Presenter: Nosha Farhadfar MD, UF Health Blood and Marrow Transplant Program
Recorded May 4, 2019 at the 2019 Celebrating a Second Chance at Life Survivorship Symposium in Orlando, Florida
Summary: Patients who undergo a stem cell transplant using their own cells (an autologous transplant) have an increased risk of heart disease, infection, pulmonary problems and sexual dysfunction. Careful monitoring and a healthy lifestyle can reduce the risk of developing serious problems.
Highlights of Presentation:
• A personal survivorship care plan, developed for you by your transplant team, can help you and your doctors monitor and prevent, complications after transplant
• Re-vaccination is recommended for autologous transplant recipients by the Centers for Disease Control
• Lifestyle changes and monitoring for cholesterol and blood pressure can reduce the risk of heart disease in transplant recipients
Key Points:
06:07: 50% of transplant survivors have at least one chronic health issue after transplant
08:17: The risk of heart disease is five times higher in transplant survivors than in the general population
12:50: Bone loss after transplant can be caused by some types of cancer, long-term steroid use, a sedentary lifestyle or smoking
16:17: Up to 50% of patients have reactivation of the shingles virus after transplant
20:09: The Shingrix® vaccine is safe and 90% effective in preventing shingles, which is common after transplant
22:13: Most lung problems after an autologous stem cell transplant are due to infection or toxicity from chemotherapy or radiation
25:30: Nearly half of transplant survivors, both men and women, report sexual problems after transplant
28:17: Transplant survivors have a slightly increased risk of developing a secondary cancer after transplant
32:48: General guidelines to help prevent and treat late complications after transplant are available from BeTheMatch.org
34:51: Transplant recipients should have a personal survivorship care plan from their transplant center, based on their specific disease and treatment history.
Transcript of Presentation
00:00 Introduction of Dr. Farhadfar: Welcome to today's presentation, Strive to Thrive: How to Protect Your Health after a Transplant Using your Own Stem Cells, also called an autologous stem cell transplant. Our presenter today is Dr. Nosha Farhadfar. Dr. Farhadfar is assistant professor of medicine at the University of Florida Health Blood and Marrow Transplant Program. There she heads up the chronic graft-versus-host disease, and long-term follow-up clinic.
Dr. Farhadfar's research is focused on better understanding complications after transplant, and interventions to reduce the effects of complications and optimize quality of life. She is currently conducting clinical trials, evaluating the relationship between diet, gut flora, and their possible effects on daily health for transplant survivors. I look forward to hearing her excellent presentation. Welcome, Dr. Farhadfar.
01:00 Thank you Sue. It is a great honor and privilege to be here to speak with all of you today. Before I begin, I would like to thank Sue and the BMT InfoNet staff for organizing this wonderful symposium. More importantly, thank you for coming and showing interest in this topic, and I hope to answer many of your questions at the end of the presentation. The topic today is how to thrive after an autologous transplant, which is a transplant using your own cells. So, the goal of this talk is to empower you by giving you knowledge so that you can take a more active role in decision affecting your health and to protect your own health after transplant.
01:55 Topics covered in the talk: Let's get started. Here is the agenda for today's talk. So, I'm going to talk about some of the complications or challenges after having an autologous transplant. Then I'm going to go over what you can do about these complications, how to screen for and prevent these complications and treat these problems. The last part of the talk is going to focus on what resources are out there to guide you to protect your health after transplant. I'm going to go over a survivorship care plan. What are the essential elements of the survivorship care plan, and how a survivorship care plan can help coordinate your care.
02:45 Autologous transplant is primarily used to treat patients with multiple myeloma or lymphoma: Just to recap, let's go over who do we treat with autologous stem cell transplants. So, it is usually a pretty clear-cut decision of who do we need to do a autologous transplant for: multiple myeloma and lymphomas are the two main diseases we do autologous transplants for. Besides multiple myeloma and lymphoma, we use autologous transplant to treat a few solid tumors like germ cell tumors, neuroblastoma, which is mostly seen in pediatric age groups. More recently over the past decade, autologous transplant has been also shown to be beneficial in treatment of some of the autoimmune diseases like lupus, multiple sclerosis, scleroderma.
This slide shows use of transplant for different type of the diseases. So, in the blue, those blue bars are allogeneic transplant and this is the type of transplant for which you need a donor, and in the green, we have autologous transplant,. Again, and this is a transplant where you use your own cells.
