled on-line with an electrospray ionisation ion-trap mass spectrometer. Chromatographic baseline separation was obtained between phosphatidylglycerol, phosphatidylcholine, phosphatidylethanolamine, lyso-phosphatidylcholine, phosphatidylinositol and phosphatidylserine, eluting in that order. The total run time was 30 min. Plasmalogen phosphatidylethanolamine and sphingomyelin, which both are substances with structural similarities to the glycerophospholipids, had similar retention time as phosphatidylethanolamine, but were well separated from the other glycerophospholipid classes. The species from each class were identified using MS2 or MS3, which forms characteristic lyso-fragments. The combination of lyso-fragment mass, molecular ion and chromatographic retention time was used to identify each species, including 20 species of phosphatidylglycerol. The mass spectra obtained for the phospholipid classes are presented. Using this system 17 disaturated phospholipid species not earlier described to be present in blood were identified. The limit of detection varied between different phospholipid classes and was in the range 0.1-5 ng of injected substance.

Investigation of binding of 125I-iodixanol to high molecular weight substances after incubation with rat liver homogenates.

PURPOSE: It has recently been shown that incubation of iodixanol in rat liver homogenates resulted in formation of iodixanol metabolites. The present study was performed to see if this incubation resulted in any binding of iodixanol to high molecular weight substances, as such a high molecular weight conjugate of iodixanol theoretically might cause initiation of an immune response against this contrast agent. MATERIAL AND METHODS: 125I-iodixanol was incubated with rat liver homogenates for 1 h at 37 degrees C and 17 h at 25 degrees C followed by analysis of the supernatant fractions using gel-permeation chromatography with on-line radiochemical detection. RESULTS: No traces of radioactivity could be detected in the chromatograms, except at the retention time of free iodixanol. CONCLUSION: No binding of iodixanol to high molecular weight substances could be demonstrated after incubation of iodixanol with rat liver homogenates.

On-line dialysis and quantitative high-performance liquid chromatography analysis of iodixanol in human, rat and monkey plasma.

A fully automated HPLC method for analysing the non-ionic X-ray contrast agent iodixanol in plasma samples, using on-line dialysis for sample preparation, was developed. Optimal conditions were obtained with a static dialysis donor solution of 110 microl and 4 ml of recipient solution (dialysate) pulsed onto a trace enrichment column, giving maximum 55% dialysis efficiency in less than the chromatographic run time of 20 min. Hence, one sample could be dialysed during the analysis of the previous. The maximum load of iodixanol on the trace enrichment column was 3.75 mg. Validation showed that the method was selective for iodixanol, sensitive down to 84 pmol/ml and had a high precision over a linear range up to 320 nmol/ml. Although developed for iodixanol, the method can easily be modified and applied to other substances with similar properties, i.e., substances having low protein binding and high water solubility, but strong enough stationary phase affinity to be retained by an appropriate trace enrichment column.

Quality of life after adjuvant chemotherapy for breast cancer.

PURPOSE: To evaluate the quality of life of breast cancer patients previously treated with adjuvant chemotherapy. METHOD: Registry data were used to recruit a sample of breast cancer patients (N = 61; mean age = 51.6 years) with no current evidence of disease who had completed adjuvant chemotherapy between 3 and 36 months earlier (average = 15.87 months). In addition, a peer nomination procedure was used to recruit an age-matched comparison group of women with no history of cancer (N = 59; mean age = 51.5 years). Both groups were mailed a survey to complete that included the Medical Outcomes Study Short Form 36 (SF-36) and the Center for Epidemiologic Studies Depression Scale (CES-D). These data were used to test the hypothesis that breast cancer patients previously treated with adjuvant chemotherapy experience impaired quality of life relative to their peers and to identify demographic and medical factors associated with individual differences in patient quality of life. RESULTS: Consistent with predictions, the postchemotherapy group scored poorer than the noncancer comparison group on the CES-D and on six of the eight subscales as well as the physical component summary scale of the SF-36 (p < 0.05). With regard to individual differences in patient quality of life, younger age and unmarried status were positively related to poorer mental well-being and greater depressive symptomatology (p < 0.05). Time since cancer diagnosis and chemotherapy completion were also positively related to greater depressive symptomatology (p < 0.05). In contrast, none of the demographic or medical variables assessed were related to physical well-being (p > 0.05). CONCLUSIONS: Breast cancer patients appear to experience problems in multiple quality of life domains following the completion of adjuvant chemotherapy treatment. Demographic and medical characteristics explain individual differences in mental but not physical aspects of patient quality of life. These findings demonstrate the need for interventions to improve the quality of life in breast cancer patients previously treated with adjuvant chemotherapy.

