Dipnarine Maharaj on Adult Stem Cell Transplants in the Outpatient Setting

Dipnarine Maharaj on Adult Stem Cell Transplants in the Outpatient Setting

 



Dipnarine Maharaj MD FACP - Medical Director of the South Florida Bone Marrow Stem Cell Transplant Institute

 

            To many people’s surprise, it is entirely possible to conduct adult stem cell transplants in the outpatient setting. We conduct stem cell transplants for blood cancers on a totally outpatient basis, and we also perform evolving stem cell therapies for cardiac and neurological diseases, and immunotherapy for cancer. In addition, we offer intermediate dose (Mob/IDC) and high dose (HDC) chemotherapy in an outpatient setting – we do not offer conventional dose chemotherapy. The conventional dose of the drug Cytoxan is 750 mg.  For patients receiving IDC the dose would be 9000 mg, and the dose for patients on a HDC regimen would be 12000-14000 mg.

            The main benefit of offering these procedures on an outpatient basis is that it significantly lowers the likelihood that your severely immunosuppressed patient will contract a hospital-acquired infection. Figure 2 illustrates the results of a study by Williams et al entitled: Hospitalized cancer patients with severe sepsis: analysis of incidence, mortality, and associated costs of care.¹

This study analyzed data of more than 600,000 cancer hospitalizations in the United States in 1999. The results showed that a patient’s risk of developing severe sepsis was dependent upon the type of cancer they had. For example, patients with acute leukemia were 66 times more likely to develop severe sepsis than a cancer-free hospitalized patient. Basically, what this study showed is that patients with hematological malignancies are at significantly higher risk of contracting hospital acquired infections. Thus, one of the best ways of preventing hospital-acquired infections is to simply keep the patient out of the hospital by treating them as an outpatient.  

 

Figure 2. The Relative Risk of Severe Sepsis is Dependent upon the Type of Tumor¹

 

            Our own data shows that treating cancer patients as outpatients is extremely effective at reducing a patient’s risk of contracting hospital-acquired infections.  The incidence of severe sepsis among outpatients treated with IDC (9000 mg Cytoxan plus 1600 mg/m² VPB16) is 0%, and our overall incidence of infection has been very low.  The incidence of mucositis, a common complication of chemotherapy, is also extremely low. In outpatients receiving HDC the incidence of sepsis is 1%, but the overall incidence of infection is extremely low.

            How do we achieve this?  We focus. We are proactive. We all know the complications that can occur with this type of chemotherapy, so we take steps to prevent them. Proactive intervention reduces the risk of infection and sepsis and decreases the toxicities associated with HDC. First and foremost, hand washing is very important and strictly adhered to.  We use prophylactic medications to prevent the known toxicities of HDC – instead of treating nausea we simply prevent the patient from feeling nauseous in the first instance! Early intervention and treatment of complications prevents hospitalization. We also ensure that the patient is treated by the same healthcare professionals throughout their treatment. We know the patient, so we know how they have responded before and we can give them almost personalized care. Treating patients in this way benefits both the patients and the hospital. The patients benefit both physically and psychologically, as they are less likely to develop infections and they are able to go home to their families each day. The hospital benefits because reducing the risk of patient complications also reduces the number of people who are needed to care for each patient, and thus keeps costs low.