So in myeloma, we almost exclusively use autologous transplants. So, that's the first bar, green bar. I'm showing that this is, myeloma is, the biggest autologous transplant indication in United States. Similarly with the lymphomas, mostly we do autologous transplant, very few allogeneic transplants going for lymphoma.
04:18 The number of autologous transplants for patients with multiple myeloma in the U.S. has increased over the last 20 years: This graph shows the trends for autologous transplant in the United States over the past two decades. So, overall, as you can see, the autologous transplant numbers are increasing. The blue line is the myeloma patients, and yellow lines are lymphoma patients. But for myeloma, the annual number of autologous transplants is increasing steadily over the past two decades.
05:02 Autologous transplants for lymphoma patients decreased slightly in 2016: For lymphoma patients, in 2016 the number of transplants decreased only slightly. This may represent the increased availability of new non-transplant treatment options for some of the lymphoma subset.
05:24: There will be a half million transplant survivors by 2030: Well, I think I mentioned before, there has been a drastic improvement, and huge number of advances in the field of transplants and they're getting better in transplanting them, providing supportive care for our patients. And this has led to an increased number of transplant survivors. So, we estimate that that it is going to be 240,000 transplants survivors in the United States by year 2020. And if transplant continue at the current pace, we will have more than half a million survivors by year 2030.
06:07 Half of transplant survivors have a chronic health issue after transplant: So, why is this important? Well, because as the number of survivors increases, and more people are living longer after transplant, we get to know more about these long-term complication and issues that happen because of the transplant.
Here I want to go over a study done at Fred Hutchinson by Dr. Sun and colleagues looking at how common is the chronic health conditions after transplant. So, what they did, they looked at 1,022 transplant patients at least two years after transplant. And what this study shows is that regardless of the type of transplant that the patient had, half of the patients had some kind of a health issue. Most of these health issues were very mild. Near 20% of the patients had severe chronic health issues. We also know that these health issues can continue as time passes from the transplant and they just don't go away by themselves.
So, what are some of these health issues or what are some of these things you worry about after transplant? So, this slide shows some of the most common health issues transplant survivors face. I divide them into two groups, physical complications and psychosocial complications. What I'm going to focus today is the physical complications of transplant, like organ toxicity, heart disease, lung disease, bone health, infection and immune system. Secondary cancers and sexual dysfunction. Some of these psychosocial complications, like neurocognitive dysfunction, which is memory problems, and sleep disturbances - these are going to be talked about in another workshop tomorrow. So, if you're interested in hearing about these topics, they're also on other workshops as well.
08:17 Risk of heart disease is five times higher in transplant survivors than in the general population: So, the first topic is heart disease. Heart disease is one of the most common late effects of transplant. Risk of heart disease is three to five times higher in transplant survivors, when compared to general population. We know that some of the patients have higher chance than other ones for developing heart disease after transplant.
08:40 Total body irradiation, radiation to the chest, high cholesterol and diabetes increase the risk heart disease after a stem cell transplant: But what are some of these risk factors? Let's go over some of these risk factors.
If you had total body radiation, or radiation to the chest, that increases your risk of having heart problem later in life. Some chemotherapies named anthracyclines, which are mostly used to treat lymphoma, ares also linked to heart disease, and this is dose-dependent. So, the higher dose of anthracycline you get, you have increased risk of having some form of heart disease later on in life.
Having high cholesterol or diabetes also increases the risk of heart disease. But this is even for general population. So, anybody with high cholesterol or diabetes, even if they haven't had a transplant, they have increased risk of having heart disease.
09:38 Metabolic syndrome increases the risk of heart disease after transplant: I want to go over metabolic syndrome because it is another major risk factor for having heart disease or stroke, and we know that metabolic syndrome is twice as common in transplant survivors compared to general population.
So, what is metabolic syndrome? Well, it's a cluster of medical problems or conditions including central obesity. Central obesity is basically having excess body fat around the waist; having high triglyceride levels, which is a type of fat found in the blood; having a low HDL level, - HDL is a good cholesterol; high blood pressure; and high blood sugar. So, if you have all these conditions together, this is called metabolic syndrome. The picture on the right-hand side shows the body type of a person who has metabolic syndrome. So, these people usually have a apple-shaped body, meaning they have larger waists and carry weight around abdomen.
