How to develop a Transplant program Which patients are best to choose

How to develop a Transplant
program
Which patients are best to choose
when you are starting?
Or you have a small program
100-day Mortality after
HLA-identical Sibling Transplants,
2008-2009
100
Mortality, %
80
60
Early Disease
Intermediate Disease
Advanced Disease
Chronic Phase
Accelerated Phase
Blast Phase
Other
40
20
0
AML
ALL
CML
MDS/MPS
Aplastic
Anemia
Immune
Deficiency
Slide 16
SUM-WW11_15.ppt
100-day Mortality after
Unrelated Donor Transplants,
2008-2009
100
Mortality, %
80
60
Early Disease
Intermediate Disease
Advanced Disease
Chronic Phase
Accelerated Phase
Blast Phase
Other
40
20
0
AML
ALL
CML
MDS/MPS
Aplastic
Anemia
Immune
Deficiency
Slide 17
SUM-WW11_16.ppt
One-year survival after myeloablative conditioning
for acute leukemias in any remission phase,
CML or MDS, age <50 years, by year of transplant
and graft source, 1988-2009
100
HLA-matched sibling
Unrelated Donor
One-Year Survival, %
80
60
40
20
0
1988- '91
'92
'93
'94
'95
'96
'97
'98
'99
'00
'01
'02
'03
'04
'05
'06
'07
'08
'09
90
Slide 14
SUM11_40.ppt
Getting Started
• What are the advantages of starting the
program with autologous HCT?
Getting Started
• What are the advantages of starting the
program with autologous HCT?
– Troubleshoot program components without
dealing with most complex immunologic issues
•
•
•
•
•
Pharmacy support
Apheresis and cell processing lab
Nursing support
Infection control
Laboratory support
Getting Started
• What are the advantages and disadvantages
of starting the program with allogeneic HCT
What are the advantages and disadvantages of
starting the program with allogeneic HCT
• Greater pool of
potential allogeneic
recipients
• Troubleshoot all
program components
during the same period
of time
• Greater risk of early
poor outcomes due to
“infrastructure”
• Loss of confidence of
stakeholders
– Referring MDs, hospital,
local authorities
Getting Started
• How should the program evaluate the needs
of the population when considering the initial
strategy?
Getting Started
• How should the program evaluate the needs
of the population when considering the initial
strategy?
– What is the impact of the transplant center upon
health in the region?
– Will the impact differ if either autologous or
allogeneic HCT are not part of the portfolio
– Is regional reputation, based upon outcomes, an
important factor of success and sustainability?
Getting Started
• What consideration should be given to
transplant candidate selection in the
program’s first few years?
Getting Started
• What consideration should be given to
transplant candidate selection in the
program’s first few years?
– Which diseases and disease status to focus upon?
• Those with best opportunity for cure?
• Those with limited alternative treatments?
– How to consider recipient risk and comorbidities
– What about distance?
Getting Started
• Does all follow-up of the HCT recipients need
to occur at the Transplant center?
Getting Started
• Does all follow-up of the HCT recipients need
to occur at the Transplant center?
– After care and support affect the outcomes
– Should the availability of good post HCT care
affect patient selection?
• And, if follow-up of the HCT recipients has to
occur at the Transplant center, for how long?
Getting Started
• Should a center establish cross-center
collaboration within a region to capitalize on
expertise and efficiencies?