Process of allogeneic hematopoietic cell transplantation decision making for older adults

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Allogeneic hematopoietic cell transplantation (alloHCT) may be the only curative option for some older adults with hematologic malignancies, and its associated risks of significant morbidity and mortality warrant a clear, informed decision-making process. As older adults have not been transplanted routinely until recent years, younger people have been the prototypical group around whom the current process has developed. Yet, this process is applied to older adults who have different considerations than younger patients when making their transplant decision. Older adults do not have the open-ended lives of younger patients and are entitled to consider how to spend their remaining time. They also possess maturity and experience, and with proper knowledge, they can make informed choices rather than moving forward in the transplant process unaware. Notably, older patients face similar problems with the informed decision-making process in nephrology. Strategies such as providing education about alloHCT gradually and repeatedly during induction, presenting recent knowledge from the literature in plain language, and utilizing a team approach to patient education may help older adults make the best decision about transplant in light of their situation and values. Understanding when and how older adults decide on alloHCT is an important first step to further exploring this problem.


Hematologic malignancies, including AML, myelodysplastic syndrome and ALL are more prevalent and biologically more aggressive in older adults than in any other age group (Table 1).1, 2, 3, 4, 5 For these cancers, treatment options that can be used to prolong their lives include allogeneic hematopoietic cell transplantation (alloHCT). AlloHCT may be the only curative option and its associated risks of significant morbidity and mortality warrant a clear, informed decision-making process.

Table 1 Incidence and 5-year relative survival for acute leukemias and common cancers by age

Although bias exists against treating older patients aggressively, studies suggest (although there is no prospective comparison between alloHCT and other consolidation treatments) alloHCT improves their survival.6, 7 Consequently, alloHCT is increasingly being selected as a treatment option for this age group (Figure 1)8 which by the year 2030, may comprise 25% of all survivors.9 As the general population ages, greater numbers of older adults will face the decision to undergo a transplant. Increasingly, treating oncologists will face the decision to refer their older patients for alloHCT, and transplant physicians will face the decision whether or not to proceed with transplant. To this point, Table 1 shows the incidence and 5-year relative survival rates for acute leukemias and common cancers by age group. Given that the 5-year relative survival for adults diagnosed with AML between ages 65 and 74 is only 11.5%, careful attention should be paid to helping them make an informed decision about treatment that will entail consequences for the remaining time they have.

Figure 1

Trends in allogenic transplants by recepient age (transplants for AML, ALL, non-Hodgkin lymphoma, Hodgkin disease and multiple myeloma).8

Differences in decision considerations between younger and older patients

Young patients who are contemplating a long and productive future have one set of criteria, and older adults looking into their golden years typically have another. Building a family, career and socio-economic equity for the future mainly affect younger patients and are irrelevant without longevity. So for them, transplant is the more obvious decision, and studies suggest they decide on transplant before the first hematopoietic cell transplantation (HCT) consultation.10, 11 Most older adults, on the other hand, have done the major things they have set out to do in life. Some older patients may want to try every aggressive therapy available; but for most, the choice whether or not to proceed to alloHCT is complex relative to a younger patient population. Table 2 summarizes and contrasts how considerations change as patients age. However, this paper does not focus on comparing older and younger patients but aims to outline problems older people have within the current system.

Table 2 Differences in decision considerations as patients age

Patients often feel like there is no choice about going to transplant.12 They see the decision as either choosing life (transplant) or choosing death (no transplant). From diagnosis onward, health-care professionals may subtly or not so subtly give the message that the goal is the potentially curative option of transplant. Instead the goal could be to empower a patient to make an informed choice about their treatment plan in light of their situation and values.

