Establishing Hematopoietic Stem Cell Transplant Unit in Resource Limited Setting: A Critical Analysis of Indian Council of Medical Research 2017 Guidelines

Quality of life and symptom burden in hematological cancer patients receiving hematopoietic stem cell transplantation: an observational study at Regional Cancer Centre, India

PURPOSE

Hematopoietic stem cell transplant (HSCT) is an intense form of treatment, resulting in major symptom burden but can prove curative. The quality of life (QOL) is a major endpoint for these patients as the survival rate in them has improved over time. The aim of the study is to assess the QOL and symptom burden of hematological malignancy patients at admission to hospital for HSCT, at 1 month and at 3 months following HSCT.

METHODS

This prospective observational study was done on hematological malignancy patients who were admitted for HSCT in a regional cancer center. The study subjects were assessed by the Functional Assessment of Cancer Therapy-Bone Marrow Transplant Scale (FACT-BMT Scale), Edmonton Symptom Assessment Scale-revised (r-ESAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21) at the time of hospital admission for transplantation, on day 30 (~ 1 month) and day100 (~ 3 months) of transplantation.

RESULTS

A total of 68 patients were included in this study. FACT-BMT scores have decreased from baseline (F0) to the first follow-up (F1) and then increased in the third follow-up (F2). The maximum r-ESAS mean score was for tiredness among all other symptoms at F0 as well as at F1 and at F2. The DASS 21 scores for depression, anxiety, and stress were maximum during F1 and minimum during F2.

CONCLUSION

Symptom burden is maximum during the first month of BMT, which improves later and QOL becomes improved with time.

Planning and designing of an inpatient isolation facility for hematopoietic stem cell transplant patients

During the last two decades the world has seen an increase in the use of Hematopoietic Stem Cell Transplant (HSCT) which has led to its worldwide expansion. Since, HSCT unit is an advanced set up, developing and maintaining a successful hematopoietic stem cell transplant program with a properly functioning unit enhances the credibility of any tertiary level medical facility especially for a country like ours which is in its early expanding phase of providing transplant services. The underlying principle for designing any HSCT facility is to maintain the highest possible level of aseptic environment for patients undergoing the transplant in order to prevent healthcare associated infections. Basic premises of designing the entire HSCT unit was to ensure restricted access to the facility and having an aseptic environment by implementing infection control parameters in design elements, which are explained subsequently in the article. The present manuscript describes the project experience of creating a positive pressure isolation facility for HSCT patients at a tertiary care hospital, India, which is a resource limited setting with an emphasis on need assessment, key elements in planning and designing along with the challenges associated with it.

Environmental monitoring for filamentous fungal pathogens in hematopoietic cell transplant units

The incidence of invasive fungal disease (IFD) is on the rise due to increasing numbers of highly immunocompromized patients. Nosocomial IFD remains common despite our better understanding of its risk factors and pathophysiology. High-efficiency particulate air filtration with or without laminar air flow, frequent air exchanges, a positive pressure care environment, and environmental hygiene, amongst other measures, have been shown to reduce the mould burden in the patient environment. Environmental monitoring for moulds in areas where high-risk patients are cared for, such as hematopoietic cell transplant units, has been considered an adjunct to other routine environmental precautions. As a collaborative effort between authors affiliated to the Infection Prevention and Control Working Group and the Fungal Infection Working Group of the International Society of Antimicrobial Chemotherapy (ISAC), we reviewed the English language literature and international guidance to describe the evidence behind the need for environmental monitoring for filamentous fungi as a quality assurance approach with an emphasis on required additional precautions during periods of construction. Many different clinical sampling approaches have been described for air, water, and surface sampling with significant variation in laboratory methodologies between reports. Importantly, there are no agreed-upon thresholds that correlate with an increase in the clinical risk of mould infections. We highlight important areas for future research to assure a safe environment for highly immunocompromized patients.

