Meeting the transplant team

Today Rose and I went to the hospital to meet the transplant team. I also had another bone marrow biopsy.

The transplant will be a "reduced intensity" regime; the alternative being "high intensity". The difference is that the high intensity kills all the immune system in the host, before the donor cells are infused. With low intensity, the host immune system is suppressed, but would recover if left long enough. The theory behind the reduced intensity approach is that the donor white cells will kill off any remaining host stem cells. The risks of a relapse with high intensity treatment is lower, but the risk of death during the transplant phase increases with age. If I were 30 instead of 50, I would probably have the high intensity treatment.

The pre-transplant chemo (called conditioning) is done in Ambicare. The day before the transplant I will be admitted, and the transplant infused (there is no operation - it is just the stem cells that were harvested from my brother that are infused IV the same as any other blood product). There then follows a few weeks in hospital where I will have no immune system. Infections are certain in a similar way to the first two cycles of chemo. During this time I will be hooked up to IV drips 24/7. In particular I get cyclosporin, which suppresses the lymphocytes of of the donor cells (the anti-viral agents), so that I do not get "graft versus host disease" (GVHD) too badly. After a couple of weeks they expect the donor cells to engraft, and my counts will return, but I stay on the cyclosporin. Once my counts recover (the donor cells engraft), they try and wean me off IV to oral medication so that I can go home. During this whole period I will inevitably get an infection; they say 1 in 3 patients spend some time in intensive care (something I have avoided so far).

After being sent home, the first 3 months are pretty bad. I will be weak, and maybe unable to get up on some days. I will visit a clinic once a week, and the hospital send transport to get me. The levels of cyclosporin are gradually reduced (giving me the ability to fight viral infection), and some GVHD is expected, even desired, as it will kill any remaining leukemic cells. The next 3 months should see me gradually regaining strength, and so clinic visits are only bi-weekly (and the hospital will not send transport anymore as they deem public transport to be safe). During this time it is not uncommon to be readmitted to hospital to treat some viral infection.

There are not very good mass test figures to derive outcome probabilities, but broadly I have a 85 - 90% chance of surviving the transplant and the subsequent weeks in hospital, and a 40% chance of surviving 5 years after. This chance increases after 18 months - i.e. most relapses happen within 18 months of transplant.