The considerations of older adults

Functional considerations

Patients wonder whether they are ‘too old’ for transplant. Although age is a factor, research has shown that co-morbidities and performance status are stronger predictors of survival than age.13, 14, 15, 16 Wedding et al. found that impairment of instrumental activities of daily living was the single most predictive variable of survival in their sample of AML patients ages 19–85 years (median 61.1).13 The ability to perform tasks necessary to live independently in the community, that is, shopping, food preparation, housekeeping, laundry, transportation, handling finances and medication bears most importantly on the survival of older adults. Muffly et al.15 found that the presence of slow walking speed and low mental health before transplant also have prognostic value for poorer survival. Finally, older age and GvHD are principal risk factors for non-relapse death and late death; and even when alloHCT is successful, life expectancy is still lower than expected.17

Patients often report cognitive problems after transplant, and research has shown these problems contribute to higher levels of distress and lower quality of life (QOL).18, 19, 20 Booth-Jones et al.18 found that while younger patients made more subjective cognitive complaints, older patients were more likely to score in the impaired range on objective cognitive tests. Notably, 81% of their sample received autologous HCT and 19% received alloHCT. Syrjala et al.21 found that 41.5% of patients had mild or greater (mostly mild) cognitive impairment 5 years post-alloHCT compared with 19.7% of matched controls. Studies on cognitive changes generally include a large age range and samples of either autologous and alloHCT patients,18, 20, 22 or only patients receiving myeloablative alloHCT.21, 23, 24 To our knowledge, the impact of non-myeloablative alloHCT on cognitive functioning in older adults is not known.

Psychosocial considerations

A patient’s social support system is a vital element of a successful HCT process. In assessing the effect of social support on the 2-year survival of AML patients, Pinquart et al. concluded that social support is relevant to decreased mortality.25 Most centers require patients to have a 24/7 caregiver for a minimum of 3 months after transplant. Therefore, questions that bear on treatment include: is there a caregiver available? Among older adults, the patient may already be providing care to a spouse or partner. If so, is there caregiver support for them both? Overall, is adequate psychosocial support available for an intensive, sometimes prolonged, treatment course?

The financial side effects of costly cancer treatment are attracting increasing attention in the literature.26, 27, 28 As many live on fixed incomes, financial matters are a real concern for older adults considering alloHCT. These include insurance coverage, medication copays and out-of-pocket costs for transportation and relocation, among others. Opportunities to increase their baseline household income after treatment are likely more limited relative to younger patients. Furthermore, older patients may consider leaving inheritance for their family vs spending their savings on cancer treatment.

Khera et al.26 studied the financial burden of alloHCT and its impact on patients’ health behaviors. Of the 268 survey respondents, 73% reported subjective financial burden related to their illness. Concern about medical cost precipitated harmful health behaviors in one-third of the study population; those who were retired were more likely to exhibit treatment noncompliance due to financial reasons. In their study of 1556 cancer survivors, Kent et al.29 concluded that those who reported cancer-related financial problems were more likely to report delaying medical care (18.1 vs 7.4%; P<0.0001) or forgoing medical care (13.5 vs 5.1%; P<0.0001) and prescription medications (13.8 vs 7.7%; P=0.001) than those without financial problems.29 Arora et al.30 found that patients with low income were over three times as likely to report frailty after transplant.23 Therefore, financial stress negatively impacts patients’ long-term health and ongoing treatment decisions.

From a functional and psychosocial standpoint, alloHCT is a taxing therapy that can take a toll on a patient’s QOL. In a study by Sekeres et al., 97% of AML and myelodysplastic syndrome patients age 60 and older reported that QOL was more important to them than length of life.31 A review article by Pidala et al.32 found that older age, advanced disease at transplant, chronic GvHD, lower functional status and less social support were predictors of poorer QOL post-HCT. In contrast, Hamilton et al.33 found that older survivors achieved comparable QOL to younger survivors.

Studies generally agree that recovery after alloHCT takes years and that physical recovery occurs more quickly than psychological recovery.34, 35 An estimated 43% of survivors experience clinically significant psychological distress,19 and 5–13% exhibit symptoms of post-traumatic stress disorder.36, 37 Furthermore, Lee et al. found a statistically significant association between psychosocial distress and medication noncompliance.38

Survivors with chronic GvHD report significantly lower QOL when compared with age- and sex-matched normative data,39 are three times as likely to report frailty as the general population, are at risk for accelerated aging and require more frequent medical visits to manage their morbidity.30 In contrast, Deschler et al.40 found that a sample of 160 older adults (60) receiving reduced-intensity conditioning alloHCT evaluated their global QOL as good or excellent post-transplant.

