The transplant process

There are several steps in the transplant process. The steps are much the same, no matter what type of transplant you are going to have.

Patient evaluation and preparation

You will first be evaluated to find out if you are eligible for a transplant. A transplant is very hard on your body. For many people, transplants can mean a cure, but complications can lead to death in some cases. You will want to weigh the pros and cons before you start.

Transplants can be hard emotionally, too. They often require being in the hospital, being isolated, and there is a high risk of side effects. Many of the effects are short-term, but some problems can go on for years. This can mean changes in the way you live your life. For some people it’s just for a while, but for others the changes may be lifelong.

It’s also very hard going through weeks and months of not knowing how your transplant will turn out. This takes a lot of time and emotional energy from the patient, caregivers, and loved ones. It’s very important to have the support of those close to you. You will need, for instance, a responsible adult who will be with you to give you medicines, help watch for problems, and stay in touch with the team after you go home. Your transplant team will help you and your caregiver learn what you need to know. The team can also help you and your loved ones work through the ups and downs as you prepare for and go through the transplant.

Many different medical tests may be done, and questions will be asked to try to find out how well you can handle the transplant process. These might include:

• HLA tissue typing
• A complete health history and physical exam
• Evaluation of your psychological and emotional strengths
• Identifying who will be your primary caregiver throughout the transplant process
• Bone marrow biopsy
• CT (computed tomography) scan or MRI (magnetic resonance imaging)
• Heart tests, such as an EKG (electrocardiogram) or echocardiogram
• Lung studies, such as a chest x-ray and PFTs (pulmonary function tests)
• Consults with other members of the transplant team, such as a dentist, dietitian, or social worker
• Blood tests, such as a complete blood count, blood chemistries, and screening for viruses like hepatitis B, CMV, and HIV

You will also talk about your health insurance coverage and related costs that you might have to pay.

You may have a central venous catheter (thin tube) put into a large vein in your chest. This is most often done as outpatient surgery, and usually only local anesthesia is needed (the place where the catheter goes in is made numb). Nurses will use the catheter to draw blood and give you medicines. If you are getting an autologous transplant, it can also be used for apheresis to harvest your stem cells. The catheter will stay in during your treatment and for some time afterward, usually until your transplanted stem cells have engrafted and your blood counts are on a steady climb to normal.

Eligibility

Younger people, those who are in the early stages of disease, or those who have not already had a lot of treatment, often do better with transplants. Some transplant centers set age limits. For instance, they may not allow regular allogeneic transplants for people over 50 or autologous transplants for people over 60 or 65. Some people also may not be eligible for transplant if they have other major health problems, such as serious heart, lung, liver, or kidney disease. A “mini-transplant,” described under “Allogeneic stem cell transplant” in the section called “Types of stem cell transplants for treating cancer” may be an option for some of these patients.

Hospital admission

The hospital’s transplant team will decide if you need to be in the hospital to have your transplant, or if it will be done in an outpatient center. If you have to be in the hospital, you will likely go in the day before the transplant is scheduled. During this time, the transplant team makes sure you and your family understand the process and want to go forward with it.

The transplant experience can be overwhelming. Your transplant team will be there to help you physically and emotionally prepare for the process and discuss your needs. Every effort will be made to answer questions so you and your family fully understand what will be happening to you as you go through transplant. This is important because once conditioning treatment begins (see the next section), there is no going back — there can be serious problems if treatment is stopped at any time during transplant.

To reduce the chance of infection during treatment, patients who are in the hospital are put in private rooms that have special air filters. The room may also have a protective barrier to separate it from other rooms and hallways. Some have a positive air pressure system to make sure no unclean outside air gets into the room.

Conditioning treatment

Conditioning, also known as bone marrow preparation or myeloablation, is treatment with high-dose chemo and/or radiation therapy. It’s done for one or more of these reasons:

• To make room in the bone marrow for the transplanted stem cells
• To suppress the patient’s immune system to lessen the chance of graft rejection
• To destroy all of the cancer cells anywhere in the patient’s body

No one conditioning treatment is used for every transplant. Your treatment will be planned just for you based on the type of cancer you have, the type of transplant, and any chemo or radiation therapy you have had in the past.

If chemo is part of your treatment plan, it will be given in an intravenous (IV) line or as pills. If radiation therapy is planned, it’s given to the entire body (called total body irradiation or TBI). TBI may be given in a single treatment session or in divided doses over a few days.

This phase of the transplant can be very uncomfortable because high treatment doses are used. Chemo and radiation side effects can make you sick, and it may take you months to fully recover. A very common problem is mouth sores that will need to be treated with strong pain medicines. You may also have nausea, vomiting, be unable to eat, lose your hair, and have lung or breathing problems. If you know what medicines your doctors will be using for conditioning, you can find out more about each drug on our Web site at www.cancer.org, or call us for more information.

Conditioning can also cause premature menopause in women and will likely make both men and women unable to have children. (See “Stem cell transplant and having children” in the section called “Long-term problems after transplant.”) Before you have a transplant, you need to discuss the transplant process and all its effects with your doctors. It also helps to talk to others who have already had transplants.

Infusion of stem cells

After the conditioning treatment, you are given a couple of days to rest before getting the stem cells. They will be given through your IV catheter, much like a blood transfusion. If the stem cells were frozen, you may get some medicines before the stem cells are given. This is done to reduce your risk of reacting to the preservatives that are used when freezing the cells.

If the stem cells were frozen, they are thawed in warm water then given right away. For allogeneic or syngeneic transplants, the donor cells may be harvested in an operating room, and then processed in the lab. Once they are ready, the cells are brought in and infused. The length of time it takes to get all the stem cells depends on how much fluid the stem cells are in.

