THE PRE-TRANSPLANT PROCESS

INITIAL EVALUATION

After carefully reviewing your case, your primary oncologist has referred you to Rocky Mountain Blood and Marrow Transplant Program for an evaluation. Your transplant physician will review the history and characteristics of your disease to determine if transplant is a good treatment option at this time. Because the treatment has side effects, some of which could be life threatening, you, your oncologist, and your transplant physician must carefully consider the benefits of transplant versus the risks. During your initial evaluation, you will receive detailed information about transplant and other treatment options. You should meet a transplant coordinator at this visit who will be a good resource and guide for you throughout the transplant process.

STANDARD CHEMOTHERAPY

Depending upon your disease status, you may need to receive further treatment prior to starting the transplant process, referred to as standard chemotherapy. This treatment is given to see if your cancer cells respond to chemotherapy drugs, and to reduce the number of cancer cells to a minimum. If the cancer cells are not affected by standard chemotherapy, the chance that the high-dose chemotherapy will affect them may be decreased. If standard chemotherapy destroys a large number of the tumor cells, this increases the chance that the high-dose chemotherapy will be able to eliminate most of the remaining cancer cells.

Standard chemotherapy is usually given at your referring oncologist’s office. The type of chemotherapy you receive will depend on your type of cancer. Your transplant physician and your oncologist will work together and recommend a treatment plan for you.

After completion of standard chemotherapy, you will be re-evaluated to determine how the treatment has affected your cancer and to assess your baseline organ function. This re-evaluation, known as restaging, involves x-rays, scans, blood tests, EKG’s, pulmonary function tests and biopsies. This re-evaluation will help in developing a plan of care for you.

PRE-TRANSPLANT EVALUATION

Pre-transplant testing is done for restaging in order to determine the spread of the disease and the safety of receiving a transplant. Depending on the type of disease you have, restaging tests may include x-rays, CT scans, MRI’s, PET scans, bone scans, blood tests, and urine tests. (In order to perform all the necessary blood tests, 10-15 tubes of blood will be taken. Do not be alarmed; although this looks like a lot of blood, your body will replace it within 24-48 hours). You will also undergo a bone marrow biopsy to determine if the disease involves your bone marrow, the extent of the involvement, and if there has been any damage to your bone marrow from previous chemotherapy.

Tests to evaluate your baseline organ functioning will include a heart scan (called a MUGA), EKG, pulmonary (lung) function tests, x-rays, urine tests, and more blood work.

Additionally, because the transplantation process is emotionally stressful, you are required to meet with the transplant psychologist before starting transplant. It is important for us to know how we can support you and your family throughout the transplant process. This appointment should be made shortly after your initial evaluation with the transplant physician. The transplant process affects your entire support system. Your primary support system, which may include family members or friends, is encouraged to come to your appointment with the psychologist.

You will need to see your dentist for an evaluation, including a Panorex x-ray of the mandible. Any dental work needing to be done will have to be taken care of prior to transplant. You will need to get written clearance from your dentist before transplant can proceed. We recommend initiating your dental evaluation as soon as possible.

Once all of the required tests and pre-transplant appointments and assessments have been performed, your physician or transplant coordinator will notify you of any abnormal results making transplant inadvisable or increasing the risks associated with transplant. If your results are within the normal range to proceed to transplant, a consent meeting will be arranged between yourself, your support system, the transplant physician and your coordinator. Prior to the meeting, you will be given a consent packet to review. The packet outlines the transplant process, risks involved, and permissions for the sharing of your medical information. The consent form for transplant is long and is often overwhelming to read. While reviewing the forms, please write down any questions you may have or call your coordinator for clarification. During the consent meeting you will have an opportunity to ask any additional questions. At the consent meeting, you will be asked by your transplant physician whether you have completed an advance directive. If you have an advance directive, please bring a copy to this meeting.

BONE MARROW BIOPSY

Despite the stories you have heard about bone marrow biopsies, the majority of our patients are surprised by how simple and relatively painless this procedure can be. The biopsy will be performed in the clinic by a nurse practitioner or transplant physician. They will explain the procedure in detail and have you sign a consent form prior to performing the procedure.