To explain the high ratings among survivors with objective impairments, it has been suggested that they may evaluate their QOL favorably in comparison with much poorer quality during treatment. Also, for survivors, QOL may simply mean that they are alive.35, 41 In a focus group study, patients and caregivers agreed presenting a range of possible QOL outcomes was an important part of the decision process. Although the majority indicated additional information would not have changed their decision, some participants reported they would have decided against transplant if they had known their caregiver’s and their own QOL outcome.41

Sources of information before HCT

HCT team members possess the most critical information patients need to know. However, patients have very limited access to information directly from the HCT team during induction. Instead, they may receive information from various sources including their referring oncologist, oncology ward staff, the Internet, family members, friends and publications from patient advocacy organizations. The quality of information from these sources can range from precise to inaccurate or uninformative.42 Some patients find it helpful to speak with a peer who has gone through transplant.41 The survivor can share their experience and what helped them. However, it must be acknowledged that these survivors are a biased sample, as they are the ones with the best outcomes, not the ones who died or who live with significant morbidity.

Information about transplant for their specific case is provided during a consultation with a transplant physician. During this visit, medical information regarding the general process, donor sources, specific protocol, timeline, risks, benefits and outcomes is presented. At some centers, the social worker also meets with the patient/family to provide information about psychosocial needs. All of this is typically presented after induction, when the patient has attained remission and needs to move to transplant quickly. At this point, their cognitive abilities are altered by chemotherapy, they are still adjusting to a new, life-threatening diagnosis and they may not even know what questions to ask. Older adults have more difficulty processing and remembering new information; they benefit from having it repeated.43 Some also benefit from having questions suggested to them.43, 44

The language and concepts of alloHCT are complex and unfamiliar, and the information presented is a great deal to grasp during one session. Low health literacy and high emotions impede the understanding of information. Demands on providers limit the time they can spend with any one patient,45 and what the physician communicates and what the patient hears and remembers can differ greatly.11, 31, 46, 47 Furthermore, physician training has historically not included communication skills, though this may be beginning to change.45 It is a challenging setting for clear dialogue between the patient/family and the members of their treatment team.

Risks and outcomes are often presented in statistical terms that patients have difficulty understanding and relating to their particular case.48 For example, Sekeres et al.31 found that patients tend to overestimate their chances for cure as well as 1-year survival, and Pisu et al.11 reported patients recalled a lower mortality risk than communicated by their physicians. In general, patients want to know their chances of survival, but the population’s median mortality statistic is not the reality for any individual patient. This is difficult to grasp for many patients and requires careful explanation.49 Risk and outcome statistics need to be translated into useful knowledge for the patient. Perhaps most relevant for patients are (1) where they are most likely to land on the survival curve, given their risk factors and (2) what can they do to ensure their best chances of landing in the extended tail of the curve?50

Older patients with other diseases: decision making in nephrology

Although we use aggressive hematological malignancies (AML, myelodysplastic syndrome and ALL) as a model to highlight problems older adults face when making an alloHCT decision, older patients with other illnesses also face these problems in the medical system. For example, nephrology literature highlights similar themes with older adults facing decisions about dialysis and kidney transplantation.51, 52, 53, 54, 55, 56 The incidence of end stage renal disease is increasing more quickly among older adults than any other age group and is associated with a low QOL and high mortality.51 Given this trend, nephrology practice guidelines were developed to promote patients’ active participation in the decision-making process.56

Multiple studies suggest that patients with chronic kidney disease may not receive adequate information to inform their treatment choices.57, 58, 59 Information about treatment options is often provided to patients after vascular access is created (for one-third of patients, after dialysis has commenced), a timing problem that seems to strongly influence the choice of hemodialysis over other options.60

Morton et al.60 suggest that understanding the factors that influence decision making can help inform patient education programs and enhance communication among providers, patients and families. They conducted thematic analysis of 18 studies and discovered four themes central to nephrology patients’ treatment decisions: confronting mortality (choosing life or death); lack of choice (lack of information); gaining knowledge of options (peer influence and timing of information); and weighing alternatives (maintaining lifestyle and family influences).60

What can be done?

