Ten years after the first inspection of a candidate European centre, an EBMT registry analysis suggests that clinical outcome is improved when hematopoietic SCT is performed in a JACIE accredited program

In Pursuit of Optimal Outcomes: A Framework for Quality Standards in Immune Effector Cell Therapy

Immune effector cell (IEC) therapy represents a transformative advancement in oncology, leveraging the immune system to combat various malignancies. This article outlines a comprehensive framework for establishing and maintaining quality standards in IEC therapy amidst rapid scientific and clinical advancements. We emphasize the integration of structured process measures, robust quality assurance, and meticulous outcome evaluation to ensure treatment efficacy and safety. Key components include multidisciplinary expertise, stringent accreditation protocols, and advanced data management systems, which facilitate standardized reporting and continual innovation. The collaborative effort among stakeholders-ranging from patients and healthcare providers to regulatory bodies-is crucial in delivering high-quality IEC therapies. This framework aims to enhance patient outcomes and cement the role of IEC therapy as a cornerstone of modern oncology, promoting continuous improvement and adherence to high standards across the therapeutic spectrum.

Current challenges in cell and gene therapy: a joint view from the European Committee of the International Society for Cell & Gene Therapy (ISCT) and the European Society for Blood and Marrow Transplantation (EBMT)

Cell and gene therapy poses evolving challenges. The current article summarizes the discussions held by European Regional Committee of the International Society for Cell & Gene Therapy and the European Society for Blood and Marrow Transplantation (EBMT) on the current challenges in this field, focusing on the European setting. This article emphasizes the imperative assessment of real-world cell and gene therapy activity, advocating for expanded registries beyond hematopoietic transplantation and chimeric antigen receptor-T-cell therapy. Accreditation's role in ensuring standardized procedures, as exemplified by JACIE (The Joint Accreditation Committee of ISCT-Europe and EBMT), is crucial for safety. Access to commercial products and reimbursement variations among countries underscore the need for uniform access to advanced therapy medical products (ATMPs). Academic product development and point-of-care manufacturing face barriers to patient access. Hospital Exemption's potential, demonstrated by some initial experiences, may increase patient accessibility in individual situations. Regulatory challenges, including the ongoing European ATMPs legislation review, necessitate standardized criteria for Hospital Exemption and mandatory reporting within registries. Efforts to combat unproven therapies and fraud involve collaboration between scientific societies, regulatory bodies and patient groups. Finally, is important to highlight the vital role of education and workforce development in meeting the escalating demand for specialized professionals in the ATMP field. Collaboration among scientific societies, academic institutions, industry, regulatory bodies and patient groups is crucial for overcoming all these challenges to increase gene and cell therapy activity in Europe.

WBMT Special Article on Key Elements in Quality and Accreditation in Hematopoietic Stem Cell Transplantation and Cellular Therapy

Hematopoietic stem cell transplantation (HSCT) represents an example of a highly complex and costly medical procedure with major applications in hematology and oncology. It is associated with life threatening complications and, consequently, increases demands on healthcare resources. While improving quality is an integral component of the healthcare strategic planning, drivers of quality may be variable and there is logical debate as to what drives quality in HSCT. Also, HSCT programs differ in their structures and availability of resources which drive the type of transplant and determine what is affordable and/or economically feasible. The complexity of HSCT procedure with involvement of different stakeholders necessitates not only regulatory frameworks but also robust quality systems to ensure consistent standards, demonstrate transparency for regulators, and define what quality means within the HSCT program. In an era of escalating healthcare complexity and heightened fiscal responsibility, transparency and accountability, accreditation contributes to ensuring that care meets the highest standards, and can serve as a risk mitigation strategy. Quality management has become an indispensable tool for the management of a complex medical intervention such as HSCT. It allows the transplant team to monitor its activities and identify areas for continuous improvement. The Worldwide Network for Blood and Marrow Transplantation (WBMT) had invited a group of international experts in HSCT and quality management to work on providing a summary document about the key elements in quality and accreditation in HSCT and highlight the foremost challenges of implementing them with special focus on low- and middle-income economies (LMIEs).

