Of faith and modern medicine: how autologous bone marrow transplants are holding the faith

Bone marrow transplantation (BMT) is being increasingly and successfully used for several indications including cancer. Cancers that cannot be cured by routine therapies may be salvaged by using BMT. A bone marrow transplant involves replacing diseased bone marrow with healthy stem cells to allow it grow and make new, healthy blood cells.

There are two main types of BMT. One is allogenic BMT, where the stem cells from a matched donor are used for transplantation. The other kind is called autologous BMT, where the patient acts as their own donor. The second kind of BMT is usually used in cancers such as multiple myeloma, lymphomas and some childhood cancers including neuroblastoma and Ewing’s Sarcoma.

Understanding autologous BMTs

In autologous BMT, the enriched blood of the patient is collected using a cell separator, and stored at a very low temperature, a process called cryopreservation. After this, the patient is given high dose chemotherapy to destroy all the cancer cells in the body. This chemotherapy also kills the patient’s bone marrow cells. After a gap of 1-2 days, the patient is given their stored blood containing healthy stem cells. The chemotherapy and the destroying of the bone marrow cause severe anaemia, low white cell counts and low platelets. This can make the cancer patient fatigued, prone to infections and bleeding, This state of affairs can go on for up to two or three weeks. During this phase patients require antibiotics, blood transfusions and even platelet transfusions.

Unique cases

Some patient groups, in particular, Jehovah’s Witnesses, (a group of Christians with unique beliefs), do not receive blood from other people due to their faith. It was thought impossible to perform autologous BMTs in this population. Now, however, with advanced drugs being available and with a few conceptual changes it is feasible to do BMTs in this group also, safely.

With having conducted BMTs in eight Jehovah’s witnesses for multiple myeloma and lymphomas, here are some lessons learnt:

When the patients initially come in, they are given red cell growth factors twice a week which improves their haemoglobin levels up to 12-13 g/dL. They are also given iron, through an IV, every 3-4 days. This is important because in many patients, haemoglobin levels can dip very low after a bone marrow transplant. But if the starting haemoglobin is 12g/dL, it can go as low as 2g/dL without a problem, making the initial boost to haemoglobin, critical.

For white cell production, patients are given growth factors for neutrophils. This can keep the white cells up and prevent infections. Due to the high dose chemotherapy, platelet counts can go very low, sometimes becoming zero. Patients can bleed from gums, stools, skin and rarely, into the brain. In rare cases, severe bleeding can result in death. Several drugs are used to prevent this problem: platelet growth factors to stimulate platelet production in the bone marrow and prophylactic calcium and Vitamin K infusions. Whenever there was bleeding, we found injected Novoseven (activated Synthetic Factor VII) useful in arresting the bleeding.

Three interesting facts that came up during these BMTs:

Even at a platelet count of 10,000, there was not significant bleeding; it was only when the count was <5,000 that there was significant bleeding, indicating that platelet transfusions may be overused or even abused routinely.

Even at haemoglobin levels of 2 g/dL many patients can live without cardiac failure. So routine correction of Hb with blood transfusions should be questioned.

More selectiveness is needed; more growth factors can be used. Other small changes that can be incorporated are: using finger prick blood for complete blood counts to avoid vein punctures; avoiding drugs like NSAIDs that reduce platelet function; treating infections aggressively as they consume platelets; and correcting any coagulation abnormality by infusing vitamin K.

Towards new goals

Modern medicine has come a long way and is still learning and growing. Each new way of treating a patient can teach doctors and potentially help other patients too. On World Cancer Day, it is good to remind ourselves that every cancer patient deserves access to care and treatment, in the manner that they want it.

(Dr. Radheshyam Naik is consultant medical oncologist, haematologist and bone marrow transplant physician at Sammprada Hospital, Bengaluru. radheshyam_n@yahoo.com)