10:51 Lifestyle changes and monitoring for cholesterol, high blood pressure and diabetes can reduce the risk of heart disease after transplant: So, what can you do to prevent this from happening? How do you prevent heart disease? How do you prevent having metabolic syndrome? We can prevent this from happening by paying attention to our lifestyle and having a healthy lifestyle and having a healthy diet: low fat diet, low processed food, lots of fruit, vegetables, maintaining healthy weight, exercising regularly. Regular exercise means at least getting 30 minutes of physical activity five times a week, and stop smoking.
Beside the lifestyle modification. we also need to monitor for diabetes, high cholesterol, and high blood pressure. In terms of diabetes monitoring based on the guidelines, they check their fasting glucose every two years after age 45, or more frequently if someone's blood glucose level is higher. Fasting lipid blood check is also recommended at age 45 for woman and 35 for men. They start checking your fasting lipid blood tests earlier for people who have other risk factors, like they have a family history of high cholesterol, they're overweight, so these people get monitored more closely.
You may ask about the imaging of the heart. So, do we do imaging of the heart on everybody? Well, we don't. In patients who do not have any symptoms, we don't routinely do an ultrasound of the heart or any other form of imaging. But if somebody has symptoms like chest pain, chest discomfort, shortness of breath, then that prompts us to do some form of imaging. Otherwise it's not done routinely.
12:50 Bone loss after transplant can be caused by some types of cancer, long-term steroid use, a sedentary lifestyle or smoking: Next topic is bone health. So, bone loss is another common problem for many people as they get older, but it is more likely to happen after transplant. The mild form of bone loss or thinning of the bone, is called "osteopenia." The more severe form of the thinning of the bone is called "osteoporosis." Thinning of the bone or bone loss after transplant usually happens early after transplant. So, most of it happens within the first year, and after that, the bone density kind of stabilizes.
So, I listed a group of risk factors for developing the osteopenia or osteoporosis. So, osteopenia can be caused by the cancer itself. Like for example, if somebody has multiple myeloma, they have bony lesions and generalized bone loss because of the multiple myeloma.
Another cause of osteoporosis or osteopenia is long-term steroid use. So, lots of people treated for blood cancer get steroids, you know that. And this is a part of the regular treatment. And we know that steroids have long-term effects on the bones. It can cause thinning of the bone, bone fracture, and muscle weakness.
Another risk for having thinning of the bone is sedentary lifestyle and smoking. Kidney dysfunction is also associated with early bone loss, and this is mostly due to the change in how our body processes the vitamin D and calcium once you have the kidney dysfunction.
14:52 Exercise, optimizing calcium and vitamin D intake and hormone supplements can help prevent bone loss after transplant: Now what can we do about these? How to prevent the bone loss? One thing you can do is to stay active. Weight bearing exercises, which means like walking, dancing, jogging, 30 minutes at least five times a week is beneficial. Optimizing calcium and vitamin D intake is very important. Another way is to use sex hormone replacement. So, if your hormone level like estrogen or testosterone is low, you may benefit from hormone supplements. But you need to discuss this with your doctor.
Hormone replacement is not for everyone. It has side effects. We know that it can increase the risk of having blood clots. So, before starting this, I highly recommend you checking this and discussing it with your doctor.
We also check bone density through imaging of the bone - another name for it is Dexascan - one year after transplant. This is sto identify people who are having early bone loss and we decide, based on the result of this test, if they will benefit from something beside calcium or vitamin D supplements. So, these patients that have osteoporosis will benefit from a medication named "bisphosphonate" that stabilizes their bone density.
16:17 Up to 50% of patients have reactivation of the shingles virus after transplant: Next topic is immune system infection and vaccination. So, we know that transplant survivors have an increased risk of infection because the immune system is weakened due to the chemotherapy and radiation and that transplant process. One of the most common infections that transplant survivors deal with is viral infection. Up to 50% can have reactivation of zoster, or shingles. That's why many of you were on acyclovir or valacyclovir. That's the medication that prevents the reactivation of shingles within a year after transplant. We know after a year the risk of having reactivation of this virus is decreased significantly.
17:11 Bacterial infections are common during the first few weeks after transplant, longer for patients who had radiation to the spleen or the spleen removed: Bacterial infection is more common. Within the first few weeks of transplant, we encounter those. So, this is a time where your white cells are low, your neutrophils are low, and you're neutropenic. The exception is patients with lymphoma who had radiation to the spleen, or for some reason the spleen was removed because of the disease, and these people are prone to get frequent bacterial infections. So, these people are on antibiotics for a long term, sometimes even a year, to prevent these bacterial infections. Pneumocystis carinii or PCP is another infection that's seen usually within the six months after transplant, and that is the reason why most of you were on Bactrim® and having some sort of medication to prevent this PCP.
