Guest: Dr. Michelle Hudspeth
Host: Dr. Linda Austin
Dr. Linda Austin: I am Dr. Linda Austin. I am talking today with Dr. Michelle Hudspeth who is the director of the Pediatric Blood and Marrow Transplant program here at the Children’s Hospital of MUSC. Dr. Hudspeth, let’s talk about allogeneic transplant. Can you explain what that is and who gets that?
Dr. Michelle Hudspeth: Absolutely. So, allogeneic is just a big word meaning transplant with cells from another person. So, allo means other. So, the reasons that we might do this in a child include cancer, like leukemia, aplastic anemia, so that the bone marrow is simply not producing the blood cells, also for certain immune deficiencies, certain metabolic diseases such as adrenal leukodystrophy. So, this is something that is an option for patients with cancerous as well as non-cancerous conditions.
Dr. Linda Austin: Is this done from infancy on up?
Dr. Michelle Hudspeth: We treat patients all the way from infancy up to age 21, yes.
Dr. Linda Austin: Walk us through the process.
Dr. Michelle Hudspeth: That is right. So, the first thing is making sure that you have the correct indication for having a bone marrow transplant. That is something we are happy to see patients in consultation for. Generally, if you have a high risk leukemia, obviously that is one of our primary reasons for doing bone marrow transplants, or if you have another metabolic disease that can be cured by transplant.
So, first we see the patient and make sure that they have a reason for having a transplant and then we need to find a match. We have to do special HLA typing. This is different than blood group typing which patients think that is what we do. But, this is very specialized typing to see if we can find a match. In general, your best chance is from a brother or sister. Each sibling has a 25 percent chance of being a match, so we first test the family. If we are not able to find a match there, we can look in the registry. So, the National Marrow Donor program in the United States maintains a registry of around 7,000,000 donors who have their typing all contained here and we can search that. We also have the capability of searching international registries as well.
So, depending on those results, you, know, hopefully we will find a match. Unfortunately, we are not always able to find a match. There is a very high rate of Caucasian donors in this registry. So, in general, we are more likely to find a donor for you if you are Caucasian because, in general, HLA typing tends to run along ethnic lines. This is certainly why we encourage all people, but certainly minority folks out there to, please, join the registry so that we have opportunities for our children. So, hopefully we are able to find a match. We look both here in the registry for unrelated donors as well as the Cord Blood Registry, to see if that might be an option for our patients.
Then, we need to get the patient ready for transplant. If they have a cancer, we need to get them into the best state possible. Meaning, we really want them to be in a state where we actually cannot detect any of the cancer. If they have a metabolic disease, we want to make sure that they are in the best condition possible for the transplant. Unfortunately, for some of those diseases, they get so affected by the disease, sometimes you actually do more harm than good by putting the patient through transplant, so we need to make that decision.
Then, the patient is sort of checked out with a number of different tests, from head to toe, to check their heart function, lung function, kidney function, all those things. Then, if all those things I mentioned are in line, then they are admitted to our hospital. We have a special bone marrow transplant unit just for these patients with specialized rooms to help prevent infection. They receive, in general, about a week’s worth of chemotherapy. We need to wipe out their bone marrow in order to prepare their body to receive the new bone marrow or the new cord blood. Depending on their disease type or their condition, we know that there are better combinations to give than others and we pick the appropriate combination.
Then, on what we call Day 0, they receive the infusion of the bone marrow or the cord blood. You know, we really celebrate this day because we consider this their new birthday. These patients have had a life threatening condition and this really marks the beginning of a new life for them. So, we actually sing to them on this day. We sing Happy Day O to the tune of Happy Birthday and have party hats and everything else because we really do feel like it is something we are celebrating, giving them a second chance at life. From there on out, it is a lot of supportive care. Obviously, there are side effects from the chemotherapy, mouth sores, fevers, infections and we do everything we can to support them through that, until that new marrow or cord blood takes hold and starts to make new cells.
In general, most patients are in the hospital about a month’s time. Then, we require them to be close to our transplant center for the first 100 days after transplant. There are a number of complications that can happen and we need to watch them closely. So, even when they are discharged, we typically see them in our clinic two or three times a week. You know, many patients live close to MUSC and then they can be at home in that time. For patients who do not live close by, we have special housing here at the Ronald McDonald house, just for our transplant patients, so it can be their home away from home while they need to be here.
Then, they are actually followed for quite a period of time, even after we have discharged them here, after that 100 days. We see them at regular intervals to monitor them for long term side effects from the chemotherapy and also to make sure that their disease is taken care of and other concerns.
Dr. Linda Austin: The question I want to ask is how often is this successful in treating the underlying disease? But, I would imagine that would depend on what the underlying disease is. Am I right about that?
