If you’ve been diagnosed with leukemia, lymphoma, myeloma, or other blood cancers and conditions, your doctor may recommend a blood or marrow stem cell transplant.
Bone marrow is the soft, spongy tissue inside the body that makes the blood’s raw materials known as stem cells. These stem cells have the ability to develop into many different blood cell types for many different functions, from white blood cells to fight infection, to platelets to control bleeding. In people with certain types of blood cancers and/or who receive certain types of high-dose chemotherapy or radiation treatments, the bone marrow can become damaged. A transplant can benefit these individuals by replacing diseased or damaged bone marrow through introducing new stem cells into the body.
Blood and marrow stem cell transplants are usually used in sequence with chemotherapy
. Knowing the details of your treatment plan – what you’re doing, why you’re doing it, and how it works—can help you prepare for treatment and make informed decisions about your care.
In addition to asking their doctor questions about this treatment
, some people may also find it helpful to discuss their options with people they trust, including family members, friends, a cancer support group, or an oncology social worker. Be careful when doing research online, as many sites can be inaccurate or misleading. Discuss any information you find on the internet with your health care team.
Types of Blood and Marrow & Stem Cell Transplants
All stem cell transplants come from bone marrow. Some transplants use a "cell source" or "product type" of bone marrow, which is collected by surgical procedure under anesthesia, whereas others use peripheral blood, or peripheral blood stem cells (PBSCs), which are collected from the blood by apheresis (no sedation required). Once the donation enters your bloodstream, the bone marrow and stem cells take the place of the cells that were destroyed by treatment.
Depending on the type of cancer you have and the treatment plan your doctor has created for you, your transplant may be autologous (from your own body) or allogeneic (from a donor).
You may be asked to donate and bank your own stem cells prior to “transplant conditioning,” which is a high dose of chemotherapy your doctor gives you prior to receiving cells to repopulate your marrow. This material will be frozen while you are undergoing treatment, then returned when the transplant conditioning is complete. By collecting and later re-administering these cells, the body’s immune system and ability to produce blood cells can be restored after high-dose treatments.
In cases where collecting and banking stem cells is not possible or advisable given the characteristics of your particular disease, your doctor may recommend an allogeneic transplant. In this procedure, the blood marrow or stem cells will come from a donor whose blood proteins (known as HLA type) closely match yours. Siblings from the same parents have the highest chance of being a full match (25% per sibling), but “haploidentical” donors, who share at least 50 percent of the genetic material (such as parents and children), may also be considered as candidates for donation. There are also donor registries (such as the Be the Match
registry in the United States), which keep a global database of donors willing to donate their bone marrow or stem cells. You will not be responsible for finding a donor; your medical team will take care of finding a suitable match.
90% of allogeneic donations are collected directly from the donor’s bloodstream using apheresis, where the donor’s blood is removed through a needle in one arm and passed through a machine that separates out the stem cells. The remaining blood is returned to the donor through the other arm. 10 percent of donations are done with a minor surgical procedure done under general anesthesia in the hospital; most donors go home the same day as the procedure.
It’s also worth noting that some people receive cord blood transplants, which is also an allogeneic transplant, but from the blood collected via the umbilical cord from the placenta after the birth of a baby. These are kept in global banks for use by patients as needed. Adults usually need two matched cord blood units (that match each other and match the patient as well) and children need one unit, due to the "cell dose" (number of stem cells) needed vs available in cord blood units.
From start to finish, a stem cell transplant can take between one (outpatient) and six (inpatient) weeks to complete. It takes about six months to recover from an autologous transplant and one-to-two years to recover from an allogeneic transplant. In addition to making you aware of the time commitment required for the treatment and intensive recovery, your cancer team will ask you questions about your lifestyle to ensure you are adequately prepared for the months following the transplant. These questions may include, but are not limited to:
- Do you have a family, member, friend, or the means to hire a home nurse to provide care and transport you to daily follow-up appointments for up to 100 days as you recover from the transplant?
- Are you located within 30 miles of the transplant center, or are you able to acquire temporary housing near the center for up to 100 days after your treatment?
- Do you have any active mental health or substance abuse issues?
- Do you have health insurance?
- Do you need help applying for disability benefits while you are recovering from the procedure?
If your transplant will be autologous, your doctor will put you on a schedule to collect your stem cells in the weeks leading up to your transplant conditioning. To begin, you will be given an injection of growth factors, which stimulate the blood stem cells in the bone marrow to multiply and be released into the bloodstream. These injections may continue for up to six days (though five is typical), and side effects of them may include bone pain (most common), and flu-like symptoms, including fever, headaches and muscle pain. These are typically minor and subside after the injections are completed.
After the injections are completed, the stem cells are collected with a process known as apheresis. The blood is removed through a needle in one arm, then pumped through a machine that separates the blood-forming cells from the rest of the blood, which is returned to the body through another needle in the other arm. This collection process can take up to eight hours.
During this time, you will be placed in a comfortable reclining chair, where you can work, watch television, read, or even nap. Some centers will even allow you to bring a companion if you wish to have company (and if not, you can stay connected with video calls on your phone or computer). The process is often a comfortable one, with only mild side effects such as tingling skin and chills caused by the anticoagulant used in the apheresis process. You may want to be prepared that you will not be able to, generally, get up at all and will need to use a bedpan or possibly a bedside commode to relieve yourself during collection. You will have to keep your arms pretty much straight and still, so don’t plan to do a lot of arm-moving. Lastly, you may receive instruction to eat Tums or to try to get extra calcium to mitigate the side effects of that tingling; listen to what the transplant coordinator suggests!
