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Introduction
The quality of life (QoL) is defined as “a patient’s sub-
jective evaluation of his life situation” (11, 13, 20). The QoL
term contains the information on an individual’s physical,
psychological, social and spiritual condition (11, 13). The
QoL evaluation is carried out by means of generic and spe-
cific questionnaires (11, 13, 20). Generic questionnaires ge-
nerally evaluate a patient’s overall condition regardless of
his disease. Specific questionnaires are designed for the
evaluation of a patient’s overall condition in a particular
type of disease. Modules are often used with these specific
questionnaires. These modules are focused on specific
symptoms and complaints in a particular type of disease
(11, 13, 20).
The haematopoietic stem cell transplantation (HSCT)
is a modern therapeutic method used for biomodulation
anti-tumour therapy of haematological malignities and of
selected solid tumours. It is also used for the therapy of
non-tumour and hereditary diseases (1, 3, 12). It is divided
into bone marrow transplantation (BMT), the transplanta-
tion of stem (progenitor) cells (PBPCT) and umbilical cord
blood transplantation (UCBT). From a donor’s point of
view there are three kinds of transplantations: syngenic
transplantation (the donor is a monozygotic twin), allo-
geneic transplantation (HLA – human leukocytes antigen –
from a compatible sibling or parent or HLA from a com-
patible donor) and autologous transplantation (patient is
his/her own donor). The aim of the HSCT is to replace
a patient’s pathological bone marrow which contains tu-
morous cells, with haematopoietic cells from a healthy do-
nor and to restore haematopoiesis, which is damaged by an
intensive anti-tumour therapy (1, 3, 12). The HSCT in-
fluences the further course of disease, and by this the qua-
lity of life (QoL) for patients in the same way as other
therapeutic methods (20).
The aim of the current QoL study was to analyse the
effect of selected demographic, psychosocial and health
119
ORIGINAL ARTICLE
QUALITY OF LIFE IN ADULT PATIENTS TREATED WITH PERIPHERAL
BLOOD PROGENITOR CELL TRANSPLANTATION: THE EFFECT
OF SELECTED PSYCHOSOCIAL, DEMOGRAPHICS AND HEALTH ASPECTS
ON QUALITY OF LIFE: A RETROSPECTIVE ANALYSIS
Ladislav Slováček1,2, Birgita Slováčková3, Ladislav Jebavý1,4, Vladimír Pavlík5
University of Defence, Faculty of Military Health Science Hradec Králové, Czech Republic: Department of Field Internal
Medicine1, Department of Field Hygiene5; Charles University in Prague, Faculty of Medicine and University Hospital in
Hradec Králové, Czech Republic: Department of Oncology and Radiotherapy2, Department of Psychiatry3, 2nd Department
of Medicine, Division of Clinical Haematology 4
Summary: Aim: this retrospective study analyses the effect of selected psychosocial, demographics and health aspects on
quality of life (QoL) in adult patients treated with peripheral blood progenitor cell transplantation (PBPCT). Patients and
Methods: The total number of respondents treated with PBPCT between the years 2001–2003 was 95. The return rate of
QoL questionnaires was 72.1 % (71 respondents). There were 100 % ratable QoL questionnaire. The average age of all res-
pondents was 55.5 years old. The Czech version of an international generic European Quality of Life Questionnaire –
Version EQ-5D was used. The effect of selected aspects on QoL of patients was determined by analysis of variance. The
QoL questionnaires were evaluated with descriptive analysis. Results: The above-mentioned aspects proved statistically sig-
nificant dependence of QoL (EQ-5D score – QoL dimensions, EQ-5D VAS – subjective health condition) on age, in-
creasing number of associated diseases, religion and type of disease. The effect of other aspects on QoL was not proven
statistically significant. The QoL in adult patients treated with PBPCT declines with increasing age and with the increa-
sing number of associated diseases. People of faith have a higher level of QoL than non-believers. Patients with multiple
myeloma treated with PBPCT have the most low QoL. Conclusion: The global QoL in an adult patients treated with
PBPCT is on a good level.