Impact of hot flashes on quality of life among postmenopausal women being treated for breast cancer.

Hot flashes are among the most commonly reported symptoms among women who have completed treatment for breast cancer. Relatively little is known, however, about hot flashes among women while they are undergoing breast cancer treatment. The present study investigated the prevalence and severity of hot flashes of women during chemotherapy and radiotherapy for breast cancer. We also sought to identify the medical, demographic, and treatment correlates of hot flashes during treatment and to document the impact of hot flashes on quality of life. Seventy postmenopausal women with breast cancer completed a self-report questionnaire packet during chemotherapy and radiotherapy. Forty percent (n = 28) reported hot flashes during the week prior to assessment. Of the 28 women endorsing hot flashes, 25% (n = 7) rated them as severe, 39% (n = 11) rated them as moderate, and 36% (n = 10) rated them as mild. Women with hot flashes were significantly (p < 0.05) younger and reported significantly (p < 0.001) more fatigue, poorer sleep quality, and poorer physical health compared to women without hot flashes. Multivariate analyses revealed that, even after controlling for relevant medical, demographic, and treatment variables, the prevalence of hot flashes significantly (p < 0.05) predicted poorer sleep quality, more fatigue, and worse physical health. The results indicate that hot flashes are experienced by a sizable percentage of postmenopausal breast cancer patients as they undergo treatment. Hot flashes during cancer treatment appear to have a negative impact upon patient quality of life that may be due, in part, to fatigue and interference with sleep. Future research should seek to evaluate interventions to relieve hot flashes during breast cancer treatment as a means of improving patient quality of life.

Symptom structure of PTSD following breast cancer.

Identification of posttraumatic stress disorder (PTSD) symptoms and diagnoses in survivors of cancer is a growing area of research, but no published data exist regarding the symptom structure of PTSD in survivors of malignant disease. Findings from investigations of the PTSD symptom structure in other trauma populations have been inconsistent and have not been concordant with the re-experiencing, avoidance/numbing, and arousal symptom clusters specified in DSM-IV. The present study employed confirmatory factor analysis to evaluate the extent to which the implied second-order factor structure of PTSD was replicated in a sample of 142 breast cancer survivors. PTSD symptoms were measured using the PTSD Checklist--Civilian Version (PCL-C). Fit indices reflected a moderate fit of the symptom structure implied by the DSM-IV. These findings provide some tentative support for the DSM-IV clustering of PTSD symptoms and for the validity of cancer-related PTSD.

NCCN Practice Guidelines for Cancer-Related Fatigue.

