Dr. Friedrich Schuening
Stem Cell Clinic will offer ease, savings
With the opening this month of a new Stem Cell Transplant Clinic for adult patients, Vanderbilt University Medical Center will offer blood stem cell transplantation on a largely outpatient basis. Transplantation involves chemotherapy followed by infusion of blood stem cells and intensive management of side effects.
Vanderbilt stem cell transplant patients currently undergo a hospital stay of three to four weeks. With patients undergoing daily evaluation at the new clinic, hospital admission will be reduced to three to five days.
“The main reason for the move to the outpatient setting is that it’s significantly cheaper,” said Dr. Friedrich G. Schuening, chief of Hematology and director of Stem Cell Transplantation. Outpatient transplant is a well-established procedure with a proven safety record, costing 20 percent to 25 percent less than inpatient transplantation and producing greater patient satisfaction. “To stay competitive it’s important to offer all treatment options,” said Schuening, Ingram Professor of Cancer Research.
Blood stem cells make red blood cells, white blood cells and platelets. Transplantation is used to treat leukemia, lymphoma, aplastic anemia, inherited disorders and many other diseases. Patients often can act as their own donor, undergoing chemotherapy before the reintroduction of their previously collected stem cells. In other cases it’s necessary to gather stem cells from a relative or unrelated donor whose tissue type matches that of the patient. Donor cells are gathered from marrow, from blood, or from frozen umbilical cord blood.
Eligibility for outpatient transplant is limited to ambulatory patients who are well disposed to the prospect of an outpatient procedure and who have a full-time adult caregiver available to monitor temperature and blood pressure and administer meds and IV fluids.
Stem cell self-donors face less risk of infection and Vanderbilt transplant hematologists will begin by offering the outpatient procedure for self-donor patients with multiple myeloma, Hodgkin’s lymphoma or non-Hodgkin’s lymphoma. These diseases, accounting for approximately two-thirds of the adult stem cell transplants performed here, tend to respond especially well to transplantation.
Medical centers that manage to do the procedure on a completely outpatient basis usually will keep these immunosuppressed patients in a hotel across the street and run a 24-hour clinic to treat fever and other common side effects. Vanderbilt hematologists will start by instead admitting patients to the 11 North myelosuppression unit for four to six days to receive chemotherapy and stem cell infusion. Patients will be discharged to the new clinic on the day after stem cell infusion, and will receive daily outpatient evaluation for two to three weeks following discharge, with follow-up becoming gradually less frequent over a period of weeks. Once the program is fully operational, patients may start the procedure in the clinic and get admitted to 11 North only for the few days when white blood cell counts are at their lowest and risk of infection is greatest.
The new clinic is located next door to Hematology on the second floor of The Vanderbilt Clinic. The clinic waiting room has been glassed in to help prevent infection. There are 13 infusion stations — some with beds, some with easy chairs. TVs and DVD players are available at all stations. A shuttle will travel between the clinic and a nearby hotel.
The clinic will start slowly, said Carol Eck, administrative director of the Cancer Patient Care Center. “Until we start we won’t fully understand some of the system issues, such as ensuring ready access to beds on 11 North. A gradual start will help ensure that the team is comfortable.” The clinic will eventually add weekend hours, but for the time being weekend outpatients will be seen on 11 North.
Transplant programs in Knoxville and Memphis are limited to self-donor patients, making Vanderbilt the only center in Tennessee to offer all modes of stem cell transplantation. VUMC draws transplant patients from across Tennessee and from surrounding states, with annual adult patient volume having doubled from 50 to 100 patients between 2000 and 2002.
Vanderbilt’s pediatric program for stem cell transplantation has also seen strong growth, Schuening said, with 32 kids having received the transplants at VUMC in 2002 (because they tend to be more responsive to chemotherapy, fewer kids need stem cell transplants). There currently are no plans to move pediatric stem cell transplantation to the outpatient setting.
At Vanderbilt and elsewhere, stem cell transplantation happens to be among the most profitable of clinical programs.
“Continued program growth will mean getting out to community hematologists to increase our referral base,” Eck said. The assumption for the next three years is 15 percent annual growth in adult stem cell transplants.