Key words: Quality of life; Peripheral blood progenitor Cell transplantation; Quality of life questionnaires
ACTA MEDICA (Hradec Králové) 2007;50(2):119–124
aspects on QoL in adult patients with haematological ma-
lignancy treated with PBPCT and to evaluate global QoL in
this cohort of patients.
Design of study
The study is a retrospective and it is based on data ob-
tained during year 2004 / 2005 (from September 1, 2004 to
January 31, 2005) in 95 adult patients treated with PBPCT
between the years 2001–2003 in the Department of Clini-
cal Haematology of 2nd Department of Medicine of Charles
University Hospital and Faculty of Medicine in Hradec
Králové, Czech Republic.
The study was approved the Ethics Commission of the
Charles University Hospital and Faculty of Medicine in
Hradec Králové, Czech Republic.
Material and methods
Group characteristics
The total number of adult patients treated with PBPCT
from 2001 to 2003 was 171 (135 patients treated with auto-
logous PBPCT and 36 patients treated with allogeneic
PBPCT). The total number of respondents was 95 (60 pa-
tients died and 16 patients were after retransplantation).
The return rate of QoL ques tionnaires was 72.1 % (71 res-
pondents) and we could evaluate 100 % of them.
The number of respondents treated with PBPCT from
2001 to 2003 was as follows: in 2001: 20 respondents (10
male and 10 female), their average age was 55.5 years old,
in 2002: 20 respondents (10 male and 10 female), their ave-
rage age was 55.0 years old, in 2003: 31 respondents (19
male and 12 female), their average age was 55.5 years old.
Out of the total number of 71 respondents, 66 respondents
were treated with autologous PBPCT and 5 respondents
were treated with allogeneic PBPCT (in 2001 there was no
respondent with allogeneic PBPCT, in 2002 there were 2
respondents and in 2003 3 respondents). In the group of
patients with allogeneic PBPCT, 3 patients had the muco-
cutaneous form of chronic graft-versus-host disease
(cGVHD). These were patients with acute myeloid leukae-
mia. Tables 1 and 2 show the representation of respondents
treated with PBPCT according to the type of transplantati-
on and according to the type of disease.
Instrument
The Czech version of an international generic European
Quality of Life Questionnaire – Version EQ-5D (EuroQol –
EQ-5D) was used (20, 22). This questionnaire evaluates 2
indicators: objective and subjective indicators. The objec-
tive indicator includes 5 dimensions of QoL: mobility,
selfcare, usual activities, pain (discomfort and anxiety)
depression. Three kinds of answers, which express the de-
gree of complaints, are offered to each question (no com-
plaints, mild complaints, severe complaints). A total of 243
(35) combinations of health conditions exits. The outcome
is the EQ-5D score (dimensions of QoL), which has values
from 0 to 1 (0 – the worst health condition, 1 – the best he-
alth condition). The subjective indicator includes a visual
analogous scale (a value of 100 – the best health condition,
a value of 0 – the worst health condition) (20, 22). The res-
pondent marks his subjectively perceived health condition
on the thermometer scale. The outcome is EQ-5D VAS
(a subjective health condition), which has values from 0 to
100 (20, 22).
Procedure
The Euro Qol EQ-5D Questionnaire, with a covering
letter in which the whole project was explained, together
with a stamped envelope, were mailed to a respondents ad-
dress. Filling in the QoL questionnaire was voluntary and
anonymous.
