In our study results, the vast majority of patients were treated with chemotherapy and the BEAM protocol and had a long hospital stay (Table 1). It is thought that the length of hospital stay is long because the SCT process is a difficult treatment option and patients experience various symptoms related to transplantation. It was determined that chemotherapy and the BEAM protocol were often applied in SCT [14, 19, 20], and that prolonged hospitalization times were observed [21]. The reason for examining the treatments was to increase the awareness of nurses applying chemotherapy protocols about patients with lymphoma undergoing SCT. In our findings, the count of cures applied to patients in remission was found to be significantly higher. It is recommended to examine the effectiveness of the count of chemotherapy cures in further studies.
In our study, it was found that patients with lymphoma undergoing SCT frequently experienced oral mucositis, febrile neutropenia, and anemia. Also, the frequency of symptoms experienced in the remission group was higher than that in the relapse group (Table 2). Nurses should provide patients with education on the prevention and management of symptoms and monitor their symptoms frequently in line with individual needs. It is important to use evidence-based guidelines in patient care, especially on symptom management. Additionally, with the developing technology, the need for programs that can support distance communication between patients and healthcare professionals and provide distance symptom management in emergencies is increasing.
In our study findings, the incidence of skin GVHD was found to be significantly higher in patients with relapse (Table 2). The reasons for this situation may be related to the diversity of SCT, disease progression, and the coexistence of more than one symptom. In SCT, it is necessary to be careful about the risks that may be caused by GVHD, as it increases the mortality and relapse rate. In a study, it was stated that GVHD increased the relapse status [22, 23], and the severity of symptoms experienced along with GVHD increased. In another study, it was reported that the BEAM protocol could be used as an alternative treatment option in the process of curing GVHD. Additionally, it was stated that the burden of other symptoms decreased rapidly during the recovery phase of GVHD [24]. In a systematic review, oral mucositis was reported in 79.7% of patients who received high-dose chemotherapy before SCT [25]. In a meta-analysis investigating the risk factors for febrile neutropenia in patients with lymphoma undergoing autologous SCT and were followed up as inpatient and outpatient, the risk of febrile neutropenia was found to be significantly lower in patients undergoing outpatient SCT compared to the inpatient group (p < 0.001) [26]. GVHD appears to be a common symptom. For this reason, nurses should educate patients with lymphoma on the early signs of GVHD during the SCT process, consider the possibility of relapse in patients who come to the clinic with GVHD and provide appropriate nursing care for their symptoms associated with severe immunological reactions and organ dysfunction due to GVHD.
Patients were found to most frequently receive oral care, antibiotics, G-CSF, antipyretic, erythrocyte transfusion, antifungal, and antiviral treatments for the symptoms after SCT. Antifungal, analgesic, or anticoagulant treatments for patients with relapse were found to be significant compared with patients in remission (Table 3). As a result of the study examining the prophylaxis of febrile neutropenia in patients with lymphoma undergoing autologous SCT, it was reported that the use of G-CSF was beneficial in terms of infection risks that may occur in patients and contributes to the reduction of the burden of other symptoms [27]. It was stated that febrile neutropenia was among the most common reasons for hospitalization in patients undergoing autologous SCT and that the use of antibiotics increased patients’ quality of life and reduced hospital admissions [28]. In our study results, it was found that there were similarities between the symptoms experienced by patients with lymphoma and the treatments applied. Oral mucositis, febrile neutropenia, and anemia symptoms were among the reasons for using the treatments applied accordingly. Patients diagnosed with lymphoma undergoing SCT should be educated by nurses about side effects related to treatment practices and they should be followed up for these side effects.
In our study, it was found that febrile neutropenia was significantly more common in the 18–64 age group, and oral intake impairment was found to be significantly higher in patients with lymphoma in the 65–74 age group (Table 4). As a result of autologous SCT applied to elderly patients with lymphoma by Sun et al., it was stated that patients between the ages of 70 and 79 often experienced thrombocytopenia [29]. Oral intake disorder due to old age is an expected symptom, and this symptom may increase further after SCT. In line with these findings, patients with lymphoma should be provided with nursing care, considering the age group characteristics and age-related changes.
