Safety of Autologous Stem Cell Transplantation Without Hematopoietic Support in Jehovah’s Witnesses With Hematologic Malignancies
In a single-center study reported in the Journal of Clinical Oncology, Ford et al found that autologous stem cell transplantation can be safely performed without hematopoietic support in Jehovah’s Witnesses with hematologic malignancies. Jehovah’s Witnesses traditionally refuse treatment with blood products.
Study Details
The study involved 125 Jehovah’s Witnesses with lymphoma (n = 55), multiple myeloma (n = 68), or amyloidosis (n = 2) treated with high-dose chemotherapy and autologous stem cell transplantation without transfusions at Pennsylvania Hospital between 1996 and March 2014.
Patients underwent priming with intravenous iron and erythropoietin to increase hemoglobin prior to transplantation, and cytokine mobilization of stem cells was performed. High-dose chemotherapy was delayed to allow hemoglobin to approach 11 g/dL and platelet level to approach 100×103/µL.
Patients with multiple myeloma received melphalan at 200 mg/m2. Patients with lymphoma received carmustine at 300 mg/m2 and cyclophosphamide at 1,500 mg/m2 on days 2 to 5, and etoposide at 700 mg/m2 on days 2 to 4. Granulocyte colony-stimulating factor, erythropoietin, aminocaproic acid, and phytonadione was given post-transplantation.
Bleeding Episodes
Overall, there were 2 major and 15 minor bleeding events, with none occurring at platelet count > 5.0×103/µL. No bleeding-related deaths occurred. Bleeding episodes included one grade 4 hemorrhagic temporal infarction with associated retinal hemorrhages, one grade 3 gastrointestinal bleed, one grade 2 retinal bleed, and one grade 2 vaginal bleed requiring administration of a progestational agent. Grade 1 bleeding episodes occurred in 15 patients; 4 patients had two or more bleeding episodes of varying severity.
Median decrease in hemoglobin was 5.0 g/dL, and median hemoglobin nadir was 7.0 g/dL. Median number of days with platelet count < 10×103/µL was 3, and median platelet nadir was 5.0×103/µL.
Cardiac Complications
Cardiac complications occurred in 40 patients (32%), including tachyarrhythmia in 20, hypotension in 17, congestive heart failure in 17, and bradyarrhythmia in 3. Death due to cardiac causes occurred in three patients, including fatal myocardial infarction in one.
The median hemoglobin at the onset of a cardiac complication was 8.9 g/dL, and the median time from reinfusion of stem cells to onset of cardiac complication was 4.5 days. At least one cardiovascular risk factor was present in 26 patients prior to treatment.
Treatment-Related Mortality
In total, there were six (4.8%) treatment-related deaths before day 30, consisting of death due to profound anemia, severe sepsis, and multiple organ failure due to pancytopenia in one patient each and the three deaths due to cardiac events. As noted by the investigators, this rate is higher than the reported national mortality rate of 1% to 3.5% for lymphoma and multiple myeloma.
The investigators concluded: “[Autologous stem cell transplantation] can safely be performed without transfusion support. A platelet transfusion trigger of ≤ 5×103/µL may be appropriate in select patients. Pharmacotherapy and cardiac monitoring are effective in the management of cardiac complications.”
Patricia A. Ford, MD, of University of Pennsylvania Health System, is the corresponding author for the Journal of Clinical Oncology article.
The study was supported by National Institutes of Health grants. The study authors reported no potential conflicts of interest.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
