Transcript
[0:00] Our next speaker is Jenny Paul. Jenny has been working within cancer services since 2013 after supporting her mother through ovarian cancer. She has found it rewarding supporting patients and their loved ones, working with a wide number of experienced nurses and colleagues. Over time, she found an interest in stem cell transplant and was keen to explore and learn more. After a few taps on the shoulder with relieving in the role and increased hours with the health service available, she was able to work as a Bone Marrow Transplant Clinical Nurse Consultant since 2021.
She is currently a member of ANZTCT – for those who aren’t familiar, that’s the Australian and New Zealand Transplant and Cellular Therapies registry – and a member of a few more organisations. She really loves what she does and, like many colleagues, goes above and beyond to support as best she can. So Jenny will be talking to us about stem cell transplantation. Take it away, Jenny.
[1:06] Thank you. I hope everyone can hear me. It’s nice to virtually meet everyone and it’s great to be able to speak to people directly who are keen to learn more about stem cell transplants. A special mention to Liam who’s going to be doing the slides. Next slide, please, Liam.
First-line therapy for myeloma involves induction treatment followed by consolidation treatment with an autologous stem cell transplant – ‘autologous’ means obtained from the same individual. So we’re getting the person’s own stem cells. Research has shown an increased overall survival in patients with myeloma who have an autologous stem cell transplant in first-line treatment.
My focus during this presentation is transplant consolidation. It’s quite a huge area; I usually spend up to an hour educating people, so I’ll try to get through it quickly. I’m sure a lot of people are familiar with the Myeloma Australia website. If people are considering a transplant, I would encourage you to definitely look at the Myeloma Australia autologous stem cell transplant booklet, a guide for people with myeloma. There’s a lot of really valuable information in that.
[2:29] My main focus is to briefly touch on the following: what are the advantages and disadvantages of an autologous stem cell transplant, proceeding to transplant, care and patient navigation, mobilising and harvesting stem cells, high-dose chemotherapy reinfusion, common side effects and nursing care, and follow-up care.
The main advantages why we do transplants is that we want to consolidate the initial response from people’s induction treatment. We want to pause the myeloma as long as possible. This is evidence-based. It does remain gold standard treatment. It is a safe procedure and it does improve people’s quality of life and leaves behind a lot less residual myeloma cells.
The downside is that people are going to get high-dose chemotherapy. This is a lot more toxic and it does increase side effects. There is a longer recovery – it can be up to 3 to 4 months. Not everyone will receive their desired response with a transplant. Fertility can be affected and there is a risk of about 1 to 2% of death.
[3:47] Proceeding to transplant: these are the considerations that the treating haematologist needs to look at. This includes patient fitness, age and co-morbidities, if you have an active or sedentary lifestyle, if you are independent with your own needs, and any issues with a physical or mental health disability. So there’s lots of things the transplant doctor needs to take into consideration.
Another important thing is definitely having a dental review and assessment. Mouth care is really, really important. Some people may need to have repeat scans such as skeletal surveys and CT scans. There are numerous blood tests that occur. So people will need to have repeat protein markers and light chains. You might need to have 24-hour urine collections to help monitor the response. Proceeding to stem cell collection, we need specific viral marker testing. Sometimes the transplant consultant would like additional testing like a lung function test, a heart scan, or a kidney scan.
[5:07] Care and patient navigation: Regarding specialist appointments, a lot of the transplants need to be done at a large hospital. It’s very important for a transplant physician to assess you properly face-to-face. Consent will occur at this time and it’s always important to try and bring a support person.
Regarding stem cell collections, majority of these treatments are attended as an outpatient. Regarding proceeding to a transplant, a lot of people actually need to be admitted, with inpatient admissions for about two to two and a half weeks. Some people with myeloma don’t live near a tertiary hospital, so in each state we do have patient travel assistance schemes.
Support referrals include community-based organisations: our Myeloma Nurses Australia, the Cancer Council in each state, the Leukaemia Foundation, Rare Cancers Australia, the Arrow Foundation, and Canteen for young people. There could be local charities, the Look Good Feel Better programme, and a new initiative called Carer Gateway which provides support for carers.