Improve knowledge

Increase duration of time of learning

How can an HCT team help maximize their patient’s ability to make an informed choice? In a thorough discussion, D’Souza et al.12 captured many pitfalls in the current HCT informed consent process and concluded that new avenues should be sought to help patients make an informed decision. They suggested opportunities for improvement including the use of interactive technology, consideration about what information is actually meaningful for the patient’s decision and enhancement of the consent forms. They also provided an example of a consent process that includes two physician visits before the consent visit, with the transplant coordinator available in between to help reinforce information.12

There is little time between diagnosis and transplant; therefore, it has been suggested that an effective decision-making collaboration among patients, treating oncologists and transplant physicians starts immediately after diagnosis.6 This collaboration may also include geriatricians and palliative care physicians. On the basis of Posma et al.'s43 work, older adults considering transplant may benefit from receiving information in a step-by-step manner throughout induction. This approach is also supported by evidence that patients with chronic kidney disease and their families preferred to receive information about treatment options as early as possible in order to absorb it and adjust to the approaching treatment, regardless of whether or not they chose home hemodialysis or palliative care.60

Finally, a study of AML patients by Bertoli et al.61 showed that the time from diagnosis to initiation of intensive chemotherapy (median 8 days, interquartile range 4–16 days) had no impact on overall survival, response rate or early death. Therefore, it may behove older adults to wait for testing that can inform targeted and more tolerable therapy options in patients who are not critically ill.61

Improve sources

A large volume of information about HCT is available from various sources, and older adults may benefit from assistance to narrow down what is actually meaningful for their decision.12, 43 Patients rely on their team members to share in plain language the knowledge that bears on their treatment decision. This should include knowledge from the most recent literature that pertains to their individual medical/psychosocial situation, rather than following the only protocol that may result in a cure. Alternative options with less burden than alloHCT are reasonable for older adults and need to be presented as such.45 These options include supportive therapy (transfusions, antibiotics as needed, easily administered oral medications, SC injections at home or less frequent IV chemotherapies). Medicine needs to progress quickly to better understand outcomes in older adults.

Some geriatric assessment measures may have prognostic value for older patients facing HCT and may be useful for patient selection.15 The results could also be used to inform patients selecting their treatment option. Geriatric assessment tools are designed to evaluate an older person’s functional ability, physical health, cognition, mental health and socioenvironmental circumstances.62 They can include activities of daily living, instrumental activities of daily living, walking speed, chair rise test, frailty testing, cognitive testing, falls assessment, depression screening and nutritional assessment. The geriatrician’s assessment can inform the development of the treatment plan and aid meaningful conversations between clinicians, patients and families.62, 63, 64

Increasing the patient’s access to the HCT team members during induction may benefit their decision-making process. Team members including the physician, nurse coordinator, nurse on the inpatient HCT ward, social worker, pharmacist and financial case manager have specific knowledge that bears on older adults’ functional, psychosocial, financial and QOL considerations. This team approach to educating the patient has been suggested for cancer, surgical and dialysis patients as well as for a general patient education protocol.45, 65, 66, 67 In addition, web-based programs,12, 45 Q&A groups, and other formats could be used to present the information. In partnership with three transplant centers, the National Marrow Donor Program/Be the Match is conducting a qualitative study to identify HCT-related information needs and learning preferences for older adult patients and their caregivers.

Providing education in a way that facilitates an older adult’s transplant decision is a paradigm shift from the current informed consent model and would require staff education. Table 3 summarizes problems with the current system and suggests solutions. Some of these solutions may also benefit older adults considering autologous transplant, even though the risks of morbidity and mortality are much lower.

Table 3 Problems with the current decision-making framework and possible solutions

Some patients (regardless of age) prefer to have less information and let their physician guide the decision.12, 43, 44 Even so, their preference for information may change, so it is necessary to check-in with them along the way.45 Most patients may ultimately base their decision on emotional and intuitive factors, and not on a rational consideration of risks, benefits and other objective factors.10 Even so, the HCT team needs to do their utmost to educate patients, engage them in dialogue and honor their right to choose.

