**13. HRQoL assessment in MM patients undergoing autologous stem cell transplantation**

HRQoL assessment in this patient setting is important as patients and even clinicians are reluctant to choose this modality for fear of declination of QoL. However, it is not the best choice for every patient. HRQoL studies may contribute to the appropriate patient selection.

In a population-based study, the Nordic Myeloma Study Group found a survival advantage for high-dose therapy and ASCT compared to conventional chemotherapy in MM patients who were less than 60 years of age. HRQoL was integrated into the trial, using the EORTC QLQ-C30 questionnaire. Of the 274 patients receiving intensive therapy, 221 (81%) were compared to 113 (94%) of 120 patients receiving conventional melphalan-prednisone treat‐ ment. Prior to treatment, there were no statistically significant differences in any HRQoL score between the two groups. One month after the start of induction chemotherapy, the patients on intensive treatment had lower scores that gradually improved and at 12 and 24 months, the HRQoL was similar to that of the control patients. At 36 months, there was a trend toward less fatigue, pain, nausea, and appetite loss in the intensive-treatment group. Despite the moderate HRQoL reduction associated with the early intensive chemotherapy phase, the 18 months of prolonged survival seem to be associated with a good HRQoL [30].

QOL results of an Australian study on MM patients who underwent dose-reduced tandem ASCT were published in 2011. Patients younger than 60 years old received conditioning with melphalan 140 mg/m2 and patients who were Older than or equal to 60 years old received 100 mg/m2 . EORTC QLQ-C30 and the QLQ-MY24 questionnaires were conducted after each ASCT and thereafter every 3 months for 24 months. Mean global health measure improved from 3.44 before transplant to 4.50 (1being very poor and 7 being excellent) at the second and subsequent follow-up visits and the mean global QoL score improved from 3.61 to 4.71. Pain symptoms were reduced and physical functioning improved throughout the period of post-transplant follow-up. The study showed that dose-reduced tandem ASCT was well tolerated with low toxicity although there was a transient reduction in QoL during both transplants. Posttransplant follow-up showed significant improvement in overall HRQoL that reflects posi‐ tively on the overall disease-outcome [31].

In a University of Arkansas study, the decreases in functioning after transplantation were less pronounced than anticipated. At stem cell collection, physical deficits were common, with most patients scoring 1 standard deviation below population norms for physical well-being (70.2%) and functional well-being (57.5%), and many reporting at least moderate fatigue (94.7%) and pain (39.4%). Clinically meaningful levels of anxiety (39.4%), depression (40.4%) and cancer-related distress (37.0%) were evident in a notable proportion of patients. After transplantation, there was a worsening of transplant-related concerns, depression and lifesatisfaction. However, pain improved and social functioning was well preserved. Older patients were not more compromised than younger ones. In multivariate analyses, they reported better overall QoL and less depression than before transplantation [32].