Febrile neutropenia was significantly higher in male patients and oral intake impairment was significantly higher in female patients in terms of symptoms observed after SCT by gender (Table 4). The prevalence of anemia and nutrition-related symptoms in females and infection-related symptoms and low IGg in males after SCT is noteworthy. It is recommended that symptoms experienced by gender should be compared in studies with larger sample groups.
In this study, oral mucositis in all patients with lymphoma and DM and pain and vomiting symptoms in patients without DM was significantly higher (Table 4). Considering the findings, such as delay in the wound healing process in diabetes and decrease in neuropathy-related pain sensation, nursing care and symptom management of patients with diabetes and lymphoma should be strengthened. In this study, anemia, skin GVHD, and thrombocytopenia symptoms were found to be significantly higher in patients with hypertension (Table 4). Long-term and continuous follow-up is necessary so that health professionals can apply appropriate and timely treatment to patients [30]. In line with these findings, it is thought that continuous comprehensive evaluation of patient's health status will improve their outcomes, as they experience various symptoms based on their age groups and chronic disease status. It is recommended that investigate the causal relationships between hypertension and diabetes and symptoms seen after SCT in further studies.
In our study, the incidence of thrombocytopenia/bleeding after SCT was significantly higher in lymphoma patients with metastasis (Table 5). It is important to educate patients with lymphoma with metastasis, particularly in terms of thrombocytopenia/bleeding symptoms, which is one of the most vital symptoms, and to follow up with them closely. The study findings indicated that the symptoms of pain, skin GVHD, and GIS GVHD were more intense in patients with allogeneic SCT (Table 5). In the study by Peng et al., (2021) it was reported that patients undergoing allogeneic SCT most frequently experienced GVHD, infection, and bleeding symptoms. In one study, it was stated that the symptoms seen in patients varied depending on treatment options and metastasis status, while it was reported that the count of SCTs did not cause any change in symptoms experienced them [20]. In another study, it was reported that patients most frequently experienced febrile neutropenia symptoms after intense chemotherapy [21]. It can be said that as the count of SCTs increases, the symptoms experienced by patients increase, as well. For this reason, patients must be supported by nurses in symptom management in every process of SCT. In our findings, oral mucositis was significantly higher in patients treated with chemotherapy alone, and dyspnea was significantly higher in those treated with both chemotherapy and radiotherapy. Additionally, it was found that febrile neutropenia, anemia, pain, and cough symptoms were more common in patients who received both chemotherapy and radiotherapy (Table 5). Patients with lymphoma should be provided with nursing care, particularly in terms of symptoms, such as oral mucositis, dyspnea, febrile neutropenia, anemia, pain, and cough, considering the type of treatment applied and the area of radiotherapy.
In our study results, it was found that the symptoms of anemia and diarrhea observed in patients after SCT were associated with the count of cures. Additionally, it was determined that patients with febrile neutropenia and secretion symptoms had a short hospital stay. Patients with thrombocytopenia/bleeding symptoms had a longer hospital stay (Table 6). In a study, it was reported that the most common symptoms experienced by patients after intensive chemotherapy were febrile neutropenia, oral mucositis, and nausea/vomiting. Chuang et al. stated that patients’ length of stay varied by the count of cures [31]. Oral mucositis and febrile neutropenia are the most common symptoms during the follow-up of the symptoms of patients with lymphoma and they affect the hospitalization process [26]. It is thought that it is important to educate patients to prevent febrile neutropenia and thrombocytopenia/bleeding, which are the most vital risks for patients with lymphoma, and these symptoms should be a health care priority in patients after SCT. It is necessary to make an early diagnosis of symptoms of patients with lymphoma as expected symptoms of intensive chemotherapy protocols, initiate an effective treatment as soon as possible and perform evidence-based nursing interventions. Thus, it is thought that the symptom load of patients can be alleviated in a short time, the length of hospital stay may be shortened, and their comfort, well-being, quality of life, and life span can be increased.
Limitations
This study has several limitations. The study data were obtained retrospectively from the HIMS database. Also, all 74 patients could not be included in the study due to incomplete data in some patients’ medical records.