Allied health referrals are usually in-hospital referrals. Examples are social work, dietician, physiotherapy, psychology. Some people are also referred to palliative care for pain management support. There are also Aboriginal Health Liaison Officers and interpreter services. I would always encourage everyone to have regular follow-up with their GP for regular prescriptions and pain relief. They can also do referrals to physio and psychology.
A lot of people with myeloma go on to prophylactic medication to decrease the risk of viruses or illnesses. Two common medications are an antiviral and Bactrim, an antibiotic which helps decrease the risk of bacterial or fungal infection. People will usually be on these for a considerable period of time.
[9:10] Mobilising stem cells: This is quite a planned and timed procedure. It usually occurs after three to four cycles of induction treatment. It’s very important to have good peripheral access; sometimes people may need a central line inserted.
There are two ways for mobilisation. Some transplant physicians will mobilise stem cells using cyclophosphamide and Granulocyte Colony-Stimulating Factor (G-CSF) injections. Others may prefer just the G-CSF injections and plerixafor. Our haematologists here usually use cyclophosphamide.
Side effects from cyclophosphamide are low blood counts, increased infection risk, decreased appetite, nausea, loose bowels, fatigue, and hair loss. The G-CSF injections are a growth factor that helps the bone marrow produce more stem cells. Side effects are bone pain, headache, temperature, and nausea. Plerixafor can enhance stem cell movement; its side effects are diarrhoea, dizziness, and headache.
[12:20] Apheresis and the stem cell collection process: We do a CD34 target blood test. CD34 is a protein found on the surface of very early blood cells. Once we have a certain number, we proceed to collection.
People will have a cannula inserted in one arm (the ‘draw’ arm). Blood is removed and goes through the apheresis machine, mixing with an anticoagulant called citrate. A centrifuge spins and separates the stem cells into a bag; the rest of the blood is infused back into a cannula in the other arm.
This is a specialised procedure taking a whole day, possibly multi-day. Wear comfortable clothes, bring your phone, headphones, a support person. We encourage people to bring their usual medications. There is a risk of citrate toxicity, which can cause mouth tingling or a locked jaw, easily resolved with a calcium infusion.
[15:33] Transplant specialists aim to get enough cells for two transplants. A minimum dose is 2 million CD34 cells per kilo of body weight. Once we have enough, they are cryopreserved and stored.
The timeframe between collection and transplant can be dependent on people’s response from induction treatment and planning. As a guide, it’s usually between three to four weeks.
[16:35] High-dose chemotherapy: People receive melphalan. This chemotherapy attacks and destroys cancer cells, acting on rapidly dividing cancer cells as well as healthy cells like bone marrow, the gastrointestinal tract, and hair follicles.
High-dose chemotherapy increases the severity and duration of side effects. The stem cell reinfusion aids in rescuing your damaged bone marrow. Without stem cells to reinfuse, people cannot proceed.
[19:35] This is an example of if someone at our centre was having a transplant as an outpatient. Melphalan is given on Day -1. Day 0 is the stem cell reinfusion. Patients receive phone calls on Days +1 and +2. They present to our day unit on Days +3 and +4 for blood tests and review. On Day +5, the plan is to admit to hospital. They start daily G-CSF injections again to aid engraftment.
Discharge follows engraftment recovery, around Day +14. For outpatient treatment to occur, a support person is required and accommodation must be close to the hospital. If a support person is not available, the patient will need to be admitted for the whole process.
[20:48] Day -1 is the conditioning chemotherapy. People need suitable venous access. The therapy is given a day prior to reinfusion, taking about 3-4 hours on the day unit. People get pre-medication and hydration. Prior to starting melphalan, people get ice chips to decrease the severity of mouth sores and mucositis.
Transplant Day, Reinfusion Day, Day 0: This occurs 24 hours after the melphalan. People get pre-medications and fluid hydration. Occasionally, prior to reinfusion, scientists wash the cells to remove the Dimethyl Sulfoxide (DMSO) cryopreservation agent.
Infusion times vary depending on the number of stem cell bags required. The infusion itself is about 5 to 10 minutes. Immediate possible side effects are breathlessness, decreased blood pressure, fever, shivering, flushing, nausea, and vomiting. In extreme but rare cases, the patient could lose consciousness.