Throughout the collection process, your nurse will come in to check your vitals and make sure you aren't reacting to the anti-coagulants. When the collection process is complete, the nurse will remove the needles in your arms. You may be asked to stay in the treatment room for up to 30 minutes after these needles are removed to ensure you do not have any adverse reactions to the medications used. You may also be given food and drink to avoid any lightheadedness.
After collection, the stem cells are taken to a processing laboratory, where they are prepared for freezing and storage in liquid nitrogen. This keeps the cells safe and stable until they are needed for transplantation.
The cycle of injections (one additional for each additional day collection is needed) and collections is continued until a sufficient number of stem cells are obtained to perform the transplant—usually no more than three days. If the transplant team can't get the cells they need after that, they may make a new plan for you, such as chemo, a clinical trial, or even an allogeneic transplant. Allogeneic donations follow this same protocol, and you will not need to be present for the donor’s apheresis procedures. Once your cancer treatment team has determined that enough stem cells are present, you will begin your transplant conditioning regimen.
What to Expect On Transplant Day
After your stem cell collection, you will undergo five-to-ten days of high-dose treatment of chemotherapy
and/or total body irradiation (TBI) known as a “conditioning regimen.” Depending on the procedures used and your proximity to the treatment center, you may be required to stay at the hospital, or you might be allowed to return to your home daily. Your medical team will explain the conditioning regimen used as well as side effects to expect and how those side effects will be managed.
During this time, most of your drugs will be delivered through a central venous catheter placed in the arm (usually) or sometimes the chest, neck, or groin This provides direct access to a large vein, which is ideal for reducing the number of needle pokes required for administering medications, fluids, and nutrition as well as drawing blood samples for testing.
This catheter is also where your bone marrow and stem cell donation will be administered. Stem cells from either your donation or your allogeneic donation will be infused into your body through the catheter, where the stem cells will find their way back into the bone marrow. This infusion can take anywhere from one to four hours, and feels no different than receiving a blood transfusion. Note that if the stem cell product has been treated with DMSO and frozen, the room can begin to smell (some patients described it as “creamed corn”). This is nothing to worry about; it’s just the smell of DMSO being metabolized.
What to Expect After Transplant
For the 14 days or so (it can happen faster or take longer) following your transplant, the bone marrow or stem cells begin a process called engraftment, where your bone marrow will be repopulated by the healthy cells infused during the transplant. To help this along, you may be given the same growth factors injected during the collection process. It’s also quite likely that you’ll need a blood transfusion after the transplant; this is very normal, so it’s worth making it your expectation.
During the engraftment process, your white blood cells will be very low, which can make you susceptible to infection. Your doctor may require you to remain in the hospital until your white blood cell counts reach a safe level, which may take as long as between two and four weeks (though occasionally as long as six). However, not all transplants require the patient to stay in the hospital while recovering. Some transplant centers have housing facilities close by, where patients can stay while being monitored via frequent visits back to the hospital or associated outpatient clinic, while others allow patients to sleep at home and return to the hospital for daily checks.
Ask your doctor about the options available for you, as well as what your insurance will cover. Note that some private insurance companies (though not Medicare) will pay up to a certain amount for hotel stays and mileage to complete the transplant. Sometimes they also cover food, so always check. If you live far enough from the transplant center (usually 200+ miles), some Medicaid plans will also pay for food, travel, and lodging.
While your immune system recovers, you may be told to undergo preventive measures to avoid infectious agents, including frequent handwashing and barring visitors (or having them wear masks and gloves when they are present). It’s important to follow your doctor’s advice, including regular monitoring and blood tests to check for signs of infection.
The recovery process for bone marrow and stem cell transplantation is not linear. Even after the patient is discharged from the hospital or treatment center, recovery will continue at home for six months to a year (sometimes longer). Many patients report feeling better one day and worse the next—this is normal, and indicative of the adjustment your body is making during the engraftment process. You may also be recovering from your high-dose treatments, which can have intense side effects. In the weeks after high-dose treatments and a subsequent transplant, you may experience:
- Bleeding and bruising
- Mouth and throat sores (mucositis)
- Skin rash and discomfort
- Feelings of isolation, depression, and helplessness
Talk with your cancer care team immediately about any side effects you are experiencing, as there are ways to make you more comfortable as you recover. Early identification of side effects can also signal more serious conditions that need to be addressed immediately.
If you had an allogeneic transplant, your symptoms may also signal a complication called graft-versus-host disease, which occurs when your donor cells attack your body’s healthy cells. Because up to 80% of people receiving allogeneic transplants develop some form (either acute or chronic) of graft-versus-host disease, it’s very important to understand what the risks of developing it are to you. Be sure to ask your transplant team every question you have about it. Understand that no symptom is "too small" to report when graft-versus-host disease is a possibility after your transplant, because early treatment is vital to your recovery. This complication must be addressed immediately with steroids or immunosuppressant drugs to prevent long-term damage. Some people end up “trading one disease for another,” in kicking cancer to the curb while acquiring lifelong chronic graft-versus-host disease. This is not uncommon in transplant patients and underscores the importance of understanding the process.
Monitoring and Results
During engraftment, the new stem cells will multiply, making more blood cells. Your doctor will track your counts of red blood cells, white blood cells, and platelets, which should gradually return to healthy levels in the weeks after your transplant.
You may also undergo regular blood testing to monitor your cancer. These tests can give your doctor a clear picture of how your body is responding to the treatment, and what adjustments (if any) need to be made.
If you received an allogeneic transplant, you will take immunosuppressant drugs for the first year or more of your recovery, to minimize your risk of graft-versus-host disease. Some patients never stop taking these medications, but some do. Your doctor will walk you through this.
You will need to be re-immunized with several of your vaccinations in the first year after your transplant as well. Your transplant team knows the schedule on which you should be re-immunized.