Discover when and how older adults decide

We know almost nothing about older adults’ personal decision-making processes as they follow a trajectory of induced remission on to transplant. Furthermore, we don’t know when it is they actually decide. In order to provide quality care to older adults, it is essential to understand the patient within the process. What considerations (QOL, psychosocial and financial) weigh on their minds? When are they less certain and more certain about going to transplant? To what extent do they utilize intuition, statistics, input from family or other ways of knowing: how do they arrive at their decision? What helps them during the consideration phase, and why do they make the decision they do?

A study can be designed to let the patient tell us about their state of mind and receptivity to information during induction and up to transplant. These likely evolve over time and/or differ with phases of treatment, so tracking the progression of the sample over time would be important. Two key questions arise: (1) what is the patient’s process; and (2) when do they decide. The answers guide the presentation of information by the HCT team and may inform novel solutions to improve the current system.

Patients want messages of hope from their physicians, and reality for patients considering alloHCT is usually frightening. Consequently, the system tends to protect the patient from potentially upsetting information about the therapy.12 Nevertheless, with proper knowledge, older adults can make informed choices rather than moving forward in the process unaware, hoping they will come out the other side well, and potentially living with regret if the other side is nothing like they thought it would be.


  1. 1

    Gökbuget N . How I treat older patients with ALL. Blood 2013; 122: 1366–1375.

  2. 2

    Klepin HD, Rao AV, Pardee TS . Acute myeloid leukemia and myelodysplastic syndromes in older adults. J Clin Oncol 2014; 32: 2541–2552.

  3. 3

    Ustun C, Marcucci G . Emerging diagnostic and therapeutic approaches in core binding factor acute myeloid leukaemia. Curr Opin Hematol 2015; 22: 85–91.

  4. 4

    SEER Cancer Statistics Factsheets [Internet]. National Cancer Institute. Bethesda, MD; Available from Accessed on 30 June 2015.

  5. 5

    Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF et al (eds). SEER Cancer Statistics Review, 1975-2012 [Internet]. National Cancer Institute, Bethesda, MD, 2014. Available from Accessed on 30 June 2015.

  6. 6

    Ustun C, Lazarus HM, Weisdorf D . To transplant or not: a dilemma for treatment of elderly AML patients in the twenty-first century. Bone Marrow Transplant 2013; 48: 1497–1505.

  7. 7

    Hahn T, McCarthy PL, Hassebroek A, Bredeson C, Gajewski JL, Hale GA et al. Significant improvement in survival after allogeneic hematopoietic cell transplantation during a period of significantly increased use, older recipient age, and use of unrelated donors. J Clin Oncol 2013; 31: 2437–2449.

  8. 8

    Pasquini MC, Zhu X Current uses and outcomes of hematopoietic stem cell transplantation: 2014 CIBMTR Summary Slides. Available from Accessed on 1 September 2015.

  9. 9

    Majhail NS, Tao L, Bredeson C, Davies S, Dehn J, Gajewski JL et al. Prevalence of hematopoietic cell transplant survivors in the United States. Biol Blood Marrow Transplant 2013; 19: 1498–1501.

  10. 10

    Jacoby LH, Maloy B, Cirenza E, Shelton W, Goggins T, Balint J . The basis of informed consent for BMT patients. Bone Marrow Transplant 1999; 23: 711–717.

  11. 11

    Pisu S, Caocci G, d’ Aloja E, Efficace F, Vacca A, Piras E et al. Reassessing the approach to informed consent: the case of unrelated hematopoietic stem cell transplantation in adult thalassemia patients. Philos Ethics Humanit Med 2014; 9: 13.

  12. 12

    D’Souza A, Pasquini M, Spellecy R . Is ‘informed consent’ an ‘understood consent’ in hematopoietic cell transplantation? Bone Marrow Transplant 2015; 50: 10–14.

  13. 13

    Wedding U, Röhrig B, Klippstein A, Fricke H-J, Sayer HG, Höffken K . Impairment in functional status and survival in patients with acute myeloid leukaemia. J Cancer Res Clin Oncol 2006; 132: 665–671.

  14. 14

    Walter RB, Othus M, Borthakur G, Ravandi F, Cortes JE, Pierce SA et al. Prediction of early death after induction therapy for newly diagnosed acute myeloid leukemia with pretreatment risk scores: a novel paradigm for treatment assignment. J Clin Oncol 2011; 29: 4417–4423.

