Maggie McKay (Host): Meaningful Medicine is a Novant Health Podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. I'm your host, Maggie McKay. Joining us today is oncologist, Dr. James Dugan to discuss stem cell transplants, the different types, who can benefit from one, who can donate, and so much more. Thank you for making the time to be here, Dr. Dugan.

Dr. James Dugan: Thank you very much. I'm happy to be here.

Host: So let's just start off with who is a good candidate for a stem cell transplant? Who would need one?

Dr. James Dugan: Yeah. So I think in order to start this conversation, we have to be very specific about what kind of transplant that we're talking about. So there are roughly two kinds. There is an autologous stem cell transplant, the stem cells come from the patient, and then there's an allogeneic stem cell transplant where the stem cells come from somebody else. And for the purposes of this conversation, we are talking about an allogeneic stem cell transplant.

So the people that benefit the most from them are those that have a disease that requires them; not all of the blood cancers that we treat require an allogeneic stem cell transplant. And then the people that really benefit the most are also those that are a bit healthier. Right, which sounds a little bit counterintuitive. They have a blood cancer and they're sick by definition. But the stem cell transplants are very difficult and hard on the body and hard on the organs, and so all of those things have to be fairly healthy so the patient can move forward and not incur more damage from the treatment itself rather than just from the disease.

Host: Are there different types of stem cell transplants?

Dr. James Dugan: Yes. So for allogeneic stem cell transplant, the different types depend on where the stem cells come from, right? So as I already said, autologous, which is not what we're talking about, the auto means it's coming from the patient themselves, right? But for the allogeneic, they're getting the stem cells from somewhere else. So that can be from a family member that is well-matched. It can be from a brother and sister that's fully matched. It could be from a child, an adult child that is half matched. It could be from a parent, or it can be from a matched, unrelated donation, which, uh, it can come from the registry at large where anybody can join the registry and they can just go to bethematch.com and submit their own typing for stem cell transplantation. And then they could be requested at a future date for somebody in need of an allogeneic stem cell transplant.

Host: How would you know if you were the right match, if you were a stranger?

Dr. James Dugan: So, if you're a stranger and you submit your DNA, essentially they send swabs and you just do kind of a, a cheek swab and then, submit that to the company. Then they register that data, and then everyone that needs a transplant, including at our program, then can cross reference that database and say, Hey look, this is our patient that we have that needs a transplant.

Here is what's called their HLA typing. And then they look into the registry to see if somebody has that same HLA typing and they can be from the United States. They could be from abroad. The registry is vast and they cross-reference other country's registries as well. So you never really know where the stem cells are going to come from.

 And the people that submit their DNA never know if they're going to be picked. For example, I have my swabs in there and I have never been asked to donate stem cells. But that can change.

Host: Why are family members often good donors?

Dr. James Dugan: Yeah, so the family members share that HLA typing, right? It's very genetic. And so the family members have similar HLA typing. Now the matched related donation, which is often kind of the best stem cells that you could have for a stem cell transplant has to come from a sibling. So the reason for that is that you're getting half of your DNA from your father and half of your DNA from your mother.

And then if you do the math, each sibling has a 25% chance of being a complete match, which means that there's less likelihood of rejection, there's less likelihood of an entity called graft versus host disease, which is one of the things that we watch out for, because it's a better match.

But in a half match, which we are doing much more frequently, it's called a haplo donation. And for example, if a parent needs a stem cell transplant, all of their children are, by definition half matched. So it allows for more people to have access to stem cell transplant because of the techniques used in haplo donation.

Host: Without getting too technical, what is the process involved for both the donor and the patient? What's actually happening to help heal the patient?

Dr. James Dugan: This is an excellent question because I think, obviously this is where we get a lot of our questions from our patients, and I think for the donor, I think often they are very apprehensive. They're like, oh, they're going to cut into my bones and suck out all of my stem cells, and I don't really want to do that.

That is definitely not what's happening. So it is a fairly benign process. I wouldn't say completely benign, but the donor requires a couple of shots, which are growth factor shots to help stimulate their white blood cells to be more productive, right, to be produced excessively. Then those cells are counted in the blood, and then they're brought in for what's called a pheresis procedure.

They're connected to a Pheresis machine that looks not dissimilar to sort of a dialysis machine, but it's just for the blood. It spins the blood. It takes out the proportion of stem cells that we need and then gives the patient everything else back, like the red blood cells, other white blood cells, platelets, plasma, et cetera.

And then those are preserved. The patient has millions of other stem cells. They're not missing those stem cells that were taken. They will be replaced immediately. They can go about the rest of their day. It is one day of collection and usually not even a full day, for those younger donors that have a rapid response to the blood cell shots. Some of the side effects from that, bone pain, they have to get a shot, which is a side effect in and of itself.

And then you have to have a catheter placed, or at least wider IVs to run the Pheresis machine. So sometimes you know that patients are apprehensive about that, but there is no surgery involved for the donor. And then once they've donated their cells. Their part is largely done. For the recipient, it is a much harder process and often we are quoting mortality rates as high as 20 or 30% from having an allogeneic stem cell transplant just within the first a hundred days.

And so to harken back to the first question, who's a good person to go through an allogeneic stem cell transplant? It has to be meaningful, right? They have to really need it. They have to fit all of the criteria. Because even in the best of times, a 20% mortality rate sounds high, which it is, you know, one in five patients.

And so the patient selection has to be perfect. And then once all the cells are collected, they've had their treatment and their disease is in a state that will allow them to get an allogeneic stem cell transplant. They have to be conditioned with chemotherapy. They're usually put into the hospital system or close to it, and being brought back every day if they're not admitted to the hospital, and then they are administered the cells, the cells go in peripherally, like through an IV. They don't go in through, any sort of surgical procedure. They go into the blood, they go back to the bone marrow through a process called homing, and then the patient is sort of waiting for their cells to take and to start proliferating again.

