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What to Expect

Each patient and his/her disease is reviewed by the transplant doctor to decide what type of transplant would hold the most promise of a cure or control of the disease with the least amount of risk. When it is decided that an autologous transplant would be the best option, several procedures are done before the start of the transplant. This timeline shows the different procedures that will be done prior to, during, and after the transplant. Although the sequence of procedures never changes, the dates may change because of unforeseen events. A calendar will be given to you that will provide dates when these procedures will take place.

1. The First Visit

At your first visit, the transplant doctor will take a complete history of your current disease, previous treatments and other medical history. A physical exam will also be done. The transplant doctor will talk to you about what is involved in a transplant and answer any questions you have.

2. Insurance Approval

At the first visit, you will be asked for information on your insurance company. The transplant team will work closely with you and your insurance company to get approval for the transplant once it is decided to move forward. In the event that your insurance will not cover a transplant, or if you don’t have insurance, other options that might be available will be discussed with you.

Claims Representative

Medical billing can be confusing. Because some of the members of your medical team work "behind the scenes", you may receive bills from persons or organizations with whom you are not familiar. Sorting through the paperwork is important because you want to be sure the bills you are paying are approrpriate for the services you have received.

At the Avera Cancer Institute, a claims representative will help you sort through your bills and assist you in filing your insurance claim forms. There is no charge for an initial visit with the financial counselor. For a small annual charge, our claims representative will completely manage your medical billing file and will contact Medicare and/or your insurance company on your behalf. We strongly encourage all of the patients to visit with the financial counselor.

3. Pre-Transplant Evaluation

If you and your transplant doctor decide to proceed, a pre-transplant evaluation will need to be done. The pre-transplant evaluation includes several tests to:

  • See whether or not your body will be able to tolerate the transplant.
  • Serve as a “baseline” so that they can be compared with the same tests completed after the transplant. This is done to see if any organs were damaged during the transplant (due to high-dose chemotherapy).
  • All tests are done as an outpatient if possible.

Tests:
Each patient’s history and disease determines what tests are ordered, so all tests described below may not be completed for every patient.

Bone marrow biopsy and aspirate: A small amount of marrow is collected from the hip bone to determine how well your bone marrow is working and whether or not disease is present in your marrow. Sedation is used during this procedure. A specially trained registered nurse will give you drugs through your vein that allow you to sleep through the procedure. This makes the test virtually pain free. You may have some discomfort following the test that you can treat with Tylenol® if needed.

Pulmonary Function tests: This study determines how well your lungs are working by measuring the amount of air you breathe in and out and how well the oxygen in your lungs crosses into your blood.

Echocardiogram: This test uses sound waves to make a picture of your heart that tell us how well your heart pumps the blood.

Electrocardiogram(EKG): This test also shows how well your heart is working.

CAT scan: This test is done to see if there is any disease present.

PET scan: This test is done to see if there is any disease present.

Gallium scan: This test is done to see if there is any disease present.

Metastatic bone survey: This test is done to see if there is any disease present.

Blood & Urine tests: These tests are done to see how well your kidneys, liver and bone marrow are working.

Infectious Disease tests: This blood test is done to check for any infections like hepatitis.

The transplant doctor will meet with you to talk to you about the test results. Once it is decided that a transplant will be part of your treatment, the transplant team will meet with you and make plans to begin the transplant process.

4. Consent Meeting

A consent meeting will be scheduled after the pre-transplant tests have been completed, and you have decided to go forward with the transplant. Family members and/or close friends are welcome to come with you. The transplant process will be reviewed including the stem cell collection, the chemotherapy drugs that will be given during the transplant, common side effects and dates for the transplant. This is done so that you have all the information you need and get all your questions answered before the transplant. Consent forms for the transplant will be given to you to read at home. We will have you sign them prior to starting the transplant process.

5. Catheter Placement & Care

A small flexible tube called a catheter with two or three “lumens” or separate lines will be inserted into a large vein in your chest under the collarbone. This surgical procedure will be done as an outpatient. The insertion may cause some discomfort at first and some soreness may be felt for several days. You will be given some pain medication to help control this discomfort, or you can take acetaminophen (Tylenol®). Avoid ibuprophen, (Advil® or Motrin®) and aspirin as these medications prevent your platelets from working like they should, so you are more prone to bleeding.

This catheter will be of great assistance, making it more comfortable to:

  • Collect stem cells
  • Draw blood for blood tests
  • To give chemotherapy
  • Give fluids
  • Administer drugs such as antibiotics and blood products
  • Administer stem cells for the transplant
  • Decreases the need to insert needles into your arms or hands

Since the catheter usually remains in place for several months, the nurses at the Leukemia and Bone Marrow Transplant Center and the Transplant Unit located at Avera McKennan will help teach you how to care for the catheter.

6. Mobilization

It is the stem cells that will restore the function of your bone marrow. Therefore, stem cells need to be collected before the high dose chemotherapy is given. Stem cells are collected from one of two sources, either the bone marrow or the peripheral blood. Generally the peripheral stem cell collection procedure is done; however, bone marrow collections can be performed if needed.

Since stem cells are found in our blood but in low numbers, we need to “mobilize” the stem cells out from the bone marrow into the blood stream. Mobilization is most often done as an outpatient in the Avera Hematology and Transplant Center by using either:

Chemotherapy and growth factors (such as Neupogen® or Leukine®): - It is very important that at the time of transplant the amount of disease present is minimal or undetectable. If there is a significant amount of disease found during the pre-transplant evaluation, the transplant doctor may decide that you will need some additional chemotherapy prior to the collection of the stem cells. Arrangements will be made to give you a specific number of chemotherapy treatments with the last treatment being the mobilizing chemotherapy.