Data collection, statistical methods
The Euro Qol EQ-5D evaluates 2 indicators, objective
(EQ-5D score) and subjective (EQ-5D visual analoques
scale). The outcome is the EQ-5D score (dimensions of
QoL), which has the values from 0 to 1 (0 – the worst
health condition, 1 – the best health condition). The sub-
jective indicator (EQ-5D VAS) includes the visual analo-
gous scale (the value of 100 – the best health condition, the
value of 0 – the worst health condition). The evaluation of
QoL questionnaires was carried out by means of descrip-
tive analysis in accordance with European Quality of Life
Group Methodology (20, 22). The independent variables
were age, sex, level of education, marital status, increasing
number of associated diseases, smoking abuse, religion,
type of PBPCT and time lapse from PSCT. We did not mo-
nitor the effect of chronic Graft Versus Host Disease on the
QoL of patients treated with allogeneic PBPCT because of
the small amount of patients in the collection. The depen-
dent variables were the EQ-5D score (dimensions of QoL)
and the EQ-5D VAS (a subjective health condition).
Tab. 1: Number of respondents according to the type of
PBPCT.
Type of PBPCT 2001 2002 2003 Total
number
Autologous PBPCT 20 18 28 66
Allogeneic PBPCT 0 2 3 5
120
Type of disease Number Autologous/
of allogeneic
respondents PBPCT
Hodgkin’s lymphoma 9 7 / 2
non-Hodgkin’s lymphoma 15 15 / 0
Acute lymphoblastic leukaemia 2 2 / 0
Acute myeloid leukaemia 12 9 / 3
Chronic myeloid leukaemia 1 1 / 0
Multiple myeloma 32 32 / 0
Tab. 2: Number of respondents according to the type of di-
seases.
The basic statistical characteristics were fixed (mean va-
lue, standard deviation, maximum and minimum value) for
all responses. The effect of selected aspects on QoL of adult
patients was evaluated by means of analysis of variance
(ANOVA). A value of P < 0.05 (5 %) was considered signi-
ficant. Software StatSoft STATISTICA Base Version 7.1 for
windows was used for analysis.
Results
The above-mentioned aspects proved a statistically sig-
nificant dependence of QoL (EQ-5D score and EQ-5 VAS)
on age (in both cases p<0,01), increasing number of as-
sociated diseases (in both cases p<0,01), religion (in both
cases p<0,01) and type of disease (in both cases p<0,05).
EQ-5D score (dimensions of QoL) and EQ-5D VAS (a sub-
jective health condition) significantly decrease with in-
creasing age and increasing number of associated diseases
(see Tab. 3, 4). These values are significantly higher in pa-
tients who believe in God compared to patient without reli-
gious beliefs (see Tab. 5). They are most significantly high
in patients with malignant lymphoma and with acute mye-
loid leukaemia and most low in patients with multiple mye-
loma (see Tab. 6). The mean EQ-5D score was 68.9 % and
mean EQ-5D VAS was 66.6 %, and in patients with malig-
nant lymphoma and acute leukaemia the mean EQ-5D score
was 82.7 % and mean EQ-5D VAS was 76.7 %.
The global QoL of patients treated by means of PBSCT
in the Department of Clinical Haematology of 2 nd Depart-
ment of Internal Medicine of Charles University Hospital
and Faculty of Medicine in Hradec Králove, Czech Re-
public, is on a good level, which is seen from the EQ-5D
score (mean value of EQ-5D score of all respondents was
72.5 %) and EQ-5D VAS (mean value of EQ-5D WAS was
76.5 %) values.
Discussion
HSCT is a therapeutic modality used in antitumorous
treatment of haematological malignancies as well as solid
tumors. Apart from that it is also used in the therapy of
non-malignant and hereditary diseases (1, 3, 12, 20). The
process of HSCT is quite challenging for patients for seve-
Tab. 5: Comparison of mean EQ-5D score and EQ-5D VAS
values with religion (n=71, p<0.05).
Tab. 3: Comparison of mean EQ-5D score and EQ-5D VAS
values in individual age groups (n=71, p<0,05).