18:05 Low immunoglobulin, mostly seen in allogeneic transplant survivors, increases the risk of infection: Low immunoglobulin is another problem. Low immunoglobulin is basically having low protein. This is the equivalent of leaving the protein in the blood that prevents infections. And low immunoglobulin is seen mostly with people who have allogeneic transplants. Again, that's a transplant that require a donor. It's rarely happens after autologous transplant. We don't check patients' immunoglobulin frequently after transplant, so we check it only for people who develop frequent infections, so we check the level. If they're low in immunoglobulin, then we replace it.
18:48: Re-vaccination is recommended by the Centers for Disease Control after an autologous stem cell transplant: So, to prevent infection, vaccination for transplant survivors is highly recommended by the Centers for Disease Control and Prevention. There are two types of vaccines, live vaccines, and inactivated vaccines. The general rule is that we don't give live vaccines to patients on chemotherapy, people who recently had a transplant, or during immunosuppression when their immune system is weak. So, we don't give them live vaccines.
Inactivated vaccines are polio, diphtheria, tetanus, hepatitis, and pneumococcal flu vaccines. Timing to start vaccination depends on the transplant center, but we usually start giving inactivated vaccines within the first 6 months to 12 months after transplant.
Live vaccines include measles, mumps, rubella, MMR - those sorts of vaccines. Again, we don't give these early on after transplant. We wait for at least two years after transplants to give these live vaccines, and we also don't give it to people who are on chemotherapy still or getting immunosuppression.
20:09 The Shingrix® vaccine is safe and 90% effective in preventing shingles which is common after transplant: I want to go over the Shingrix® vaccine, because it is a relatively new vaccine. So, Shringrix® prevents shingles. It is an inactivated vaccine, so it's safe to give right after transplant. This vaccine is currently recommended for a healthy adult, 50 years or older. So, these healthy adults get two doses, two to six months apart. And this vaccine has shown to be 90% effective in preventing shingles.
So, what about patients with history of cancer? Do we give this vaccine to somebody who has a history of cancer or transplant? Well, there has been a reasonable amount of research that has shown that if you have a cancer diagnosis, or if you have had a transplant, you are at increased risk of having shingles. We know that. And there was a study actually looked at safety and how effective Shingrix® is for people who get an autologous stem cell transplant.
So, in these studies, people who had an autologous transplant had total of four doses of Shingrix® vaccine a few weeks before transplant, one month, three months and six months after transplant. And the result of this study showed that Shingrix® vaccine reduced the risk of shingles by 70% after autologous transplant. It also improved the pain after shingles. So, it reduces the pain for people who got shingles despite having a Shingrix® vaccine. They had less pain at the site of the shingles. And this vaccine was very well tolerated, minimal side effects. So, currently in most of the institutions, they offer Shingrix® vaccine to autologous transplant survivors.
22:13 Most lung problems after an autologous stem cell transplant are due to infection or toxicity from chemotherapy or radiation: Next topic is late lung problems. The majority of the lung problems we see in transplant survivors are either due to infection or toxicity from chemo and radiation. Late lung infection can be seen in patients even months to years after transplant, because patients can have weak immune system after transplant. But again this happens mostly after allogeneic transplants - the transplant that requires a donor - not autologous transplant.
Toxicity from chemotherapy or radiation can cause two form of lung diseases I listed here. Idiopathic pulmonary syndrome, which is, another name for it is inflammation of the lungs, it happens usually the few months following an autologous transplant., And this is mostly due to the chemotherapy you received right before transplant. One of these chemos that's used for lymphoma is carmustine, and that has been linked to inflammation of the lungs.
And second form of toxicity from chemotherapy or radiation is pulmonary fibrosis. Another name for is scarring of the lungs. So, this can happen many years after exposure to chemotherapy or radiation to the chest. Chemotherapies that have been linked to scarring of the lungs are bleomycin - this is a chemo use to treat Hodgkin's disease; carmustine, again used for lymphomas, and brentuximab is another chemo., when you combine it with other chemotherapies, that's been linked to scarring of the lungs. Again, this one is used mostly in lymphoma patients.