  15. 15

    Muffly LS, Kocherginsky M, Stock W, Chu Q, Bishop MR, Godley LA et al. Geriatric assessment to predict survival in older allogeneic hematopoietic cell transplantation recipients. Haematologica 2014; 99: 1373–1379.

  16. 16

    Deschler B, Ihorst G, Platzbecker U, Germing U, März E, de Figuerido M et al. Parameters detected by geriatric and quality of life assessment in 195 older patients with myelodysplastic syndromes and acute myeloid leukemia are highly predictive for outcome. Haematologica 2013; 98: 208–216.

  17. 17

    Wingard JR, Majhail NS, Brazauskas R, Wang Z, Sobocinski KA, Jacobsohn D et al. Long-term survival and late deaths after allogeneic hematopoietic cell transplantation. J Clin Oncol 2011; 29: 2230–2239.

  18. 18

    Booth-Jones M, Jacobsen PB, Ransom S, Soety E . Characteristics and correlates of cognitive functioning following. Bone Marrow Transplant 2005; 36: 695–702.

  19. 19

    Rusiewicz A, DuHamel KN, Burkhalter J, Ostroff J, Winkel G, Scigliano E et al. Psychological distress in long-term survivors of hematopoietic stem cell transplantation. Psychooncology 2008; 17: 329–337.

  20. 20

    Harder H, Cornelissen JJ, Van Gool AR, Duivenvoorden HJ, Eijkenboom WMH, van den Bent MJ . Cognitive functioning and quality of life in long-term adult survivors of bone marrow transplantation. Cancer 2002; 95: 183–192.

  21. 21

    Syrjala KL, Artherholt SB, Kurland BF, Langer SL, Roth-Roemer S, Elrod JB et al. Prospective neurocognitive function over 5 years after allogeneic hematopoietic cell transplantation for cancer survivors compared with matched controls at 5 years. J Clin Oncol 2011; 29: 2397–2404.

  22. 22

    Jacobs SR, Small BJ, Booth-Jones M, Jacobsen PB, Fields KK . Changes in cognitive functioning in the year after hematopoietic stem cell transplantation. Cancer 2007; 110: 1560–1567.

  23. 23

    Syrjala KL, Dikmen S, Langer SL, Roth-Roemer S, Abrams JR . Neuropsychologic changes from before transplantation to 1 year in patients receiving myeloablative allogeneic hematopoietic cell transplant. Blood 2004; 104: 3386–3392.

  24. 24

    Sostak P, Padovan CS, Yousry TA, Ledderose G, Kolb H-J, Straube A . Prospective evaluation of neurological complications after allogeneic bone marrow transplantation. Neurology 2003; 60: 842–848.

  25. 25

    Pinquart M, Höffken K, Silbereisen RK, Wedding U . Social support and survival in patients with acute myeloid leukaemia. Support Care Cancer 2007; 15: 81–87.

  26. 26

    Khera N, Chang Y, Hashmi S, Slack J, Beebe T, Roy V et al. Financial burden in recipients of allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2014; 20: 1375–1381.

  27. 27

    Khera N . Reporting and grading financial toxicity. J Clin Oncol 2014; 32: 3337–3338.

  28. 28

    De Souza JA, Yap BJ, Hlubocky FJ, Wroblewski K, Ratain MJ, Cella D et al. The development of a financial toxicity patient-reported outcome in cancer: the COST measure. Cancer 2014; 120: 3245–3253.

  29. 29

    Kent EE, Forsythe LP, Yabroff KR, Weaver KE, de Moor JS, Rodriguez JL et al. Are survivors who report cancer-related financial problems more likely to forgo or delay medical care? Cancer 2013; 119: 3710–3717.

  30. 30

    Arora M, Sun C, Ness K, Teh JB, Schad A, Hanby C et al. Older survivors of allogeneic hematopoietic cell transplantation (HCT) with chronic graft vs. host disease (cGvHD) demonstrate higher risk of frailty as compared with autologous hct recipients: a report from the Bone Marrow Transplant Survivor Study-2. Biol Blood Marrow Transpl 2015; 21: S72–S73.

