The Changing Face of Bone Marrow Transplant
“The early days of bone marrow transplantation (BMT) were a mixture of ‘the joy of victory and the agony of defeat’,” confesses ONS member Rosemary Ford, RN, BSN, OCN®, manager of the Transplant Clinic at the Seattle Cancer Care Alliance in Washington.
Like many oncology treatment modalities, much has changed in BMT since those early years. Ford has been a BMT nurse for 34 years; ONS member Kate Tierney, RN, PhD, clinical nurse specialist for the BMT unit at Stanford Medical Center in California, has 32 years’ experience. Together, they provide a fascinating peek at the evolution of this treatment.
The Early Years
For many years, BMT was considered investigational, and patients were enrolled in phase I or II clinical trials to study both the treatment and ways to prevent its side effects.
“One study I remember involved testing cyclosporine for graft-versus-host disease (GVHD) prevention,” Tierney explains. “We administered it over a short period of time and then had to draw what seemed like endless pharmacokinetic samples. Of course we learned that a short infusion was very nephrotoxic. I also learned that with research, you might not get it right the first time.”
“Our first attempt to use cyclosporine in 1980 was a failure,” Ford laments. “The first five patients died from renal failure. It was two years before we tried again, and eventually it became the benchmark therapy against which all other GVHD therapies were measured. But I think the hardest aspect was cytomegalovirus (CMV) pneumonia; back then, 20% of our patients died from CMV by day 70 post-transplant.”
The Joys and Struggles of a Transplant Nurse
“I had never heard of marrow transplant back in 1978,” says Ford, who had previously worked in a burn unit. “But nursing for patients with severe burns and nursing for BMT recipients had a great deal in common. Both populations face a life-threatening diagnosis and are at high risk for infection. Both require blood products, have fluid maintenance issues, need central venous lines, and can quickly progress to needing ICU care. But perhaps the two most important similarities for me were that both populations establish long-term relations with their nurses, and good nursing care makes an obvious difference to their quality of life.”
Tierney’s impressions are similar. “I had started my career as a new graduate working on an inpatient oncology unit and found that I was really drawn to working with BMT recipients because the long length of stay provided an opportunity to really get to know them.”
Ford admits she had some initial challenges in the beginning. “The hardest part for me—not coming from an oncology background—was how well the patients looked before we started high-dose chemoradiotherapy. In the burn unit, there was no question that the patients needed treatment. But transplant recipients looked surprisingly healthy when they were admitted. A fellow nurse had to remind me that they had less than a year’s life expectancy, which helped me come to grips with the fact that our treatment quickly made them sick.”
For Tierney, dealing with the suffering is still difficult. “The suffering may be physical or psychological. It is the suffering of the patient and their families, the devastation of finding out a patient has relapsed six months after the transplant, the grief over lost fertility for those who haven’t completed their families, and the despair when a young mother or father realizes they will not be there to raise their child.”
“I remember one articulate, charismatic patient who developed severe veno-occlusive disease,” says Ford. “He died a horrible death on a ventilator, with massive ascites and this bizarre orange color. We didn’t know that preexisting liver disease was a risk factor.”
Evolving Treatments and Patient Populations
Both Tierney and Ford acknowledge tremendous improvements with the development of newer antiemetics, antibiotics, antifungals, and antivirals.
“When I started, we administered high-dose cyclophosphamide at night, using secobarbital for nausea because there really wasn’t anything else. We just hoped the patients would sleep through it,” Tierney remembers.
“We were still learning what worked and what didn’t,” Ford points out. “We’d tried a new transparent dressing for Hickman catheters only to discover that a 1000 Rads of single-dose of radiation would cause patients’ skin to peel off when we changed the dressings.”
One of the most significant improvements has been in the detection and treatment of infection. “In the early years, we lost so many patients to infections,” Ford says.
But now, Tierney explains, “we can detect CMV viremia early and initiate therapy (therapy that didn’t exist until the mid-1990s) before the disease develops.”
In addition to increased knowledge and decreased toxicities, the patients themselves have changed. “When I started,” Ford says, “30 was the cut-off age for older transplant patients. Then it was 50. Now there doesn’t seem to be a limit!”
But with the age increase comes new challenges. “Older patients are likely to have other comorbid medical conditions and are at higher risk of physical decompensation after an infection or graft-versus-host disease,” Tierney says.
The Future of BMT
Tierney is the first to admit that we can’t predict the future. As a new BMT nurse, one night she called the resident about a patient with a fever and severe mucositis. “I was discouraged by the patient’s suffering and my inability to provide relief and told the oncology resident that BMT was just too toxic and it would fade away as a treatment. He said he believed it would become less toxic and we would get better at it. So we made a dinner wager. Twenty years later, I met up with that former resident and admitted he was right; BMT had gotten safer. Needless to say, I paid my wager.”
On the other hand, Ford hopes that one day Tierney’s prediction will come true. “Like BMT pioneer and Nobel Laureate Dr. Donnall Thomas, I am hoping that BMT will become obsolete.”
If that doesn’t happen, both nurses have faith that new treatments will someday make BMT a little easier for patients. “I am hoping that targeted therapies will replace the toxicity of high-dose chemotherapy and radiation,” Ford says.
Likewise, Tierney hopes for “sophisticated graft engineering to provide powerful anticancer therapy without the need for high doses of radiation and chemotherapy.”
Without a doubt, BMT continues to evolve. As Tierney explains, “I have served as witness to the tremendous advances in both BMT medicine and nursing. I did not anticipate at the beginning of my career how richly rewarding it would be to remain within this specialty and watch progress unfold. As that resident told me many years ago, science has made BMT safer and more effective. While we have not solved every puzzle, we have certainly come a long way.”