Quality Improvement in Hematopoietic Stem Cell Transplant and Cellular Therapy: Using the Model for Improvement to impact Outcomes

Quality improvement and quality assurance form a complementary and independent relationship. Quality assurance measures compliance against industry standards utilizing audits, whereas quality improvement is a continuous process focused on processes and systems that can improve care. The Model for Improvement is a robust quality improvement tool that transplant and cellular therapy teams can employ to redesign healthcare processes. The Model for Improvement utilizes several components addressed in sequence to organize and critically evaluate improvement activities. Unlike other health sciences clinical research, quality improvement projects, and research are based on dynamic hypotheses that develop into observable, serial tests of change with continuous collection and feedback of performance data to stakeholders.

Manipulation, and cryopreservation of autologous peripheral blood stem cell products in Italy: A survey by GITMO, SIDEM and GIIMA societies

There is considerable heterogeneity in manipulation and cryopreservation of hematopoietic stem cells (HSC) for autologous HSC transplantation across Europe and Italy. To better address this point, three Italian Scientific Societies (GITMO- Gruppo Italiano per il Trapianto di Midollo Osseo; SIDEM- Società Italiana Emaferesi e Manipolazione Cellulare; and GIIMA- Gruppo Italiano Interdisciplinare Manipolazione e Aferesi per Terapie Cellulari), in collaboration with the Competent Authority "National Transplant Center" (CNT) sent to 85 Italian transplant centers (TC) a survey, which included 12 questions related to the most critical elements in graft processing. Fifty-nine centers (70 %) responded to the questionnaire. Overall, this survey demonstrates that the majority (>90 %) of responding TC used standardized procedures for HSC processing; however, an intercenter heterogeneity was clearly documented in several standard operating procedures adopted by different TC. These results seem to suggest that further standardization and efforts are needed to provide recommendations and guidelines on HSC manipulation, cryopreservation and functional assessment of cryopreserved material for autologous HSCT.

JACIE: A 20 year-old voluntary body functioning worldwide

Hematopoietic Stem Cell Transplantation (HSCT) is a well estabished treatment modality for patients with severe disorders of the hematopoietic system. HSCT is the pioneer of not the adoptive immunotherapy but also cellular therapies. It was first performed in 1957; since then the transplantation numbers have increased every year in almost all parts of the World. However, the increase in the quality of this procedure was not as fast as the numbers. The first Standards for hematopoeietic cell collection, processing and transplantation in Europe was established in 1998 by the European Group for Bone Marrow Transplantation (EBMT) and The International Society for Hematotherapy and Graft Engineering Europe I (SHAGE Europe) and the Joint Accreditation Committee of ISCT EBMT (JACIE) was founded. JACIE is a non-profit voluntary organization that helps all the stakeholders of HSCT, the teams, goverments, regulators, payers and, mostly, the patients. In this review the aims and the twenty years history of JACIE in the World and in Turkey is explained.

[Indications and follow-up for autologous hematopoietic stem cell transplantation in autoimmune and autoinflammatory diseases: Guidelines from the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC)]

The Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC) organized the 7th allogeneic hematopoietic stem cell transplantation clinical practices harmonization workshop series in September 2017 in Lille, France and updated recommendations for indications and follow-up in autologous hematopoietic stem cell transplantation in autoimmune and autoinflammatory diseases, previously published under the auspices of SFGM-TC.

Current concepts on hematopoietic stem cell transplantation outcome registries; Emphases on resource requirements for new registries

There is tremendous variability in size, scope, and resource requirements for registries depending on the number of patients and participating sites. The outcome registries are organized systems to collect uniform data using an observational study methodology. Patient registries are used to determine specified outcomes for a population for predetermined scientific, clinical, or policy purposes. Historically, outcome registries established in the development of hematopoietic stem cell transplantation (HSCT) have now evolved into myriads of locoregional and international transplant activity and outcome resources. Over time, these registries have contributed immensely in determining trends, patterns, and treatment outcomes in HSCT. There is wider variation in the goals, mission, objectives, and outcomes of the ongoing registries depending on the organizational structure. There is a growing trend toward overarching relationship of these registries to serve as complementary and interoperable resources for high potential collaborative research. In addition to capacity building, standardized, accredited, and optimally operational registries can provide unmatched and unparalleled research data that cannot be obtained otherwise. Moving forward, HSCT data collection, collation, and interpretation should be an integral part of the treatment rather than an option. Quality assurance and continuous quality improvement of the data are pivotal for credibility, measurable/quantifiable outcomes, clinically significant impact, and setting new benchmarks.

