Integrated care
The hematopoietic (blood-forming) pediatric stem cell transplantation program at Dana-Farber/Children's Hospital Cancer Care, one of the nation's largest, performs about 80 transplants a year for youngsters with cancer, blood and immune diseases, and no two are alike. Some undergo autologous transplants, in which their own stem cells are harvested, frozen, and re-infused to become healthy bone marrow. Others have allogeneic transplants, in which stem cells are donated by a family member or unrelated donor, or taken from an umbilical cord.
"Children may undergo a transplant because they need new bone marrow," explains Callaway. "Or they may have nothing wrong with their marrow, but the procedure allows us to store their stem cells, give them heavier doses of chemotherapy than they could normally tolerate, and re-infuse the cells to become healthy new marrow."
Some patients have already received other therapies for their illness, while others pursue a transplant as their first line of treatment. In either case, transplant recipients typically spend four to six weeks as inpatients at Children's, and several months receiving frequent follow-up care in the Jimmy Fund Clinic, phasing out as they regain their health.
A bright, state-of-the-art unit on 6 West at Children's, remodeled in 2002, has done away with plastic curtains around each patient and staff in gowns and masks, a scenario once known as "life in a bubble." Although patients recovering from transplants remain at high risk for infections while their fledgling marrow begins to take hold, a filter cleanses the air on the whole unit instead of just individual rooms, allowing patients, staff, and visitors to move about freely.
Surviving two stem cell transplants has given Hannah Green, 21, a take-charge attitude about life.
Children well enough can use the play area, and each room includes a desk, computer, and an extra bed for a parent or guest — important features for a long hospitalization. There are bright lights that make examinations easier and alert caregivers to problems such as skin rashes, and windows in each private room allow nurses to monitor each patient better. Best of all for patients like Hannah Green, 21, there are bathrooms with showers.
Green has the distinction of experiencing the transplant process, old style and new. The first time was in 1994 as a treatment for acute myelogenous leukemia (AML). "I could not venture beyond the plastic curtain surrounding my bed," she remembers, "and even worse, I had to use a commode. My visitors scrubbed their arms and hands for 15 minutes, washed their skin with iodine, and wore masks."
After 10 years of good health and monitoring by the Jimmy Fund Clinic (JFC), Green's cancer came back, and she returned to the unit last year for a second transplant. Both times, her sister Megan donated her stem cells. "When I walked in, it felt surreal," Hannah says. "It was like entering a spaceship. The first set of doors opened, then a second set, and we were sealed off. The unit was open and bright. I had my own room with a door and private bathroom."
Green was also greeted by a renovated JFC, where older patients such as herself now have a separate waiting area, younger children can climb on a fishing boat structure, and a nautical theme pervades. Stem cell patients are usually seen in private rooms for several months after the transplant.
In addition to new facilities, many advances in the art and science of transplantation have occurred in the years since Green's first procedure. They include the ability to obtain stem cells from circulating or umbilical cord blood, better antibiotics and antiviral agents to fight infections, and more precise matching of donated cells, thanks to a better understanding of genetics. In addition, stem cell transplants are being used to treat a wider variety of diseases, including brain tumors.
The Dana-Farber/Children's program is also at the forefront of research to make it possible to use stem cells from a relative whose marrow is not a perfect match, a procedure known as haploidentical hematopoietic stem cell transplant. Early studies have shown some success with this approach, called ex vivo induction of tolerance, which involves making the T-cells in donated marrow accept the recipient's tissue. Soon, an international trial will test this approach more widely than ever before.
"If this works, we can offer the technique to all our patients and further protect them from graft-versus-host disease (GVHD), in which the donor's immune cells attack the recipient's body," explains program Director Eva Guinan, MD, who is leading the research and has overseen many of the stem cell program's recent changes. "Unlike other approaches, this should not compromise the ability of a new immune system to fight infection and residual cancer cells. It will also greatly benefit patients of color, who have a harder time finding a donor match than other patients do."
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