  31. 31

    Sekeres MA, Stone RM, Zahrieh D, Neuberg D, Morrison V, De Angelo DJ et al. Decision-making and quality of life in older adults with acute myeloid leukemia or advanced myelodysplastic syndrome. Leukemia 2004; 18: 809–816.

  32. 32

    Pidala J, Anasetti C, Jim H . Quality of life after allogeneic hematopoietic cell transplantation. Blood 2009; 114: 7–19.

  33. 33

    Hamilton BK, Rybicki L, Dabney J, McLellan L, Haddad H, Foster L et al. Quality of life and outcomes in patients60 years of age after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2014; 49: 1426–1431.

  34. 34

    Syrjala KL, Langer SL, Abrams JR, Storer B, Sanders JE, Flowers MED et al. Recovery and long-term function after hematopoietic cell transplantation for leukemia or lymphoma. JAMA 2004; 291: 2335–2343.

  35. 35

    Mosher CE, Redd WH, Rini CM, Burkhalter JE, DuHamel KN . Physical, psychological, and social sequelae following hematopoietic stem cell transplantation: a review of the literature. Psychooncology 2009; 18: 113–127.

  36. 36

    Smith MY, Redd W, DuHamel K, Vickberg SJ, Ricketts P . Validation of the PTSD Checklist-Civilian Version in survivors of bone marrow transplantation. J Trauma Stress 1999; 12: 485–499.

  37. 37

    DuHamel KN, Ostrof J, Ashman T, Winkel G, Mundy EA, Keane TM et al. Construct validity of the posttraumatic stress disorder checklist in cancer survivors: analyses based on two samples. Psychol Assess 2004; 16: 255–266.

  38. 38

    Lee SJ, Loberiza FR, Antin JH, Kirkpatrick T, Prokop L, Alyea EP et al. Routine screening for psychosocial distress following hematopoietic stem cell transplantation. Bone Marrow Transplant 2005; 35: 77–83.

  39. 39

    Pidala J, Kurland B, Chai X, Majhail N, Weisdorf DJ, Pavletic S et al. Patient-reported quality of life is associated with severity of chronic graft-versus-host disease as measured by NIH criteria: report on baseline data from the Chronic GVHD Consortium. Blood 2011; 117: 4651–4657.

  40. 40

    Deschler B, Binek K, Ihorst G, Marks R, Wäsch R, Bertz H et al. Prognostic factor and quality of life analysis in 160 patients aged ≥60 years with hematologic neoplasias treated with allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2010; 16: 967–975.

  41. 41

    Jim HSL, Quinn GP, Gwede CK, Cases MG, Barata A, Cessna J et al. Patient education in allogeneic hematopoietic cell transplant: what patients wish they had known about quality of life. Bone Marrow Transplant 2014; 49: 299–303.

  42. 42

    National Institute on AgingOnline Health Information: Can You Trust It? [Internet], 2011 [cited 2015 Feb 17]. Available from Accessed on 17 February 2015.

  43. 43

    Posma ER, Weert JC, van Jansen J, Bensing JM . Older cancer patients’ information and support needs surrounding treatment: an evaluation through the eyes of patients, relatives and professionals. BMC Nurs 2009; 8: 1.

  44. 44

    Xuereb MC, Dunlop R . The experience of leukaemia and bone marrow transplant: searching for meaning and agency. Psychooncology 2003; 12: 397–409.

  45. 45

    Kane HL, Halpern MT, Squiers LB, Treiman KA, McCormack LA . Implementing and evaluating shared decision making in oncology practice. CA Cancer J Clin 2014; 64: 377–388.

  46. 46

    Weeks JC, Catalano PJ, Cronin A, Finkelman MD, Mack JW, Keating NL et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J Med 2012; 367: 1616–1625.

  47. 47

    Rothberg MB, Sivalingam SK, Ashraf J, Visintainer P, Joelson J, Kleppel R et al. Patients’ and cardiologists’ perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med 2010; 153: 307–313.

  48. 48

    Discussing Cancer Prognosis | Cancer Network [Internet], 2015 [cited 2015 Mar 26]. Available from Accessed on 25 March 2015.