121
Age Number Mean Standard Mean Standard
range of values of devia- values of devia-
respon- EQ-5D tion EQ-5D tion
dents score VAS
(in %) (in %)
20–29 6 93.3 11.4 79.2 13.6
30–39 8 96.2 5.3 85.0 8.4
40–49 11 89.6 12.7 76.2 15.6
50–59 23 70.2 15.4 67.0 14.0
60–69 17 65.4 9.5 64.1 13.7
70–79 6 57 9.6 64.5 11.1
Number Number Mean Standard Mean Standard
of of values of devia- values of devia-
diseases respon- EQ-5D tion EQ-5D tion
dents score VAS
(in %) (in %)
0 30 83.9 16.4 76.3 12.4
1 13 74.7 18.8 71.5 18.4
2 14 70.9 15.2 66.2 13.0
3 7 71.0 12.8 67.1 12.9
>3 7 56.7 11.4 57.1 14.7
Tab. 4: Comparison of mean EQ-5D score and EQ-5D VAS
values in an increasing number of associated diseases (n=71,
p<0.05).
Religion Number Mean Standard Mean Standard
of values of devia- values of devia-
respon- EQ-5D tion EQ-5D tion
dents score VAS
(in %) (in %)
Believers 43 85.6 12.9 76.6 12.8
Non- 28 60.4 11.9 57.6 12.9believers
Dimension Level of Malignant Multiple
of QoL evaluation lymphoma myeloma
and acute
myeloid
leukaemia
Number rel Rel.
of Respondents
Mobility none troubles 70.8 % 41 %
with troubles 29.2 % 59 %
immobile 00
Self-care none troubles 91.7 % 81.2 %
with troubles 8.3 % 18.8 %
incapable 00
Usual activities none troubles 70.8 % 18.8 %
with troubles 25.0 % 81.2 %
incapable 4.2 % 0
Pain / Discomfort none 66.7 % 28.1 %
weighty 33.3 % 68.8 %
extremely 03 . 1 %
Anxiety / Depression none 75.0 % 41 %
weighty 20.8 % 59 %
extremely 4.2 % 0
Number 38 32of Respondents
Tab. 6: Comparison of respondents with multiple myelo-
ma, malignant lymphoma and acute leukaemia treated with
PBPCT according to the level of troubles.
ral reasons. First of all, there are unwanted effects of syste-
matic chemotherapy, repetitive invasive performances –
central and peripheral vein catetrization, diagnostic aspira-
tion of bone marrow and so on. In men, it is also a question
of sperm taking followed by cryoconservation of seminal
fluid because of the possibility of reproductive organs dys-
function caused by intensive antitumorous therapy (perma-
nent or temporary infertility). Hormonal substitutional
therapy is indicated in young females because of possibility
of damaging the reproductive organs. We also have to con-
sider several weeks of isolation in a sterile box. There is in-
creased sensibility to opportunive infections (bacterial,
viral, fungal, mycoplasmatic etc.) as an affect of bone mar-
row toxicity caused by high-dose chemotherapy. Beside
those symptoms, the patient is loaded with results of toxi-
city caused by high dose chemotherapy (mucositis, gastro-
enteritis, dermatitis, alveolitis, signs of cardiotoxicity and
neurotixicity). A serious complication is acute or chronic
graft-versus-host disease (GVHD), which is the result of
allogeneic transplantation (from a relative or non-relative
donor). Acute GVHD especially affects the liver, mucosa of
intestinal tract and skin. Serious forms can cause death.
Chronic GVHD damage, particularly intestinal tract and
skin, can handicap the patient. By listing all possible risks
and complications, it is necessary to mention that high-
dose chemotherapy followed by HSCT can not 100 % ensu-
re by, that all malignant cells will be eliminate. There is
a possibility of relapse and as an optional treatment we can
again choose high dose chemotherapy followed by HSCT
(1, 3, 6, 12, 16, 20).
In our QoL study, we found three main outcomes in
subjective well-being patients who were able to undergo
high-dose chemotherapy supported by autologous PBPCT.