24:01 Transplant survivors should keep up-to-date on vaccinations and report any changes in exercise tolerance to their doctors: So, what can you do to protect your lungs after transplant? If you notice any changes in your exercise tolerance, don't ignore it. Report any changes, even if it's a minor change, to your doctor. Because your doctor would be able to jump on things early and intervene before this becomes a major problem later on.
The second way to protect your lung is to make sure you get all your vaccinations to prevent infections, including pneumonia. Avoid smoking. Vapor control in your workplace is also important. The people who are involved in work like welding or working with corrosive chemicals and fumes, these can irritate the lungs and cause lung problems in the future.
We do perform screening, pulmonary function tests. This is a screening test to see how your lungs are doing, only for patients at risk. So, not for everybody. This is for people who are at a high risk of developing lung disease after transplant. And you do pulmonary function testing mostly, again, after an allogeneic transplant, the donor type transplant, not autologous.
25:30 Nearly half of transplant survivors, both men and women, report sexual problems after transplant: So, let's go over to sexual health after transplant. Well, sexual dysfunction is one of the most common and persistent long-term consequences of cancer treatment. This can affect both men and women. So, nearly half of the people experience sexual dysfunction after the transplant, so it is very common.
For men, these symptoms include loss of interest or low sex drive. Some develop some sort of erectile dysfunction. So, if you have these symptoms, ask your doctors to check some of your hormones because hormone deficiency, like low testosterone, can cause these symptoms.
For a woman, the symptoms are similar to having early menopause due to ovarian failure caused by chemotherapy and radiation. So, this is called "treatment-induced menopause," which is very different than natural menopause. So, this type of menopause is a very sudden onset. With natural menopause, our body has a few years to get used to a slow decrease in the hormone, estrogen. But in a treatment-induced menopause that can be caused by chemotherapy and radiation, this dropping hormone level in estrogen happens very quickly, so our body doesn't have the opportunity to get used to it. So, you develop very severe symptoms like vaginal dryness, pain during sexual activity, low sex drive, feeling fatigued. Low estrogen also can cause low bone mass.
So, what can we do about this? Well, first we need to be open about this issue and discuss sexual health with your doctor. Some of the treatments include hormone replacement therapies like estrogen, testosterone replacement, use of moisturizers and lubricants, pelvic physical therapy. I'm not going to go into a lot of detail about the treatment here because we have ... There are two workshop on sexual health, one for a woman, and one for a man tomorrow. So, if you're interested to hear more about these topics, I recommend you attending these workshops. And they're great speakers, and these workshops are very informative.
28:17 Transplant survivors have a slightly increased risk of developing a secondary cancer after transplant: Next topic is secondary cancers. Secondary cancers are new cancers that happen because of chemotherapy and radiation you received, or the high doses of radiation before an autologous transplant. Secondary cancers are not common, but we know that transplant survivors have a slightly increased risk compared to general population.
There are two type of secondary cancers. One of them is blood diseases like acute leukemia, myelodysplasia, which happens early after transplant, within two to three years. Second type of secondary cancers are solid tumors. These happen relatively later after an autologous transplant, three to five years after. These include oral cavity cancers, a skin cancer, breast, colon cancers.
29:23 Some chemotherapies and viruses increase the risk of a secondary cancer: Here are the risk factors for secondary cancers.
• So, certain types of chemotherapy before or during transplant, including etoposide, cytoxan, can increase the chance of having a different type of blood cancer afterwards. Any one of these: - total body irradiation or radiation to the chest - particularly in women, increases the risk of breast cancer.
• Infection. So, certain type of viruses increases the risk of cancers. For example, human papillomavirus or HPV, a virus that we typically screen for in women with pap smear, this virus has been linked to cervical cancers. HCV or hepatitis C virus has been linked to liver cancer. Epstein-Barr Virus or EBV, increases the risk of lymphoma.
30:22 Revlimid® increases the risk of cancer slightly after transplant: One specific medication that I want to mention is the Revlimid®, because Revlimid® has been linked to an increased chance of cancers for people who are receiving maintenance, Revlimid® maintenance.
So, Revlimid® is a drug that's used as a maintenance therapy after autologous transplant in patients with multiple myeloma. The benefit of Revlimid® maintenance is huge, we know that. It's shown to decrease the risk of myeloma progressing, and there are some studies that show people who receive Revlimid® maintenance have increased survival. So, a lot of people are on Revlimid® maintenance after autologous transplant for myeloma.
However, Revlimid® has been associated with a very small increase in risk of secondary cancer. And the majority of these cancers are superficial skin cancers, so they're not aggressive at all, and they can be easily removed.