You will be awake for this process and it doesn’t hurt. This is big step and often has great meaning for recipients and their families. Many people consider this their rebirth or chance at a second life. They may celebrate this day as they would their actual birthday.

Infusion side effects are rare and usually mild. The preserving agent used when freezing the cells (called dimethylsulfoxide or DMSO) causes many of the side effects. You might have a strong taste of garlic or creamed corn in your mouth. Sucking on candy or sipping flavored drinks during and after the infusion can help with the taste. Your body will also smell like this. The smell may bother those around you, but you might not even notice it. The smell, along with the taste, may last for a few days, but slowly fades away. Often having cut oranges in the room will offset the odor. Patients who have transplants from cells that were not frozen do not have this problem because the cells are not mixed with the preserving agent.

Other short-term side effects of the stem cell infusion might include:

• Fever or chills
• Shortness of breath
• Hives
• Tightness in the chest
• Low blood pressure
• Coughing
• Chest pain
• Less urine output
• Feeling weak

Again, side effects are rare and usually mild. If they do happen, they are treated as needed. The stem cell infusion must always be completed.

Recovery

The recovery stage begins after the stem cell infusion. During this time, you and your family wait for the cells to engraft, or “take,” after which they begin to multiply and make new blood cells. The time it takes to start seeing a steady return to normal blood counts varies depending on the patient and the transplant type, but it’s usually about 2 to 6 weeks.

During the first couple of weeks you will have low numbers of red and white blood cells and platelets. Right after transplant, when your counts are the lowest, you may be given antibiotics to help keep you from getting infections (this is called prophylactic antibiotics). You may get a combination of anti-bacterial, anti-fungal, and anti-viral drugs. These are usually given until your white blood cell count reaches a certain level. Still, you can have problems, such as infection from too few white blood cells (neutropenia), or bleeding from too few platelets (thrombocytopenia). Many patients have high fevers and need IV antibiotics to treat serious infections. Transfusions of red blood cells and platelets are given until the bone marrow is working again and new blood cells are being made by the infused stem cells.

Except for graft-versus-host disease, which only happens with allogeneic transplants, the side effects from autologous, allogeneic, and syngeneic stem cell transplants are much the same. Problems may include gastrointestinal (GI) or stomach problems, and heart, lung, liver or kidney problems. (We will talk more about these later, in the section called “Problems that may come up shortly after transplant.”) You might also go through feelings of distress, anxiety, depression, joy, or anger. Adjusting emotionally after the stem cells can be hard because of the length of time you feel ill and isolated from others.

Having a transplant is a big decision. Your life and your relationships will be disrupted. Your future becomes uncertain, the process makes you feel bad, and financially it can be overwhelming. You might feel as if you are on an emotional roller coaster during this time. Support and encouragement from family, friends, and the transplant team are very important to get you through the challenges of transplant.

Discharge

Discharge planning

The discharge process actually begins weeks before your transplant. It starts with the transplant team teaching you and your primary (main) caregiver about:

• The precautions you will need to take
• How to prepare your home
• How to care for your central venous catheter
• How to take good care of your mouth and teeth
• What foods you should and shouldn’t eat
• Activities you can and can’t do
• When to call the transplant team or other health care professionals
• Who will take the role of primary caregiver and what the job will involve, and who will be the back-up caregiver in case your main caregiver gets sick and can’t be near you

Discharge criteria

For the most part, transplant centers don’t discharge patients until they meet the following criteria (see the section called “What are stem cells and why are they transplanted?” for more information about neutrophils, platelets, and hematocrit):

• They have no fever for 48 hours
• They are able to take and keep down pills or other drugs for 48 hours
• Their nausea, vomiting, and diarrhea are controlled with medicine
• Their neutrophil count (absolute neutrophil count or ANC) is at least 500 to 1,000/mm³
• They have a hematocrit of at least 25% to 30%
• They have a platelet count of at least 15,000 to 20,000/mm³
• They have someone to help them at home and a safe and supportive home environment

If patients do not meet all of these requirements, but still don’t need the intensive care of the transplant unit, they may be moved another oncology unit.

Rehabilitation

The roller coaster ride often continues after you go home. Plus, you will be feeling pretty tired after going through the transplant process. After discharge, in the rehabilitation period, some people have physical or mental health problems. These ongoing needs must now be managed at home and caregiver and friend/family support is very important.

Transplant patients are still followed closely during rehab. You may need daily or weekly exams along with things like blood tests, chest x-rays, bone marrow tests, or spinal taps (lumbar punctures). During early rehab, you also might need blood and platelet transfusions, antibiotics, or other treatments. The exams are frequent at first, maybe even every day, but will be needed less often if things are going well. It can take 6 to 12 months, or even longer, for blood counts to get close to normal and your immune system to work well.

Some problems might show up even a year or more after the stem cells are infused. Physical problems are usually from the chemo and/or radiation treatment, but other issues may pop up too. Problems can include:

• Graft-versus-host disease (in allogeneic transplants)
• Infections
• Lung problems, such as pneumonia or inflammation that makes it hard to breathe
• Kidney, liver, or heart problems
• Low thyroid function
• Overwhelming tiredness (fatigue)
• Limited ability to exercise
• Memory loss, trouble concentrating
• Emotional distress, depression, body image changes, anxiety
• Social isolation
• Changes in relationships
• Changes in how you view the meaning of life
• Feeling indebted to others
• Job and insurance discrimination
• Slowed growth and development (in children)
• Cataracts
• Reproductive or sexual problems (like infertility and early menopause)
• Secondary cancers

Your transplant team is still available to help you. It’s important that you talk to them about any problems you are having — they can help you get the support you need to manage the changes that you are going through.