These guidelines propose a treatment algorithm in which patients are evaluated regularly for fatigue, using a brief screening instrument, and are treated as indicated by their fatigue level. The algorithm's goal is to identify and treat all patients with fatigue that causes distress or interferes with daily activities or functioning. Management of fatigue begins with primary oncology team members who perform the initial screening and either provide basic education and counseling or expand the initial screening to a more focused evaluation for moderate or higher levels of fatigue. At this point the patient is assessed for the five primary factors known to be associated with fatigue: pain, emotional distress, sleep disturbance, anemia, and hypothyroidism. If any of these conditions are present, it should be treated according to practice guidelines, and the patient's fatigue should be reevaluated regularly. If none of the primary factors is present or the fatigue is unresolved, a more comprehensive assessment is indicated--with referral to other care providers as appropriate. The comprehensive assessment should include a thorough review of systems, review of medications, assessment of comorbidities, nutritional/metabolic evaluation, and assessment of activity level. Management of fatigue is cause-specific when conditions known to cause fatigue can be identified and treated. When specific causes, such as infection, fluid and electrolyte imbalances, or cardiac dysfunction, cannot be identified and corrected, nonpharmacologic and pharmacologic treatment of the fatigue should be considered. Nonpharmacologic interventions may include a moderate exercise program to improve functional capacity and activity tolerance, restorative therapies to decrease cognitive alterations and improve mood state, and nutritional and sleep interventions for patients with disturbances in eating or sleeping. Pharmacologic therapy may include drugs such as antidepressants for depression or erythropoietin for anemia. A few clinical reports of the use of corticosteroids and psychostimulants suggest the need for further research on these agents as a potential treatment modalities in managing fatigue. Basic to these interventions, the effective management of cancer-related fatigue involves an informed and supportive oncology care team that assesses patients' fatigue levels regularly and systematically and incorporates education and counseling regarding strategies for coping with fatigue (Johnson, 1999), as well as using institutional fatigue management experts for referral of patients with unresolved fatigue.

Relation of psychological vulnerability factors to posttraumatic stress disorder symptomatology in bone marrow transplant recipients.

OBJECTIVE: Prior research suggests that the diagnosis and treatment of cancer can result in the development of symptoms of posttraumatic stress disorder (PTSD). Based on Lazarus and Folkman's model of stress, the current study examined whether trauma appraisals, coping, social support, and social constraint were associated with the severity of PTSD symptoms in cancer patients who had undergone bone marrow transplantation (BMT). METHODS: Participants were 23 males and 79 females treated with BMT an average of 20 months previously (range = 3-62 months). Past and current psychiatric diagnoses were assessed through a structured clinical interview. PTSD symptomatology and other psychological variables were assessed using standardized self-report measures. RESULTS: Results indicated that 5% of participants met diagnostic criteria for current PTSD. Participants reported an average of three to four symptoms of PTSD (range = 0-16). Univariate analyses confirmed predictions that increased PTSD symptomatology would be associated with more negative appraisals of the BMT experience, greater use of avoidance-based coping strategies, lower levels of social support, and greater social constraint (p < .05). Regression analyses indicated that each of these variables accounted for significant (p < .05) variability in PTSD symptomatology above and beyond relevant demographic and medical variables. CONCLUSIONS: Results of the present study confirm and extend prior research regarding the prevalence of PTSD and PTSD symptoms among patients treated for cancer. In addition, the study identified a set of theoretically derived psychological characteristics that seem to place patients at risk for greater PTSD symptomatology after BMT.

Patients' psychosocial concerns following stem cell transplantation.

Information regarding the nature, frequency, correlates and temporal trajectory of concerns of stem cell transplantation (SCT) recipients is critical to the development of interventions to enhance quality of life (QOL) in these individuals. This study examined psychosocial concerns in 110 SCT (87% autologous) recipients drawn from two SCT centers. Participants were a mean of 46 years of age and 17 months post-SCT (range 3-62 months). Information regarding current and past SCT-related concerns, performance status, and demographic characteristics was collected by telephone interview or questionnaire. Recipients reported a wide variety of psychosocial concerns following SCT. Recipients who were younger, female and evidenced a poorer performance status reported a larger number of post-SCT concerns. Examination of the temporal trajectory of concerns suggests that some concerns are salient throughout the course of post-SCT recovery (eg disease recurrence, energy level, 'returning to normal'), some are salient early in the course of recovery (eg quality of medical care, overprotectiveness by others), and others emerge later in the course of recovery (eg feeling tense or anxious, sexual life, sleep, relationship with spouse/partner, ability to be affectionate). Implications for the development of interventions to enhance post-SCT QOL are identified.