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Coping With Psychological Distress Prior to Hematopoietic Cell Transplantation With Richard Newcomb, MD

Patients with hematologic malignancies undergoing hospitalization for hematopoietic cell transplantation experience significant psychological distress, and they cope in different ways. In this interview from the 2023 American Society of Hematology (ASH), Dr. Richard Newcomb, Instructor of Medicine at Harvard Medical School, discusses his presentation on coping mechanisms employed by patients who are preparing for transplantation and ways that health care providers can help support their patients during this time.  

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're here at the ASH Annual Meeting, and I'm joined by Dr. Richard Newcomb. Thanks much for coming by today.

Richard Newcomb, MD: You bet, thank you so much for having me.

Oncology Data Advisor: To start off, would you like to introduce yourself and share what you do in your work?

Richard Newcomb, MD: Sure, my name is Richard Newcomb. I am a Bone Marrow Transplant Physician at Massachusetts General Hospital. I just finished my fellowship there.

Oncology Data Advisor: Congratulations.

Dr Newcomb: Thank you, yes, it's very exciting to be starting my practice. I do research on the experience of patients with cancer and trying to figure out ways in which we can improve their quality of life.

Oncology Data Advisor: I know you had a poster that you presented here a couple nights ago titled, "Coping in Patients With Hematologic Malignancies Undergoing Hematopoietic Cell Transplantation." For background, would you like to tell us a little bit about some of the physical and psychological challenges that patients cope with when they're hospitalized for a transplant?

Dr. Newcomb: Yes, thank you so much. I think we've known this for a bit, both clinically as well as when you actually survey patients from a systematic patient-reported outcome perspective. Transplant hospitalization, whether you're talking about autologous transplant or allogeneic transplant, is an incredibly challenging time. Physically, people experience the symptoms associated with conditioning chemotherapy as well as the count nadir and potential complications. Then there's also emotional toll and psychological burden of being in the hospital, away from usual things that might help people cope. We know that it's a very challenging time and one of the things that makes transplantation a daunting process for patients.

Oncology Data Advisor: What did you decide to investigate with this study?

Dr. Newcomb: We know from work that my mentors have done, Dr. Areej El-Jawahri and Dr. Hermioni Amonoo, as well as work by others in the field, that how people cope with illness is likely a very important thing to understand and that it's also a potentially modifiable thing. For instance, if you take patients who have acute myeloid leukemia and you compare a group that has access to integrative palliative care versus those that don't, those with integrative palliative care have sustained levels of approach-oriented coping, while they use less avoidant coping.

What does that mean? Coping, in general, includes are a variety of different strategies. In our work, we generally categorize them into approach-oriented coping and avoidant coping. Approach-oriented coping would be things like practicing positive reframing, seeking emotional support, looking to others, and things of that nature; whereas avoidant coping can be things like disengaging with the diagnosis, blaming yourself for these things, or denying that it's actually happening. These are similar patient populations, but people haven't systematically looked at how people cope going into the transplant hospitalization. It might be an important thing to look at because we think you can preserve approach-oriented coping while trying to mitigate avoidant coping when possible.

Oncology Data Advisor: Definitely. So, tell us about the study. How did you go about designing it?

Dr. Newcomb: This was a secondary analysis of initial baseline data from a multisite, randomized controlled trial of integrative palliative care. Actually, my mentor, Dr. El-Jawahri, is presenting the findings from the randomized controlled trial this afternoon. This is looking at the baseline data collected within 72 hours of people being admitted to the hospital.

We had several findings. The first is that people use a lot of different coping mechanisms. Predominantly, around 50% of patients do things like seeking emotional support, practicing acceptance, and looking to others. They use those at high levels, which is good to see. Then a substantial proportion of patients, about a third, will practice things like denial or self-blame as it relates to their illness going into transplant. And then there are about 10% of people that practice both. They use avoidant strategies and approach-oriented strategies. That was interesting just to say that people don't necessarily fit into one bucket in terms of how they decide to cope with their illness. That was the first major striking finding at baseline.

Oncology Data Advisor: Were any other results either surprising to you or anything that stood out as particularly striking?

Dr. Newcomb: I think the thing that is important now is to say, okay, are those things then correlated with people's quality of life and level of psychological distress? Patients who highly used approach-oriented coping had better quality of life and lower symptoms of depression and anxiety heading into transplant; whereas those who highly practiced avoidant coping had lower quality of life and higher symptoms of anxiety, depression, and posttraumatic stress disorder (PTSD) heading into transplant.