Okay? So, who is the person most likely to get this type of cancer after Revlimid® therapy? Well, this is somebody with high stage, like stage III myeloma. Older individuals, older than age 65 at the time of transplant, or the ones who received multiple older types of standard chemotherapy, like alkalizing agents. I'm not talking about Velcade® or dexamethasone. So, these are different types of chemotherapy we used many years ago, and that can increase the risk of cancer.
31:57 Cancer screening recommendations for stem cell transplant survivors: So, there are screening recommendations for transplant survivors. At minimum, transplant survivors should follow the same screening, cancer screening as a general population. But the recommendation may be a little different based on the treatment you have received. For example, for a woman who received prior radiation to the chest or total body irradiation, they need to start annual mammograms at age 25 or eight years after radiation. So, this is earlier than the general population. I listed here on a table, some of the very common cancer screening recommendations.
32:48 General guidelines to help prevent and treat late complications after transplant are available at BeTheMatch.org: So, let's move on in the direction of survivorship. Because your transplant doctors are invested in improving your post-transplant care, in 2012 a group of experts decided to come together and develop some guideline to help patients and physicians know and understand the challenges that exist for transplant survivors, and what needs to be done to improve survivors' health.
So, this general guideline outlines what some of the complication are that happen after transplant, what tests need to be done. These guidelines even list the preventative measure for 6 months, 12 months, and your annual appointment. Also, they include recommendations for special populations such as pediatric patients and patients who received total body radiation. So, this guideline is a tool for you and your physician, your doctor, to use to think about the things that you would need to help you stay healthy for the rest of your life after transplant.
So, where can you get these guidelines? These guidelines are freely available to you at the National Marrow Donor Program website [bethematch.org]. It comes in a print form or online form and mobile app. They're very easy to use. You can also get a lot of guidance and information by going to the BMT InfoNet website [bmtinfonet.org]. You can also connect with transplant providers or family caregivers for peer support. There are video learning libraries, several videos on medical, financial and emotional issues after transplant. All of these videos again are on the BMT InfoNet website.
34:51 You should have a personal survivorship care plan from your transplant center, based on your disease and treatment history: So, all these guidelines that I talked about over the past few slides that have been used to screen for complications after autologous transplant, are general guidelines. So, these are not specific to you. So, the focus over the past few years in the transplant community is to develop personalized survivorship care plans, which is a survivorship plan for each transplant patient, based on your disease, based on the treatment you have received.
So, these personalized survivorship care plans are prepared by a principal provider. So, in this case your transplant doctor who coordinates care for you with input from other other physicians, other providers. These survivorship care plans should be given to the patient at the time of completion of the therapy. It contains all the records of all the care you have received, everything about the disease, the treatment, the follow-up care plan.
36:14 Personalized survivorship care plans can decrease stress and give survivors a better understanding of their transplant treatment, possible side effects and general health management: Well this slide shows a first study that looked at how important personalized care plans are for transplant survivors. This study was funded by PCORI, Patient-Centered Outcomes Research Institute. It included 495 survivors, at least 1 to 5 years after transplant. So, these survivors, they're randomized to either receiving routine care. So, this is whatever transplant centers do routinely, or individual treatment summary or a personalized survivorship care plan.
Six months later, the study team called each patient and asked them to see how they were doing. The result of these studies show that people who had a personalized survivorship care plan reported a significant decrease in cancer and treatment-related distress and had better quality of life.
A personalized survivorship care plan was also very useful for helping survivors better understand their transplant treatments, potential side effects, general health management. If you want to learn more about the survivorship, or personalized survivorship care plan, I encourage you to listen to Dr. Linda Burn's lecture. She's talking at this symposium and if you can't attend the lecture, it's recorded.
37:52 Summary of Presentation: In summary, the take-home points are all transplant survivors have risks for health problems even many years after transplant, we know that. But most of these health problems are preventable. Regular monitoring and health maintenance is very important to prevent these problems, to detect them early, and get rid of them.
You also need to be your own advocate. Well, several resources are available to guide you to have healthy life after transplant. Learn about these resources, learn about your treatment, risk factors after transplant, and learn about how to prevent these complications. And lastly, ask your doctor to provide you with your survivorship care plan. This way, you know what needs to be done by whom and when. So, this concludes our talk today, and I'm happy to take any questions. Thank you.
38:55 Thank you, Dr. Farhadfar, that was an excellent presentation.
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