When the mobilizing chemotherapy is given your blood counts will be followed. The chemotherapy will cause the blood counts to fall, and during this time you will be at risk for infection and bleeding.

After the chemotherapy, you will start to receive daily growth factor. This growth factor will decrease the number of days that your WBC is low. Once your blood counts start to recover, the stem cells will flood the bloodstream. Stem cell collection will begin at the discretion of the transplant physician.

Growth factors only: If, at the time of the evaluation the tests show that there is minimal or undetectable disease present, the transplant doctor may decide to use growth factors only for the mobilization. This mobilization usually begins on a Thursday, at which time you will start daily growth factor injections for five days. On the fifth day, the stem cells will be collected. This mobilization allows for a fair amount of predictability as to when the stem cell collection will begin.

7. Stem Cell Collection

Stem cell collection is done using a procedure called apheresis (ay-fer-ee-sis). This is an outpatient procedure performed by specially trained registered nurses supervised by the transplant doctor. The catheter you had placed will be used for stem cell collection. Two tubes or lumens of your catheter will be connected to the aphaeresis machine. Through the catheter, a small amount of your blood is removed and returned to you by the aphaeresis machine. As your blood travels through the aphaeresis machine, the stem cells are separated from the other blood cells in your blood and are removed and collected into a separate bag. The rest of the blood is returned to you.

Aphaeresis is painless and causes very few side effects. Common side effects are lightheadedness, chills, numbness around the lips, and cramping in the hands. These side effects are due to a lowering of the calcium in your blood. The aphaeresis nurse will give you calcium during the procedure to prevent these side effects from happening.

The aphaeresis procedure lasts about 4-6 hours. After each collection, we need to determine the number of stem cells that have been collected. The target number of stem cells is at least 2 million cells per kilogram of the patient's weight. aphaeresis is done daily until the target number of cells is reached. The average number of times the aphaeresis procedure needs to be done varies, but generally speaking, 2-4 collections are needed. After each day of collection, the stem cells are frozen and kept frozen until the time of the transplant.

8. Conditioning Therapy

The chemotherapy and/or radiation therapy you will receive during transplant is very strong. Great attention to detail is taken as the transplant team plans for your conditioning therapy. The goal of the conditioning therapy is to destroy any disease that might still be remaining in your body, to suppress the immune system and to make room for the stem cells that will be given.

This high dose chemotherapy is so strong that it will hopefully overwhelm the remaining disease and kill it. Unfortunately the high dose chemotherapy will not only kill any remaining disease but will also “wipe out” your bone marrow. This will prevent it from manufacturing the white and red blood cells and platelets that you need. The stem cells we collected earlier will be able to rescue your bone marrow from the effects of the chemotherapy and allow your bone marrow to recover and produce normal blood counts.

Conditioning therapy begins after admission to the hospital or in the Transplant Center if you are having an “outpatient” transplant. During the days of chemotherapy, you will receive anti-nausea medications on a schedule to decrease your risk of becoming nauseated. You will receive plenty of intravenous fluids to make sure that you are flushing the chemotherapy out of your body. Most often the chemotherapy remains in the body for only 24 to 48 hours. The days of chemotherapy are numbered in minus numbers, and we count backwards to Day 0. On Day 0, there is no remaining chemotherapy in your body, and the stem cells can be given at that time.

Total Body Irradiation Therapy
If you will be receiving radiation therapy as a part of your preparative therapy, the radiation is given either before or after your chemotherapy, depending on the treatment regimen your transplant physician has chosen for you.

9. Day of Transplant

Stem Cell Infusion (Day 0)
The day the stem cells are infused is called “Day 0”. The infusion of stem cells will take place after the chemotherapy is done and enough time has passed to make sure no chemotherapy remains in your body. Unlike chemotherapy, radiation therapy does not require any time to leave your body. Once the radiation therapy is done, the stem cells can be given immediately without any harmful effect on them. The infusion of stem cells can happen anytime during the day. The transplant team will set up a time based on your last dose of chemotherapy or radiation treatment. Your nurse will let you know what time the infusion is scheduled, so family members or friends who want to be there can plan accordingly.

The infusion of stem cells is done in your room. There are very few problems with the infusion of stem cells, but we do monitor you closely, so if problems arise we can take care of them quickly. Before the infusion, your nurse will connect you to several monitors:

  • A clip will be placed on your finger to measure the oxygen level in your blood.
  • Patches are put on your chest which are connected to a machine in order to monitor your heart rhythm.
  • A blood pressure cuff will be placed on your arm to monitor your blood pressure and pulse.
  • A special blood tubing will be connected to your catheter which is used to infuse the stem cells slowly through your catheter similar to red blood cells or platelets.

There are few side effects of the infusion of stem cells. The side effects are:

  • Reaction similar to an allergic reaction like hives
  • Shortness of breath, or chest tightness

If these occur, medications will be given to reverse them

After the stem cells enter the bloodstream, it will take them approximately 24 hours or so to travel into the bone marrow. Once in the bone marrow, the stem cells will begin the process of producing new white blood cells, red blood cells, and platelets. It generally takes these stem cells between 12 – 20 days to make enough cells to be measurable in the blood sample. Your blood counts will be checked daily, and when the counts start to increase, we know that the stem cells have “engrafted”. Even though your blood counts have recovered, recovery of your immune function takes much longer - up to several months for an autologous transplant.

10. Transplant Timeline

If you would like to see a graphic timeline of the transplant process, download this timeline pdf file. Note, this timeline covers both autologous and allogeneic transplant processes.

Other Information

You can also view patient education about the allogeneic transplant process.