The bone marrow is taken from the upper, backside of your hip, called the posterior iliac crest. A local anesthesia called Lidocaine will be given using a small needle. You will feel a poke and a slight burn as the Lidocaine takes effect. The nurse practitioner/physician will numb you to the bone and then insert a large needle and withdraw about 10cc (a few tablespoons) of bone marrow using a syringe. The removal of the liquid marrow is the most uncomfortable part, but the pain should only last as long as the marrow is being withdrawn (about 10 seconds). You will then feel more pressure as a piece of bone, about ½ - inch long, is taken from the same spot. This is usually not painful. After the procedure, the numbing medication will wear off and you may feel soreness similar to having a deep bruise for a day or two. Tylenol and icing the area will help relieve this discomfort. We recommend you have someone drive you to and from this procedure.

CENTRAL VENOUS CATHETER

Throughout the transplant process, you will need a central venous catheter (CVC). A CVC is a tube that is placed in a large vein in your chest with the internal tip extending as far as your heart. The external portion of the tube will have two or three “tails,” referred to as ports or lumens. Common types of CVCs are HICKMAN^® Catheters, Optiflows, and Neostars. The catheter is inserted by a doctor using IV sedation or general anesthesia.

The CVC will be used to administer chemotherapy, medications, IV fluids, blood products, and to draw blood. For autologous transplant patients, this catheter will also be utilized for stem cell collection. If you already have a CVC when you are ready to start the transplant process, your transplant physician will evaluate if you can use your existing catheter or if it needs to be replaced.

Central Venous Catheter Placement
CVC placements are done either in the operating room or interventional radiology at Presbyterian/St. Luke’s (P/SL) Medical Center. You will receive further instruction by your Coordinator regarding check-in times and locations for the procedure.

The night before line placement, you are not allowed to eat or drink anything after midnight. On the day of the procedure, you will go to P/SL. A nurse will obtain your health history, you may have some blood drawn, and/or you may have an EKG. The physician placing the line will meet you prior to the procedure and obtain consent. The line will be placed in a procedure room where you will be given medications so that you have no memory of the procedure (conscious sedation) and a local anesthetic will be used.

After your CVC is inserted, the area around the catheter may feel sore and uncomfortable for a few days. Your transplant physician can give you medication to ease this soreness until it resolves. Please do not take products containing aspirin or ibuprofen while you have your CVC line. Keep in mind that your catheter site needs to remain dry for 72 hours after insertion.

If you have any of the following symptoms, call your transplant physician immediately:

• Oozing from the catheter site
• Uncontrolled Pain
• Fever (Temperature > 101.0°)
• Shortness of Breath
• Difficulty Breathing
• Swelling in chest, hand, or arm
• Red streak on chest along CVC tube

MOBILIZATION

We use certain drugs to increase the number of stem cells in the peripheral blood prior to collection for the transplant. This process is called mobilization. Two common methods of mobilization are colony stimulating factors (CSF’s) and chemotherapy.

• CSF’s

CSF’s are human proteins that are produced by the body to increase blood cell production. As the stem cells in the bone marrow begin producing more blood cells, increased numbers of stem cells are also produced and released into the blood stream. The most common side effects of CSF’s are mild-to-moderate bone pain or fever, which can often be controlled with Tylenol.


• Allogeneic Patients

If you are receiving an allogeneic transplant, your donor may receive CSF’s to mobilize stem cells prior to collecting their peripheral blood stem cells. CSF’s are given to the donor by daily injections for a period of approximately 5 days. Your conditioning regimen will coincide with your donor’s mobilization and collection processes.


• Autologous Patients

If you are receiving an autologous transplant, CSF’s are given by daily injections for approximately 10 to 15 days prior to stem cell collection. Your nurse may teach you or your Caregiver how to inject this medication, or you may receive it in the clinic, depending on your comfort level as well as the wishes of your insurance company.


• Chemotherapy

Mobilization chemotherapy is only used for autologous transplant patients. The chemotherapy used for mobilization varies depending on many factors including your disease and past treatments. Your transplant physician will make the appropriate recommendation as to which mobilization chemotherapy is best for you. Commonly used chemotherapy agents are cytoxan, VP-16, and Taxol, either alone or in combination.