Hematopoietic Stem Cell Transplantation: A Bioethical Lens

Hematopoietic stem cell transplantation (HSCT) is one of a range of therapeutic options available to patients suffering from various diseases. HSCT procedure involves important ethical and legal aspects that can occur at every phase of the procedure: the clinical choice of whether to perform the procedure, pretransplantation preparation regimens, donor selection, stem cell harvest procedure, transplantation phase, and short-term and long-term follow-up care. In this discussion paper, we outline the ethical issue-facing physicians involved in HSCT. Currently, HSCT is a widely accepted treatment for many life-threatening diseases. It thus represents a real therapeutic hope for many patients. It does, however, carry a burden of possible morbidity and mortality. Consequently, there are substantial information and communication issues involved in the consent process for HSCT. In the final decision, the judgements of different parties, such as patients, family members, and healthcare professionals, intersect and overlap and this is particularly true when the patient is a minor. Finally, HSCT is a very expensive procedure. The social and economic concerns of HSCT are discussed within the actual contextual framework of the dramatic increase in healthcare costs and inequalities in healthcare in relation to socioeconomic status, educational status, and ethnicity.

JACIE accreditation for blood and marrow transplantation: past, present and future directions of an international model for healthcare quality improvement

Blood and marrow transplantation (BMT) is a complex and evolving medical speciality that makes substantial demands on healthcare resources. To meet a professional responsibility to both patients and public health services, the European Society for Blood and Marrow Transplantation (EBMT) initiated and developed the Joint Accreditation Committee of the International Society for Cellular Therapy and EBMT-better known by the acronym, JACIE. Since its inception, JACIE has performed over 530 voluntary accreditation inspections (62% first time; 38% reaccreditation) in 25 countries, representing 40% of transplant centres in Europe. As well as widespread professional acceptance, JACIE has become incorporated into the regulatory framework for delivery of BMT and other haematopoietic cellular therapies in several countries. In recent years, JACIE has been validated using the EBMT registry as an effective means of quality improvement with a substantial positive impact on survival outcomes. Future directions include development of Europe-wide risk-adjusted outcome benchmarking through the EBMT registry and further extension beyond Europe, including goals to faciliate access for BMT programmes in in low- and middle-income economies (LMIEs) via a 'first-step' process.

Optimizing Quality and Efficiency of Healthcare Delivery in Hematopoietic Cell Transplantation

Hematopoietic cell transplantation is a complex and resource intense procedure that can be associated with high risks of treatment failure due to disease relapse or complications. There also exists considerable variability among transplant centers with respect to the number of procedures performed, available resources and personnel, patient selection, transplant practices, and supportive care. Hematopoietic cell transplantation as a specialty has been a pioneer in incorporating the constructs of quality and efficiency routinely in patient care. However, several challenges still remain. Harmonization of data collection and reporting, use of innovative technological tools, evidence-based practice supported by clinical trials, better efforts towards care coordination and transition of care, and reduction of variation will facilitate these efforts and will lead to improved experience and outcomes for hematopoietic cell transplant recipients.

Ethical and clinical aspects of intensive care unit admission in patients with hematological malignancies: guidelines of the ethics commission of the French society of hematology

Admission of patients with hematological malignancies to intensive care unit (ICU) raises recurrent ethical issues for both hematological and intensivist teams. The decision of transfer to ICU has major consequences for end of life care for patients and their relatives. It also impacts organizational human and economic aspects for the ICU and global health policy. In light of the recent advances in hematology and critical care medicine, a wide multidisciplinary debate has been conducted resulting in guidelines approved by consensus by both disciplines. The main aspects developed were (i) clarification of the clinical situations that could lead to a transfer to ICU taking into account the severity criteria of both hematological malignancy and clinical distress, (ii) understanding the process of decision-making in a context of regular interdisciplinary concertation involving the patient and his relatives, (iii) organization of a collegial concertation at the time of the initial decision of transfer to ICU and throughout and beyond the stay in ICU. The aim of this work is to propose suggestions to strengthen the collaboration between the different teams involved, to facilitate the daily decision-making process, and to allow improvement of clinical practice.