  49. 49

    Levin TT . Discussing cancer prognosis. Oncology (Williston Park) 2015; 29: 142–144, C3.

  50. 50

    Gould SJ . The median isn’t the message. Discover 1985. Accessed on 12 March 2014.

  51. 51

    Collins AJ, Kasiske B, Herzog C, Chavers B, Foley R, Gilbertson D et al. United States Renal Data System 2006 Annual Data Report Abstract. Am J Kidney Dis 2007; 49: A6–A7.

  52. 52

    Murtagh FEM, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE . Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007; 22: 1955–1962.

  53. 53

    Carson RC, Juszczak M, Davenport A, Burns A . Is maximum conservative management an equivalent treatment option to dialysis for elderly patients with significant comorbid disease? Clin J Am Soc Nephrol 2009; 4: 1611–1619.

  54. 54

    Kurella Tamura M, Covinsky KE, Chertow GM, Yaffe K, Landefeld CS, McCulloch CE . Functional status of elderly adults before and after initiation of dialysis. N Engl J Med 2009; 361: 1539–1547.

  55. 55

    Rao PS, Merion RM, Ashby VB, Port FK, Wolfe RA, Kayler LK . Renal transplantation in elderly patients older than 70 years of age: results from the Scientific Registry of Transplant Recipients. Transplantation 2007; 83: 1069–1074.

  56. 56

    Galla JH . Clinical practice guideline on shared decision-making in the appropriate initiation of and withdrawal from dialysis. J Am Soc Nephrol 2000; 11: 1340–1342.

  57. 57

    Mehrotra R, Marsh D, Vonesh E, Peters V, Nissenson A . Patient education and access of ESRD patients to renal replacement therapies beyond in-center hemodialysis. Kidney Int 2005; 68: 378–390.

  58. 58

    Heaf J . UNderutilization of peritoneal dialysis. JAMA 2004; 291: 740–742.

  59. 59

    The USRDS Dialysis Morbidity and Mortality Study: Wave 2. US Renal Data System. USRDS 1997 Annual Data Report. National Institutes of Health, USRDS Coordinating Center, Ann Arbor, MI, USA, pp 49–68.

  60. 60

    Morton RL, Tong A, Howard K, Snelling P, Webster AC . The views of patients and carers in treatment decision making for chronic kidney disease: systematic review and thematic synthesis of qualitative studies. BMJ 2010; 340: c112.

  61. 61

    Bertoli S, Bérard E, Huguet F, Huynh A, Tavitian S, Vergez F et al. Time from diagnosis to intensive chemotherapy initiation does not adversely impact the outcome of patients with acute myeloid leukemia. Blood 2013; 121: 2618–2626.

  62. 62

    Elsawy B, Higgins KE . The geriatric assessment. Am Fam Physician 2011; 83: 48–56.

  63. 63

    Fukuse T, Satoda N, Hijiya K, Fujinaga T . Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest 2005; 127: 886–891.

  64. 64

    Aaldriks AA, Maartense E, le Cessie S, Giltay EJ, Verlaan HACM, van der Geest LGM et al. Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol Hematol 2011; 79: 205–212.

  65. 65

    Johansson K, Leino-Kilpi H, Salanterä S, Lehtikunnas T, Ahonen P, Elomaa L et al. Need for change in patient education: a Finnish survey from the patient’s perspective. Patient Educ Couns 2003; 51: 239–245.

  66. 66

    Rantanen M, Kallio T, Johansson K, Salanterä S, Virtanen H, Leino-Kilpi H . Knowledge expectations of patients on dialysis treatment. Nephrol Nurs J 2008; 35: 249–255 quiz 256.

  67. 67

    Rankinen S, Salanterä S, Heikkinen K, Johansson K, Kaljonen A, Virtanen H et al. Expectations and received knowledge by surgical patients. Int J Qual Health Care 2007; 19: 113–119.

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Randall, J., Keven, K., Atli, T. et al. Process of allogeneic hematopoietic cell transplantation decision making for older adults. Bone Marrow Transplant 51, 623–628 (2016) doi:10.1038/bmt.2015.241

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