We expect your blood counts to drop for several days after you receive your chemotherapy. For this reason, we closely monitor your complete blood count (CBC) during the 10 days following the mobilization chemotherapy. To protect you during the time when your blood counts are low, an oral antibiotic will be prescribed.

The drop in your complete blood count is followed by a rapid rise in your white blood cell count, approximately 9 –11 days after receiving your mobilization chemotherapy. Your blood will be drawn in the clinic as your white count rises to evaluate the number of circulating stem cells (CD34 cells). Once this number is equal to or greater than 10, you will begin stem cell collection (apheresis).

STEM CELL COLLECTION

• Apheresis

Apheresis is the procedure used to collect stem cells from your blood. The collection of stem cells takes 2-5 days for approximately 4 hours each morning. The procedure is performed at P/SL Medical Center. You will see a Transplant physician or a Nurse Practitioner daily prior to being connected to the apheresis machine (cell separating machine).

The apheresis machine withdraws blood from your central line (CVC) and circulates it through a centrifuge, which separates out your stem cells and returns the remaining blood back to you. There is only a small amount of your blood (a little over one cup) in the separator machine at any given time. The procedure is the same for allogeneic donors, but peripheral IV catheters are placed instead of a central line. During the procedure you may relax in your chair while watching television, movies, or reading.

There are very few side effects associated with the apheresis procedure. The main side effects are:

• Numbness/tingling of fingers or toes
• Numbness/tingling of skin, especially lips
• Cold Intolerance
• Nausea
• Muscle cramps


All of these symptoms can be signs of low calcium in your blood. Citrate, a calcium-binding substance used during the collection of your stem cells, prevents blood from clotting while it is circulating through the machine. Eating a breakfast that includes calcium-rich foods (for example milk, yogurt or cheese), may reduce or eliminate symptoms caused by the low calcium. Alert an apheresis staff member if you experience any these symptoms or have any other concerns.

During the time you are undergoing apheresis, daily lab tests are done to count the number of stem cells collected. Each patient has a target goal of stem cells to collect for transplant. It may take a number of days to attain this goal. The apheresis staff will notify you when your target goal has been met. The minimum number of stem cells required for transplant is 2,000,000.

For autologous patients, your cells are frozen (cryopreserved) and stored under special conditions until they are needed for transplant. Cryopreserved cells can be stored for up to 10 years.
For allogeneic patients, stems cells from related donors are most often infused into the patient on the same day they are collected from the donor, eliminating the need for cryopreservation. Fresh stem cells are viable for 48 hours. In the event that all of the stem cells are not needed, the excess cells will be cryopreserved for possible future use.

• Bone Marrow Harvest

In rare situations, a bone marrow harvest may be recommended for the collection of stem cells instead of apheresis. If you will require a bone marrow harvest, your physician will discuss the procedure with you in detail.

PSYCHOSOCIAL

The initial meeting with your transplant doctor is usually filled with some nervousness. The shock, denial and numbness that followed the initial diagnosis of your illness may now be replaced by worries and questions: Is a transplant for you? Will the transplant work? How will you tolerate the chemotherapy? Pre-transplant is the time to get these questions answered. Obtaining this information can help reduce some of your fears.

It is hard to absorb and understand all of the information about your disease and treatment when you first hear it, especially during that initial meeting when you are nervous about what the doctor will say. Some people have found that writing down questions is helpful. People also bring a tape recorder or take notes during the initial meeting with the transplant physician so they can refer to it later. We recommend bringing a family member or close friend with you to appointments, that way, someone else will hear the information. After all, two heads are better than one! Give these methods a try and see what works for you.

As transplant nears, anxiety and worries usually increase. Problems with sleep, irritability or low mood can occur. Medications can be helpful during this time to manage anxiety or improve sleep or mood. Relaxation exercises, such as deep breathing, imagery or progressive muscle relaxation exercises, can also help to reduce anxiety. Please let your transplant physician or the transplant psychologist know if you are experiencing problems.