A review of stem cell translation and potential confounds by cancer stem cells

Mesenchymal stem cells (MSCs) are multipotent cells found in both fetal and adult tissues. MSCs show promise for cellular therapy for several disorders such as those associated with inflammation. In adults, MSCs primarily reside in the bone marrow (BM) and adipose tissues. In BM, MSCs are found at low frequency around blood vessels and trabecula. MSCs are attractive candidates for regenerative medicine given their ease in harvesting and expansion and their unique ability to bypass the immune system in an allogeneic host. Additionally, MSCs exert pathotropism by their ability to migrate to diseased regions. Despite the "attractive" properties of MSCs, their translation to patients requires indepth research. "Off-the-shelf" MSCs are proposed for use in an allogeneic host. Thus, the transplanted MSCs, when placed in a foreign host, could receive cue from the microenvironment for cellular transformation. An important problem with the use of MSCs involves their ability to facilitate the support of breast and other cancers as carcinoma-associated fibroblasts. MSCs could show distinct effect on each subset of cancer cells. This could lead to untoward effect during MSC therapy since the MSCs would be able to interact with undiagnosed cancer cells, which might be in a dormant state. Based on these arguments, further preclinical research is needed to ensure patient safety with MSC therapy. Here, we discuss the basic biology of MSCs, discuss current applications, and provide evidence why it is important to understand MSC biology in the context of diseased microenvironment for safe application.

Relationship between pediatric blood and marrow transplant center volume and day +100 mortality: Pediatric Blood and Marrow Transplant Consortium experience

The number of patients receiving a BMT is currently being used as a factor in the accreditation process in determining whether a center can provide a high-quality BMT. Such criteria particularly impact pediatric BMT centers as most of them perform a relatively small number of BMTs. To determine whether patient volume is a valid marker of pediatric BMT center's capabilities, the Pediatric Blood and Marrow Transplant Consortium (PBMTC) evaluated data from its registry to define the relationship between a pediatric transplant center's patient volume and day +100 mortality. The analyses evaluated 2575 transplants from 60 centers reporting to the PBMTC between the years 2002 and 2004. The volume-outcome relationship was evaluated while adjusting for 46 independent data categories divided between nine variables that were known- or suspected-mortality risk factors. We found no association between transplant center volume and day +100 mortality in several analyses. A calculated intraclass correlation coefficient also indicated that differences in individual transplant center volume contributed to only 1% of the variance in day +100 mortality within the PBMTC. The results of this study suggest that factors other than transplant center volume contribute to variation in day +100 mortality among pediatric patients.

Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation

In 1997, the first consensus guidelines for haematopoietic SCT (HSCT) in autoimmune diseases (ADs) were published, while an international coordinated clinical programme was launched. These guidelines provided broad principles for the field over the following decade and were accompanied by comprehensive data collection in the European Group for Blood and Marrow Transplantation (EBMT) AD Registry. Subsequently, retrospective analyses and prospective phase I/II studies generated evidence to support the feasibility, safety and efficacy of HSCT in several types of severe, treatment-resistant ADs, which became the basis for larger-scale phase II and III studies. In parallel, there has also been an era of immense progress in biological therapy in ADs. The aim of this document is to provide revised and updated guidelines for both the current application and future development of HSCT in ADs in relation to the benefits, risks and health economic considerations of other modern treatments. Patient safety considerations are central to guidance on patient selection and HSCT procedural aspects within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and EBMT accredited centres. A need for prospective interventional and non-interventional studies, where feasible, along with systematic data reporting, in accordance with EBMT policies and procedures, is emphasized.