Dr. Michelle Hudspeth: That is right. So, there are a number of important factors. One is, underlying disease. The other is the type of donor that we have. We know that, in general, you tend to have fewer complications if you have a matched sibling donor. Although, our pediatric patients were getting awfully good so that, in general, using a well matched unrelated donor is getting awfully close to being just as good as using a sibling donor for a number of these conditions. Overall, if you look at most leukemias in general, our success rate is somewhere between 50 to 60 percent and that is, you know, in line with national statistics. For things like aplastic anemia, in general, that is successful 85 to 95 percent of the time, so a very high portion of the time. For some of the metabolic diseases, it simply depends on where they are in their disease and what kind of transplant they are having.
Dr. Linda Austin: Now, once it is successful, is the patient cured?
Dr. Michelle Hudspeth: Yes, and we also need to watch them for a bit of time. So, say for instance, the leukemia patients, we in general get very excited at one year if they show no signs of relapse. But, really, the two-year mark is really the critical one for patients with leukemia. For patients who have non-malignant diseases, really, the major things we look at are, are they going to reject this new bone marrow, which they have a higher incidence of doing than the cancer patients do? In general, by the time they get to a year and things are stable, we can feel pretty confident that things are going quite well.
Dr. Linda Austin: If a person wanted to register for the bone marrow registry, how would they do that?
Dr. Michelle Hudspeth: Thank you, that is something I think is very important and very easy to do. You can actually go online at www.marrow.org and if you are a member of a minority population, you can do this for free. If you are not a member of a minority population, it is a tax deductible cost of $55. They will send you a kit and, actually, all you have to do is swab the inside of your cheeks, that gets enough DNA that can be tested, and I strongly encourage this. Probably, right now lots of people are hearing this and thinking, yeah yeah, it sounds great, and I would encourage you not to hesitate.
I can tell you a personal side of this, when I was doing my oncology training, the hospital I was working at never having a bone marrow drive. I was very interested in bone marrow transplantation at that time but I was not on the registry and I was awfully embarrassed that I was not on the registry. But, at the time, I was about a month pregnant with my oldest daughter and so you cannot donate when you are pregnant. So, I kind of thought, well I will get on the registry, you know, after she is born since I cannot donate now. But, I ended up getting on right then because I was just so embarrassed that I was not on the registry, being an oncologist.
Well, about two weeks after my oldest daughter was born, I got a call saying, and can you come in for some additional testing? It turns out I was actually the only match for a 50-year-old woman who had relapsed leukemia. Had I waited until a time after my daughter was born, I would not have been on the registry at the time that she needed a donor. Being her only match, she would not have had the transplant option and would not have survived. Thankfully, I had the chance of meeting her several years ago and she is three years out of transplant and alive and well and has now seen all of her children graduate from high school.
Dr. Linda Austin: What a great story.
Dr. Michelle Hudspeth: It is just kind of unusual that I am now a transplant physician but I feel very passionate about it. You know, I think of myself as very garden variety. I would not have thought that I would have had something that would have been so rare, to have been the only person on the registry. So, that is why I really encourage everyone to register. You know, as an oncologist, people often say, your job must be very difficult and I say, yes it is. It is very difficult to tell a family that their child has cancer. But, actually what I find the most painful is to come back and tell them that we cannot find a match. As long as we have a match and we can go along with transplant, we have hope and that is a very powerful thing. So, actually, you know, having to come and tell a family that we cannot find a match for your child and we are at the end of our road, is far far worse than that initial conversation.
Dr. Linda Austin: Now, what is the process? What process did you go through when your bone marrow was actually harvested, for that woman?
Dr. Michelle Hudspeth: That is right. So, at first there was additional blood work that was taken and that was very simple and easy to do. Then, you undergo a physical examination. They want to make sure that you are in physical shape, that you can handle this and you will not be put at any increased risk. Then, there are two ways you can donate. For adult donors, they commonly use something called peripheral blood stem cells. In children, for a number of reasons, we tend to use bone marrow because it has a better outcome. But, for adults, they often use these peripheral blood stem cells.
So, if you are asked to be a donor, you may have the bone marrow harvested or you actually may have the peripheral blood cells taken. If you are going to have the peripheral blood cells taken, that consists of taking a shot each day that helps stimulate those cells in your body. Then, you have two IVs placed and you are hooked up to a machine. You can sit there and watch TV, watch movies and the machine collects those cells. It is actually a very simple process. If you are a bone marrow donor, again, it tends to be just an outpatient procedure, where you are not admitted to the hospital, but come first thing that morning. You can have general anesthesia. You are asleep and they take the bone marrow from you hips. You will be sore for a couple of days afterwards. I was back at work in a couple of days and it went quite well.
Dr. Linda Austin: And back to taking care of your baby.
Dr. Michelle Hudspeth: Actually that night, even.
Dr. Linda Austin: That is a wonderful story. Thanks so much for talking to us today.
Dr. Michelle Hudspeth: Thank you.
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