There are other techniques as the patient progresses through their hospitalization, but often patients are admitted to the hospital for a month to continue undergoing the processes that are required in order to survive and be successful with an allogeneic stem cell transplant.

Host: Wow, that is a process. What's the most common question you get from patients and from donors?

Dr. James Dugan: From the donors, I think the most common question is, is there surgery involved? And the answer is no. And then we kind of go over the short process. It's a four day process of stimulating the cells typically, and then the collection is a day and then they're done. Right? And so I think the donors feel much better about that once they understand the process.

For the recipients, you're going over all of the mortality benefits and you know, all of the things that they have to look out for and all of the risks, right? But we should focus on all of the benefits of the allogeneic stem cell transplant. Because often what we're doing with these patients is we are searching for that cure, right?

These patients need a stem cell transplant because otherwise they are not going to survive their disease. And to push them into an allogeneic stem cell transplant is difficult. The decisions that the patients have to make are challenging, and it's certainly a family decision. They have to go back and look to all their loved ones to really make this a clear decision because they're going to need help, they're going to need support, they're going to have to have people around to help them through this process of recovery from an allogeneic stem cell transplant. So the process is long, but often at the end of the process, we are talking about cures that otherwise wouldn't be available.

Host: So is this a cure after you're done it all?

Dr. James Dugan: Yep. So is it a guaranteed cure? No. Is it a cure though? Yes. And for many patients it is the only opportunity for cure. In diseases like myelodysplastic syndrome or acute myeloid leukemia, many patients will never see a cure unless they can get to an allogeneic stem cell transplant. Now, there is still risk of relapse.

There is still risk of graft failure or complications from the delivery of the allogeneic graft, but there is no other option. If they have an opportunity for a cure. This is it.

Host: And do patients need to plan to travel to like an academic medical center for care?

Dr. James Dugan: They do not. And if we're talking about North Carolina, patients have great access to fabulous hospitals all around the region. And here at Novant, we have our own allogeneic stem cell transplant program, both in Charlotte and in Winston-Salem at Forsyth Medical Center. You do not need to travel out of state.

You do not need to travel long distances to get some of the best care that is available for these patients with these diseases.

Host: That's encouraging. So can anybody donate stem cells, Dr. Dugan, and if they want to, what's the next step for people who are interested how to get on that registry?

Dr. James Dugan: So yes, anybody can put their name into the registry. And so all they have to do is go to bethematch.com. It will walk you through a couple of different disclaimers and kind of go over some minor health history. And then they'll send you a swab and you can submit your swab and then send it out. That swab that you send, and then it does not commit you.

You're not signing a contract that says if we pick you, you have to come. Often we will ask a patient or a donor to come and be available for a stem cell transplant. But maybe they're out of the country, maybe they're busy, maybe they've decided they've had second thoughts about being a donor, and those things are all okay.

It is a big deal to donate your stem cells, to another patient that may not be even related to you and certainly not related to you if you're coming through the registry. And so we often will submit from multiple different sources for stem cells because we know that there are going to be people that are just going to be unavailable, but anybody can be part of the registry.

And then to sort of expand that question a little bit is, who as a family member can donate, to their loved one, to offer them a cure of their disease using their stem cells. And the indication or the ability to donate is broad, but there are some patients or some donors that won't be able to, you know, if they have other severe health conditions that might cause complications during the collection. We usually try to screen those donors out.

Host: So looking at the future of stem cell surgery, what excites you about the future?

Dr. James Dugan: We sort of already touched on some of these points, but the stem cell process is long. It's expensive and the scalability is hard, right? So we are doing a lot of these things, jumping through all these hoops, trying to find appropriate donors, giving all these medicines, all for that product, that final stem cell collected product to be available for one patient.

And that's great for that one patient when they need it. And it works. And it is amazing. And the, and the science is amazing behind all of these advances that we've had in the stem cell therapy. But at the end of the day, it is going, that product is going to one person. There's more research in the field now going to what's called off the shelf allogeneic products, which means that they have been produced and they have been scaled so that they're going to be available for multiple patients, right? So you still have a lot of work to be done in, in the beginning, but then once that product is made, it can be made available for more than one patient and in many instances can be made available for hundreds of patients.

And that will also help bring down the costs. So I think that as those products become more available, we'll see more people being able to receive these lifesaving therapies.

Host: That's awesome. In closing, I'd love to know who or what got you interested in becoming an oncologist and stem cell specialist.

Dr. James Dugan: Yeah. It is a long process, starting back from medical school, which now seems ages ago. But as you proceed through the medical onslaught of education, I think you have to kind of think internally about what are your interests? And in, undergrad I was a philosophy and biology major, and as you try to marry those two things together, which might seem sort of opposed, I think eventually you do get into a world of oncology where you are sort of marrying those two ideas together.

You're dealing with patients at some of their worst of times and being able to walk them through that process and talking about life and death. And it gets a bit philosophical sometimes. But then also using this cutting edge science to then help patients when they need it the most. And so that prompted me to go into oncology and then taking care of sick patients, was always my motivation.

You know, ICU level patients and malignant hematology is in that wheelhouse. And so at the end of the day, I like to call myself more of a malignant hematologist that needs tools, and one of those tools is allogeneic stem cell transplant.

Host: Well, this has been so fascinating and cleared up a lot of questions for a lot of different people, including me, so thank you again for joining us today.

Dr. James Dugan: Well, I really appreciate the opportunity. Thank you very much.

Host: Again, that's Dr. James Dugan, and if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. To find a physician, visit novanthealth.org. For more health and wellness information from our experts, visit healthyheadlines.org.