First, our results show that a lower QoL correlates with
increasing age of patients treated by means of PBPCT. We
think that increasing age correlates with an increasing
number of associated diseases. The QoL of patients with
increasing age should be stressed. Also, we think that in-
creasing overall fatigue and emotional complaints, which
decrease the QoL, correlate with increasing age. De Souza
(8) points this out in his longitudinal study conducted on
a group of 26 patients. Also, this author (8) further ex-
plained his statements by the fact that with increasing age
a number of associated diseases can occur. These diseases
reduce the QoL (8). Choidi (7) also agrees with this opi-
nion in his transversal study conducted on a group of 244
patients with haematological malignancy who underwent
allogeneic BMT. This author (7) also points out the fact that,
in addition to the number of associated diseases, the nega-
tive effects of chronic Graft Versus Host Disease (cGVHD)
on a lower QoL in patients with increasing age should be
stressed. Wang (24), Wong (25) and Andrykowski (2) also
agree with the negative influence of cGVHD on QoL in pa-
tients with increasing age. Zittoun (26) discovered another
interesting piece of information in his transversal study
conducted on a group of 179 patients with haematological
malignancy who underwent HSCT. He points out that in-
creasing overall fatigue and emotional complaints, which
decrease the QoL, correlate with increasing age (26). So
(21) also discovered an interesting piece of information in
his transversal study conducted on a group of 157 patients
with haematological malignancy who underwent BMT. He
proved a high degree of overall fatigue in patients over the
age of 50 with associated diseases (21).
Second, our results show that a lower QoL correlates
with an increasing number of associated diseases. We think
that with the increasing number of associated diseases cor-
relating with overall fatigue along with emotional difficul-
ties in patients with an increasing number of associated
diseases, there is lower overall physical fitness. This causes
a lower QoL. Zittoun (26) discovered an interesting piece
of information which showed the correlation among an in-
creasing number of associated diseases, overall fatigue and
emotional difficulties. Molassiotis (18) also agrees in his
longitudinal study, conducted on a group of 40 patients
after BMT, with the opinion concerning emotional lability.
He evaluated the emotional lability of these patients by
means of Emotional Difficulties Scale (EDS) (18). This
scale was presented to patients before the BMT. Another
scientist who agreed with this opinion was So (21) in his
transversal study conducted on a group of 157 patients with
hematological malignities after BMT. He proved a high de-
gree of overall fatigue in patients over the age of 50 with
associated diseases. Patients were tested by means of Fati-
gue Scale – Chinese Version. Saleh (19) also agrees in his
transversal study conducted on patients after HSCT with
Zittoun’s (26) and So’s (21) opinions. This author stresses
the fact that in patients with an increasing number of as-
sociated diseases there is a lower overall physical fitness,
and this causes a lower QoL. Heinonen (14, 15) recorded in
his longitudinal study, conducted on a group of 109 pa-
tients after allogeneic BMT, a lower QoL in patients in con-
nection with an increasing number of associated diseases,
increased morbidity, increasing overall fatigue and worse
quality of sleep. When he compared polymorbid men and
women after allogeneic BMT, he discovered a lower QoL in
women (14, 15). Edman (9) arrived at similar conclusions
in his transversal study conducted in the group of 25
Swedish patients after allogeneic PBSCT. He states that an
increasing number of associated diseases is associated with
greater physical complaints, increased morbidity, emotio-
nal lability (anxiety and depression), sexual problems and
sleep disorders (9). Patients were divided into 3 groups and
then tested. The first group was tested by means of a gene-
ric Sickness Impact Profile (SIP). The second group was
tested by means of Frequency Intensity and Distress Scale
(SFID-BMT) and the third group by means of Sense of
Coherence Scale (SOC). All three questionnaires evaluate
subjective functional condition, physical complaints and
the ability to cope with a particular disease. Patients were
tested 2 years after allogeneic PBPCT. Edman (9) found no
differences in the QoL evaluation in patients after HSCT.