Then when you take a look at people who had that diversity of coping strategies—if you put people into bins of only using approach-oriented, using both, only using avoidant, or not highly using either—any use of avoidant coping increased levels of distress pretty substantially. That was also interesting to get back to that point where people use a variety of things to cope, and it really seems that any use of avoidant coping has negative impacts on quality of life.

I think the last thing to say is that it's good to find these things, but can you use other things that are easily identifiable to identify groups who may benefit from a particular supportive care intervention during transplant? Those who highly used avoiding coping were less likely to be older than 65, and they were more likely to identify as female. They were also more likely to be on disability or be unable to work, as that is a recent change related to their illness. Most transplant centers have systematic social work screening and psychosocial assessments, and those are things that would be easily identifiable to put people into bins of maybe needing a coping intervention during the transplant process. Of course, that's future work.

Oncology Data Advisor: Along these lines, can this knowledge that you found be used to design specific supportive care interventions for these patients?

Dr. Newcomb: I think so, and I hope so. We know that integrative palliative care is a great way to do this. I think one unfortunate thing is that there just aren't enough palliative care physicians to see everybody getting hospitalized for transplant, at least when you think about a large scalable intervention. We're thinking about ways to devise particular interventions. You might imagine in the future, in a similar way, that we target different things molecularly when we're treating diseases. When we're thinking about supportive care, there may just be different bins of people to whom you can say, "You really need physical symptom management" or "you really need coping assessment" or "you really need your emotional support from your family." This way, we can identify what exactly the supportive care need is and whether we can meet that.

Oncology Data Advisor: Exactly. Do you have any other additional advice for clinicians on how they can help support their patients who are preparing for transplant and while they're coping with this?

Dr. Newcomb: Absolutely. I think one of the biggest things—and this is more anecdotal but has also been shown in the work that Dr. El-Jawahri has done previously—is that when patients know what to expect, it makes coping with things much easier. I think the features about transplantation and hospitalization that patients benefit from knowing are they will have these symptoms, they will feel psychologically not in the greatest place during their hospitalization, and that it's temporary, that things do get better. This way, they can have that knowledge of what to expect and the reassurance that feeling bad does not mean that the thing is going poorly. I think that that's a huge takeaway from our work.

Then I think the other takeaway, and what we hope to show in future work, is that in our psychosocial assessments pre-transplant, we're hoping to argue for systematic assessments of coping, because we think that that's such an important thing. I'm not sure that's done universally currently. If we can do that, then that would be a way to identify people who might just need a little bit of extra support.

Oncology Data Advisor: It definitely speaks to the importance of education and preparing patients so that they know what to expect and involving them in those decisions.

Dr. Newcomb: Yes, and I think the other thing is that this is a one-timepoint thing, so the hospitalization is just the beginning of the journey. But I think it is a formative one. We know that people's experiences during the hospitalization show up later in people's transplant courses as potential trauma symptoms and things like that. The more we can do to improve that experience, the more it matters long-term.

Oncology Data Advisor: Absolutely. Anything else you'd like to mention about either the poster or your research in this area?

Dr. Newcomb: No, just thank you for the opportunity to speak and to be interviewed on this. We obviously think the work's really important in improving the experience of our really sick and vulnerable patients, so thanks for the opportunity to share.

Oncology Data Advisor: Absolutely, and I'm glad we were able to speak with you to help raise awareness and prioritize the importance of helping patients cope during transplantation. Thank you again for coming by.

About Dr. Newcomb

Richard Newcomb, MD, is an Instructor of Medicine at Harvard Medical School and an Assistant Physician in the Bone Marrow Transplant Program at Massachusetts General Hospital. His research focuses on improving quality of life for patients with malignant and benign hematologic diseases through patient-centered health services, particularly through coping assessments and interventions.

For More Information

El-Jawahri A, LeBlanc TW, Kavanaugh T (2023). Multi-site randomized trial of inpatient palliative care for hospitalized patients undergoing hematopoietic stem cell transplantation. Presented at: 2023 American Society of Hematology Annual Meeting. Abstract 913. Available at: https://ash.confex.com/ash/2023/webprogram/Paper185735.html

Newcomb R, Amonoo HL, Nelson AM (2023). Coping in patients with hematologic malignancies undergoing hematopoietic cell transplantation. Presented at: 2023 American Society of Hematology Annual Meeting. Abstract 2424. Available at: https://ash.confex.com/ash/2023/webprogram/Paper179471.html

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor. 


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