Developing an Allogeneic Hematopoietic Progenitor Cell Transplant Service in a Resource-Limited Country: Challenges and Outcomes

Introduction Allogeneic stem cell transplant has curative potential for many hematological disorders. Building an allogeneic hematopoietic progenitor cell transplant (HPCT) unit requires huge investment, infrastructure, equipment, medical supplies, and training of health care professionals. The key objective of this study is to share our experience of developing an allogeneic HPCT service at our tertiary care cancer hospital in a low-middle-income country. In addition, this study presents the outcomes of the first 30 allogeneic HPCTs done at our center. Methods This retrospective observational study included adult patients 18 years old or older with hematological malignancies who underwent allogeneic HPCT between July 2019 and April 2023 at Shaukat Khanum Memorial Cancer Hospital and Research Centre. Result Of the 30 patients, 24 underwent matched sibling donor (MSD) transplants in which a myeloablative-conditioning regimen (MAC) was used in 19, and a reduced conditioning regimen (RIC) was used in one. Of the six haploidentical-related donor transplants, four received MAC, and two received RIC. The median recipient age at HPCT was 23 and 21 years for MSD and Haplo-related donor transplants, respectively. The median follow-up duration was 12 months (Range: 10 days - 33 months). The overall survival rate at one year was 71.3% among all allogeneic stem cell transplant patients, whereas the disease-free survival rate at one year was 63.7%. In the acute lymphoblastic leukemia group, the disease-free survival rate at one year post allograft was 51.5%, while in the acute myeloid leukemia group, it was 78.7%. Conclusion This study demonstrates the successful development of an allogeneic bone marrow transplant unit at our hospital despite significant financial constraints. This has allowed us to provide a potentially curative and life-saving treatment to a substantial number of cancer patients. The bone marrow transplant outcomes of this study are comparable to those reported by international bone marrow transplant registries.

Evaluation of a group-based exercise and relaxation rehabilitation program during hospitalization for allogeneic hematopoietic stem cell transplant

BACKGROUND

Exercise and relaxation interventions have demonstrated benefits in allogeneic hematopoietic stem cell transplant (allo-HSCT) patients; however, little is known about the implementation enablers and barriers for inpatient rehabilitation or its impact on health outcomes.

OBJECTIVE

To conduct a program evaluation of group-based rehabilitation consisting of exercise and relaxation classes for allo-HSCT inpatients.

DESIGN

Prospective program evaluation using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework.

SETTING

Inpatient hospital unit at a tertiary care center.

PARTICIPANTS

Forty-five adult patients admitted for allo-HSCT.

INTERVENTIONS

Standard of care rehabilitation.

MAIN OUTCOME MEASURES

Program attendance, safety, satisfaction, and fidelity were assessed. Exploratory effectiveness analyses were conducted via the measurement of physical, psychosocial, clinical, and health resource use outcomes at hospital admission and discharge.

RESULTS

Forty-seven of the 63 patients receiving allo-HSCT between November 2019 and March 2020 were consented. Data presented in this publication are from the 33 participants who completed study assessments (high attrition due to cancellation of research during the COVID-19 pandemic). Eighty-two percent of participants attended at least one class; however, 55% of the participants invited to the classes on a daily basis were not able to attend. Barriers to participation included transplant complications, isolation for infection prevention, and fatigue. There were no adverse events associated with the intervention and 82% of participants adhered to the prescribed activities. Participants reported satisfaction with the program and enjoyed the motivational support and social interaction. Between hospital admission and discharge, anxiety scores improved; however, fatigue, depression, grip strength, functional mobility, and quality of life scores declined. Physical activity volume and lower body strength were maintained.

CONCLUSIONS

Group-based exercise and relaxation classes seem to be feasible and safe during hospitalization for allo-HSCT; however, there are pragmatic barriers to be considered for optimal program implementation. Further research examining program effectiveness and adoption is warranted.

Why and How Should Ethiopia Establish a Stem Cell Transplant Service? A Review Article