Common side effects of the DMSO preservative are a flushed face, feeling cold, a tickle in the throat, and an unusual taste or smell. A common smell, often described as tinned cream corn or tomato soup, lasts about 24 hours as the DMSO is excreted through the skin and breath. We encourage bringing lozenges. We ensure a doctor is on the unit during reinfusion.
[24:29] Common side effects of the conditioning chemotherapy are mucositis, infection, nausea and vomiting, diarrhoea, decreased appetite, pain, fatigue, changes in memory and concentration, and hair loss. It is very important to let someone know if you experience symptoms or if medications aren’t effective.
Oral mucositis is very common. It involves swelling and inflammation of the lining of the mouth and digestive system. Treatment is oral hygiene with sodium bicarbonate mouthwashes and salt water gargles. Some may need antifungal lozenges, gel for pain, regular pain relief, or in extreme cases, a syringe driver for pain or nutritional support.
[26:51] Infection and pancytopaenia: There is a huge infection risk during neutropaenia. A thorough septic workup would occur with antibiotics, blood cultures, and scans. People may need additional fluids. Blood product replacement and platelet transfusion are common. G-CSF injections start on Day +5. Consider the patient environment: a single room, mindful of visitors, good hand hygiene.
[29:47] Nausea and vomiting: Regular anti-nausea medication is important; there is always stronger medication available. There is a risk of dehydration, so fluid replacement is key. Dietitians encourage regular small meals, eating slowly, and sitting out of bed. Peppermint or ginger tea can help.
Diarrhoea is very common in about 80% of people, usually occurring 24-96 hours after melphalan. We send a specimen to check for infection. If no bug is found, medications can help. Dietitians advise a special protein diet, avoiding fatty, creamy, sugary foods, stringy vegetables, and coffee.
[31:41] Fatigue: Unfortunately, there’s no magic cure. Patients feel physically and mentally drained with low energy and motivation. They can have trouble concentrating and sleeping. It’s important to pace yourself, plan ahead, break down tasks, keep a diary, and consider gentle physical activity. Some people get memory loss and forgetfulness; reassurance, a calendar, and a support person are handy.
[32:45] Engraftment syndrome: I’ve added this as I’ve seen it recently. It usually occurs following an autologous transplant, characterised by non-infectious fever, weight gain, rash, and organ dysfunction. It’s thought to be related to inflammatory cytokines and occurs around engraftment (Day +9 to +17). Most cases are mild. It’s more common in females, younger patients, and myeloma patients. If it occurs, a full septic workup is done and steroids may be given. The take-home message is to keep an eye on infection risk post-discharge.
[34:13] Follow-up: As a guide, inpatients are usually in for about two to two and a half weeks. At our centre, we do a phone call follow-up within the first week. It is important to have a specialist review 2 to 4 weeks post-discharge. Definitely make an appointment with your GP. Maintenance treatment can be commenced about 2 to 3 months after transplant.
People are eligible to have their vaccinations as per the immunisation schedule from about 6 months following a transplant. It’s very important to continue having regular flu jabs and COVID-19 vaccinations. I would also encourage hepatitis B and respiratory revaccinations.
Another plug for the support groups and services. Regarding returning to work, I try and encourage people to recover for at least four to six weeks. If people need to return for financial reasons, engage in a safe return to practice and start off slowly.
[36:54] Fatigue management: Everyone manages fatigue differently. Physiotherapy and exercise are really important to focus on. Gradually, people will realise they might be better in the morning. By around the 6-week mark, most people start to feel a bit better and stronger. But it is an individual process.
[37:45] That’s it. There are some references there. Definitely check out the Myeloma website if you haven’t already. eviQ is where there are a lot of treatment protocols online. The last slide shows a ’90s version of stem cell collection, chemotherapy, and transplant. That’s it. I’m very sorry I’ve probably spoken too much, but there is a lot of information to try and get in.
[38:19] Thanks very much, Jenny. That was very comprehensive and informative. We don’t have time for questions, but as mentioned previously, if anyone does have any questions please feel free to email us and if we can answer them we’ll certainly help. Otherwise, we’ll forward them on to the relevant speaker.
