Physical and Emotional Health of Caregivers for People Who Have Had Stem Cell Transplants

There are approximately 65.7 million unpaid caregivers in the United States with an estimated
8 percent providing care to someone with cancer. Although benefit-finding has been reported,
providing care to a spouse or loved one with cancer is stressful and can have negative
consequences for an individual s psychological and physical health. In cancer caregivers,
studies have documented negative outcomes including symptoms of fatigue, impaired sleep
quality, poor quality of life, anxiety and depression. These outcomes are of particular
concern when cancer patients receive intense treatment such as hematopoietic stem cell
transplantation (HSCT) where caregivers are embedded in a treatment trajectory that can
extend 4 12 months. In dementia caregivers, additional outcomes have been reported including
poor health habits and impaired immunity. In addition, longitudinal studies have also
reported caregivers have an increased risk of morbidity and mortality, particularly from
cardiovascular disease.

The stress response is initiated in the brain, which determines both the physiological and
behavioral responses to an event. The normal physiologic response is complex and dynamic
process by which the body responds to daily events in an effort to maintain equilibrium. If
the stress becomes overwhelming for the individual, either due to the number or magnitude of
stressors, the burden or overload can lead to dysregulation of biologic mediators and
behavioral changes (poor sleep, eating or drinking too much, smoking, lack of physical
activity) that can exacerbate disease (e.g. cardiovascular disease). A recent study in cancer
caregivers demonstrated marked changes in neurohormonal and inflammatory processes in the
year following a loved one s cancer diagnosis which may place the caregiver at risk for
morbidity and mortality from disease. The relationships among the physiologic and
psychological responses as well as behavioral changes to stress have not been explored in
HSCT caregivers.

What is clear from the literature is that caregiving is stressful, and it appears to increase
one s risk for morbidity and mortality, particularly by increasing cardiovascular risk. What
is less clear is what behavioral, psychological, physiological and clinical changes are
associated with the process of caregiver for individuals undergoing allogeneic HSCT, a
particularly long and stressful experience. The purpose of this exploratory, pilot study is
threefold: to longitudinally examine physiological, behavioral and clinical factors in HSCT
caregivers during the acute transplant recovery period, to compare those factors in HSCT
caregivers to non-caregivers, and to explore the associations among physiological,
psychological, behavioral and clinical factors in HSCT caregivers.

Subjects will be accrued to this protocol if they are adult caregivers for a transplant
recipient participating in their first allogeneic HSCT protocol at the Clinical Center. An
equal sample of healthy volunteers that are non-caregivers will be recruited to serve as
control subjects. A sample of 40 subjects (20 caregiver and 20 non-caregiver volunteers) will
be recruited to capture the essence of the experience and adequately explore this population.

Each caregiver participant will have data collected prior to the recipient s HSCT (day 0),
during the first week of outpatient visits following the recipient s initial discharge from
the inpatient setting, and finally 6 weeks post the transplant recipients initial discharge
from the hospital. Questionnaires will capture the psychological and behavioral outcomes and
include: Caregiver Reaction Assessment (caregivers only), Health-Promoting Lifestyle Profile
II, Perceived Stress Scale, The UCLA Loneliness Scale (Version 3), General Self-Efficacy
Scale, and PROMIS Short Forms for Anxiety, Depression, Sleep disturbance and Fatigue.
Clinical variables (e.g. vital signs) and physiological variables (e.g. cortisol) will be
collected along with the questionnaires during the clinic visit and following history and
physical exam by a Licensed Independent Practitioner (LIP). A sample of non-caregivers will
be minimally matched for age, gender, and race/ethnicity, and complete all study procedures
except the questionnaires that are specific to the caregiver s experience (e.g. caregiver
burden). There will be no long term follow-up after the study participation period.
Exploratory, hypothesis generating analyses will be performed using parametric and
non-parametric techniques.

- INCLUSION CRITERIA:

Caregiver Subjects

- Age greater than or equal to 18 years old

- Ability to comprehend the investigational nature of the study

- Able to read and speak English or Spanish

- Agrees to participate in the study

- Intends to serve as an active caregiver for a patient undergoing their 1st allogeneic
HSCT at the NIH Clinical Center

Non-Caregiver Subjects

- Age greater than or equal to 18 years old

- Ability to comprehend the investigational nature of the study and provide informed
consent

- Able to read and speak English or Spanish

- Agrees to participate in the study

- Match caregiver subject based on age, gender, and race/ethnicity.

If more than one caregiver is planned for the transplant recipient during the transplant
phase, all caregivers will be invited to participate in the study. An active caregiver is
defined as someone who lives with (at least 6 hours/day) the HSCT recipient during the
study period (pre-HSCHT through 6 weeks post-discharge).

EXCLUSION CRITERIA: (all subjects)

- Age less than or equal to 18 years old

- Pregnant or lactating women

- Inability to comprehend investigational nature of study

- Inability to provide informed consent

- Unable to read and speak English or Spanish

- Does not agree to participate in study or follow study design (Beta)

- Glucocorticosteroid treatment in the last 2 months

- Diagnosis of Cushing, Addison or Parkinson s disease

- Prior heart transplant, have a pacemaker, diagnosis of orthostatic hypotension or
autonomic dysfunction

- Smokers unwilling to cease smoking for at least 12 hours before specimen collection

- Unwilling to cease alcohol consumption for at least 24 hours before specimen
collection

- Serving as a paid caregiver for any individual

- Serving as the HSCT donor (undergoing Stem Cell Mobilization)

EXCLUSION CRITERIA NON-CAREGIVER SUBJECTS:

Experienced a stressful life event in the preceding 3 months before enrollment (as
determined by the following pre-screening questions:

In the last 3 months have you experienced?

- A serious illness, yourself or with someone close to you?

- Death of someone close?

- Faced imprisonment for yourself or someone close or had legal difficulties?

- Been unemployed or had a change in your work?

- Moved from your home or remodeled your home?

- Been involved in a natural disaster?

- A change in your marital status?

- A pregnancy, birth, miscarriage, or stillbirth?

Currently receiving mental health services or taking psychiatric medications

Currently or in the last 3 months served as a caregiver