Ethiopia is attempting to reduce cancer-related morbidity and mortality through a strategic national cancer control plan but according to Globocan 2020, hematologic malignancies particularly leukemia and non-Hodgkin's lymphoma rank among the top five leading causes of new cancer incidence and cause of death among all age groups in both sexes. Hematopoietic stem-cell transplantation (HSCT) is an advanced treatment modality that makes the only effective treatment for cancer and non-cancer-related hematologic diseases unresponsive to conventional therapy. Patients who need stem cell transplants must travel to abroad countries to get the treatment. Meanwhile, the Ethiopian National Specialty and Subspecialty Roadmap sets the goal of establishing HSCT centers in 2020-2029 GC, yet leaders and planners must start taking steps to put the setup in place. Setting up an HSCT facility is challenging for developing countries due to the high costs, limited infrastructure, and need for intensive medical staff training; however, several nations have been able to start successful stem cell transplant programs. This review summarizes the basic steps and requirements of the program in light of guidelines recommendations and lessons learned from other developing countries. It also highlights possible cost-effective opportunities, bottlenecks, and areas that will require work and investment to make the objective reality in Ethiopia. Provides key information to assist administrators and policymakers to set priorities in planning and making informed decisions to establish and maintain the service.

Cost of HSCT in a Tertiary Care Public Sector Hospital in India

India harbours a significant burden of hematological diseases including cancers for which Hematopoietic Cell Transplant (HCT) is a definitive life-saving procedure. Very few studies in India have carried out the costing of the important procedure, hence we undertook a study to ascertain the cost of auto HCT in our tertiary care teaching hospital. We did a prospective study using Top-down and Bottom-up approach to arrive at the cost of autologous HCT which came out to be INR 699,200 ($10,282) out of which hospital bears 34% of the cost. The major share of the hospital cost is on account of expenditure on Human Resources. The rest 66% is Out of Pocket Expenditure (OOPE) for the patients. We also calculated the cost which is borne by patient attendants over & above the cost of procedure while caring for the patient, which on an average came to be INR 88,598. This is approximately 19% of the cost borne by the patient for the procedure itself. The cost is usually not factored in while contemplating the procedure and is not covered by any insurance scheme. The overall cost, OOPE & attendant cost can all lead to a substantial financial hardship. Hence, steps need to be taken to make HCT an affordable and accessible procedure.

Overcoming barriers for the establishment of a consolidated hematopoietic cell transplantation program in a developing country

The first hematopoietic cell transplantation (HCT) in Mexico was performed at our institution; however, outcomes were suboptimal the following years, until 1998, when a consolidated HCT was established. The aim of this study was to describe the barriers and the implemented strategies to establish a successful HCT program at a referral center in Mexico and to analyze the outcomes. Barriers were detected based on the results from 1980 to 1997. For the analysis of outcomes, a retrospective study was performed including consecutive patients undergoing autologous, allogeneic, and haploidentical HCT. From November 1998 to December 2018, 363 HCTs were performed (autologous, 59%) in 323 patients. Overall non-relapse mortality (NRM) in autologous and allogeneic HCT was 2% and 14%, respectively. The 5-year overall survival was 71% and 57% for autologous and allogeneic HCT, respectively. The cost of the medications was one of the main limitations for the patients and was successfully overcome by the creation of the non-governmental organization "Unidos". NRM was diminished after reducing the BuCy2 regimen along with the use of bone marrow. Our results highlight that the implementation of unique strategies at our center, led HCT to represent a financially viable and feasible procedure with optimal results.

Current state of nonengrafting donor leukocyte infusion (focus on microtransplantation for acute myeloid leukemia)

PURPOSE OF REVIEW

Microtransplantation (or micro-stem cell transplantation, MST) is one permutation of alloreactive immunotherapy increasingly studied in clinical trials. It is most commonly applied to patients with myeloid malignancies who are not suitable candidates for allogeneic hematopoietic cell transplantation. This review highlights the past 2 years of work on stem/progenitor cell products in the field of nonengrafting donor leukocyte infusion (NE-DLI), with a focus on applications of MST in acute myeloid leukemia (AML).

RECENT FINDINGS

Assessing the utility of MST is hampered by lack of randomized controlled trials and by variability in donor selection algorithms, treatment timing, and unknown factors. The inherent complexity of the bidirectional alloreactive reactions, implicating many cell types, makes it challenging to move beyond correlative, population-level biology toward mechanistic explanations for MST's actions in any given patient-donor pair. Yet there are indicators that by stimulating a recipient-vs.-tumor effect, MST might substantially improve complete remission rates in AML and that it might find a role in postremission therapy.

SUMMARY

The mechanistic underpinnings of MST are gradually being disentangled and its clinical development remains in early stages.