122
However, physical complaints, sexual problems, increased
morbidity, anxiety, depression and sleep disorders were re-
corded in all three questionnaires and in more than half of
the patients. In the same way as Heinonen (14, 15), he
points out that the above-mentioned complaints are con-
nected with an increasing number of associated diseases.
Third, it is clear from our results that the QoL of pa-
tients treated by means of PBSCT and believing in God was
higher than in patients who were non-believers. We think
that the non-believing patients have to stop various activi-
ties, including interests and hobbies. Entonen (10) and Bach
(4) recorded these changes in values in patients after BMT.
The above-mentioned changes often mean that the patient
has to stop various activities, including his interests and
hobbies (4). Boyd (5) proved significant changes in pa-
tients after HSCT who believed in God. Patients who be-
lieved in God had a higher QoL than non-believers (5).
Fourth, we confirmed in our retrospective study a sta-
tistically significant dependence of QoL of adult patients
treated by means of PBPCT on the type of disease. We
found a most low QoL in the cohort of patients with mul-
tiple myeloma and most high QoL in the cohort of patients
with malignant lymphoma and acute leukaemia treated by
means of PBPCT. Prevailing complaints in the cohort of pa-
tients with multiple myeloma were: 1. regular activity with
complaints 81.2 %, 2. medium serious pain / discomfort
68.8 %, 3. movement with complaints 59 %, 4. medium se-
rious anxiety / depression 59 %. Prevailing complaints in
the cohort of patients with malignant lymphoma and acute
leukaemia were: 1. medium serious pain / discomfort 33.3 %,
2. movement with complaints 29.2 %, regular activity with
complaints 25 %, medium serious anxiety / depression 20.8 %.
Conclusion
In summary, our study is the first probe in QoL of adult
patients treated by means of PBSCT in our country. We are
glad that the global QoL of our adult patients treated by
means of PSCT is on a good level. Yet we understand that
the data interpretation is not unambiguous, and for a more
exact evaluation of our patients’ QoL it would be useful to
carry out a longitudinal study.
This study has limitations. The first is that study deals
only with the effect of selected aspects on the QoL. We
could add a few other aspects but we decided for these as-
pects because patients were able and willing to provide this
information in a retrospectively and anonymously carried
out study. The second is that we used only generic Euro Qol
EQ-5D for evaluation of QoL of adult patients in our study.
We decided for its evaluation because our patients were
able and willing to complete only this QoL questionnaire.
Our patients emphasized that this questionnaire was very
intelligible and especially brief. We could use the originaly
Czech version of Functional Assessement of Cancer Treat-
ment – General Version (FACT – G) Questionnaire or
EORTC QLQ-C30, but our patients responded negatively
in terms of completing one of these QoL questionnaires.
The patients emphasized that this QoL questionnaires is
very comprehensive and time consuming. The third that the
small collection of patients undergoing allogeneic PBPCT.
The fourth is the limited information about the effect of
selected aspects, especially religion, on QoL of patients
treated by means of PBPCT in literature reviews for exten-
sive discussion.
The dimensional module of QoL represents a manifold
approach to a number of life aspects. The affection of seve-
ral aspects could vary, because they depend on the phase of
the disease and treatment. These findings show our know-
ledge about patient needs in a different perspective and
could significantly contribute to the improvement of health
care. They also can discover mechanisms which modify the
disease origin and process (17,20).
Acknowledgements
The study was supported by research project of the Mi-
nistry of Defence of the Czech Republic No. FVZ0000503.
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Corresponding author:
Ladislav Slováček, M.D., Ph.D., major, University of Defence, Faculty of Military Health Science,
Department of Field Internal Medicine, Trebešská 1575, 500 01 Hradec Králové 1, Czech Republic,
e-mail: ladislav.slovacek@seznam.cz
Submitted February 2007.
Accepted April 2007.