The outlook for patients with leukemia and other life-threatening blood cancers has improved dramatically since Scripps Health founded San Diego County’s first blood and marrow transplantation (BMT) program, which celebrates its 30th anniversary in 2010.
James Mason, MD, the medical director of the Scripps Blood and Marrow Transplant Center at Scripps Green Hospital, says the survival rate of Scripps’ BMT patients has more than doubled since 1980, and the number of transplants performed annually by Scripps has increased tenfold.
“The field has gone from being viewed as something of a last resort in its early days to now being a viable option where likelihood of recovery is often strong,” Dr. Mason says. “We’ve become much more adept at matching appropriate donors with patients, developing medications to fight previously lethal infections and creating new techniques to make transplants tolerable for older patients. We’re also seeing many patients return to productive lives in a matter of weeks or months after transplant, instead of years or not at all.”
Russ Zinser of Encinitas is a case in point. Diagnosed with chronic leukemia in 1984, Zinser is now healthy, active and completely free of the disease. Zinser found a blood marrow donor among his 12 siblings and underwent a successful transplant at Scripps Green in June of 1986.
He was back at work by Halloween of the same year and has been cancer-free ever since. “The experience made me realize how fragile life is and that there are lots of things I want to do,” says the retired engineer, who today keeps busy as a musician, woodcarver, author, mentor and golfer, among other activities.
Still, blood and marrow transplants do not always lead to a cure, and the most common forms of blood disease – leukemia, lymphoma and myeloma – continue to pose major public health concerns. These three diseases collectively caused approximately 53,000 deaths in the United States last year and accounted for nearly 10 percent of all cancer-related deaths in the country.
Despite persistent challenges in the quest to eradicate blood cancers, a number of significant advances have been achieved in the past 30 years to help doctors improve clinical outcomes for patients. These include:
Thirty years ago, those needing a bone marrow transplant usually had to rely on a sibling to be their donor – a difficult proposition, since about 70 percent of patients don’t have a matching donor in their family.
But today, the prospect of finding a donor has evolved from a hope to an expectation, thanks to the creation of the National Marrow Donor Program (NMDP), a computer database of more than 8 million volunteer donors worldwide. Scripps’ BMT program is the NMDP’s only collection center in San Diego and Imperial counties, and also serves much of Orange and Riverside counties.
Scripps collects stem cell products from donors every week and either uses them for patients in San Diego, or ships them off to NMDP network hospitals around the world for their patients. Likewise, Scripps taps into the NMDP’s extensive database to find bone marrow donors and receives blood products from around the world for Scripps patients in San Diego.
In the 1980s, the process of donating bone marrow for transplantation was highly invasive. Donors were put under general anesthesia while a large needle was inserted into the middle of a large bone (typically the pelvis) to extract bone marrow for transplant into the patient.
Now, doctors rarely use bone marrow for transplantation, instead opting for peripheral blood stem cells, which are removed from the donor via a relatively painless blood donation technique called apheresis. The donor’s blood is withdrawn through a sterile needle in one arm and passed through a machine that removes the white blood cells (red blood cells are returned to the donor).
The peripheral stem cell yield is boosted with daily injections of a stimulating factor, serving to mobilize stem cells from the donor’s bone marrow into the recipient’s peripheral circulation. Peripheral blood cells are usually better for recipients too, helping them recover faster from the transplant.
Transplants are most commonly performed for patients with acute leukemia, a disease that usually occurs in people age 50 and older. This created a catch-22 in the early days of transplantation, since most people over 50 couldn’t tolerate transplantation due to the harsh chemicals involved.
Today, the development of a newer technique – a non-ablative transplant, or “mini-transplant” – involves a gentler regimen that allows people up to age 70 to successfully endure transplantation, with lower risk of serious infection and transplant-related mortality.
In years past, many blood disease patients who developed post-transplant complications such as cytomegalovirus (CMV) infections simply died due to lack of medications. In recent decades, significant improvements have been made in managing post-transplant infections. Highly effective antibiotics such as gancyclovir and voriconazole are now available to fight infections and aid in patients’ recovery.
A major shift has taken place in the last five years that has improved doctors’ ability to accurately determine donors’ compatibility with patients. Thirty years ago, screening for donor compatibility was a relatively crude process in which donor and patient cells were mixed together into a culture to see if they’d fight each other.
Today, typing has become computerized, using advanced DNA technology to sequence and match up parts of the donor and patient genomes. This shift has expanded the number of potential donors, while helping to winnow out who should and shouldn’t be donating cells. In some cases, this technology can find a donor who’s a better biologic fit than a sibling.
When Scripps’ BMT program first began, patients were limited to allogenic transplantation – that is, the use of cells from one person (the donor) for another (the patient). Subsequently, doctors have developed techniques for autologous transplantation, in which the patient’s own stem cells are harvested, frozen and returned to the body following chemotherapy and other possible treatment.
Autologous transplants have the advantage of lower risk of infection during the immune-compromised portion of treatment. Autologous transplants have become standard for diseases such as lymphoma, but in other cases such as acute myeloid leukemia, allogenic transplantation may still be preferred to combat the likelihood of cancer recurrence.
Dr. William Miller has been with Scripps’ BMT program from its very beginning and has seen the progress firsthand. “There was some skepticism in the early days of the program, even from our own colleagues,” says Dr. Miller, who counts Scripps BMT program co-founders Drs. Ernest Beutler and Robert McMillan among his mentors.
“But over time, the hope for a cure has expanded for patients with a variety of blood disorders. The field has grown tremendously over the years and it’s going to continue to evolve. I’m just as excited about the next 10 years as I am about the last 30.”
Likewise, nurse coordinator Cindy Nelson has been with Scripps’ BMT program since its founding in 1980. “Patients are much more comfortable now, much more open to receiving a transplant because they have more knowledge about it,” Nelson says. “The process is also generally easier on patients now because their diseases are under better control and they’re in better shape physically.”
More than half of the program’s clinical staff of 30 has been in place for at least 10 years, and three have been on staff for more than 25 years. “The people who join us tend to stay,” Nelson says.
Housed on a dedicated 31-bed unit at Scripps Green Hospital in La Jolla, Scripps’ BMT program is available to all cancer patients across the Scripps Health system of five hospital campuses and 19 outpatient centers. Scripps offers the region’s only comprehensive BMT program, with all services operated under a single medical director to provide greater continuity of care, flexibility and convenience to patients.
Scripps is currently expanding its capacity to collect blood stem cells from donors with a renovation of a third-floor lab space at Scripps Green Hospital. The new apheresis room will accommodate four people at a time and will augment the hospital’s two existing apheresis rooms.
With more than 300 affiliated physicians, Scripps Cancer Center is a nationally recognized leader in cancer care, providing comprehensive care at its four hospitals and various Scripps Clinic locations.
In collaboration with The Scripps Research Institute, the Scripps Cancer Center seeks to provide the best possible treatment and cutting-edge research trials for patients by coordinating medical expertise in the areas of clinical cancer care, community outreach and clinical, translational and basic research. In 2008, Scripps Cancer Center earned network accreditation from the American College of Surgeons’ Commission on Cancer.
Founded in 1924 by philanthropist Ellen Browning Scripps, Scripps Health is a $2 billion nonprofit community health system based in San Diego, Calif. Scripps treats a half-million patients annually through the dedication of 2,500 affiliated physicians and 12,700 employees among its five acute-care hospital campuses, home health care services and an ambulatory care network of clinics, physician offices and outpatient centers. Recognized as a leader in the prevention, diagnosis and treatment of disease, Scripps is also at the forefront of clinical research and graduate medical education.
Contact: Steve Carpowich