ST. LUKE’S MEDICAL CENTER PIONEERS MISMATCH STEM CELL TRANSPLANT FOR BLOOD DISORDERS
St. Luke’s Medical Center (SLMC) has proven that for more than a century of patient-centered health care, a once free dispensary clinic could rise into a hospital of three-stories high and ultimately reach, and even exceed, to local and international standards. So for 114 years, SLMC already set a high bar—still unparalleled—for medical institutions in the Philippines, making it the country’s first hospital to offer mismatch stem cell transplant, or haploidentical hematopoietic stem cell transplantation (HSCT).
St. Luke’s Global City’s Stem Cell Center is founded upon topnotch doctors who are experts in the field of HSCT. The hospital has been accredited by the Department of Health for stem cell processing and administration. The stem cell team is led by Dr. Francisco Lopez, Head of Bone Marrow Transplant. Dr. Lopez coordinates with three other stem cell specialists: Dr. Arvin Faundo on stem cell processing, Dr. Ernesto Datu on stem cell collection and harvesting, and Dr. Rodelio Lim on stem cell ethics.
The discovery of blood forming or hematopoietic stem cells (HSC) in the 1960’s advanced medical science immeasurably. Through rigorous scientific research since then, these blood forming stem cells have proven capable of regenerating itself, dividing into other blood cells such as red cells, white cells, and platelets. Eventually, with a deeper understanding of the immune system (particularly tissue typing), the era of bone marrow transplant began, moving forward to treat various blood diseases.
In the past, the HSC were aspirated from the pelvic bone of a patient or donor, filtered, then infused again into the patient or recipient. This relatively old practice has evolved into an advanced technology, and took form in an apheresis machine which works as a centrifuge in collecting and separating blood cells. It is programmed depending on the number of blood cells needed by the patient and can selectively filter platelets, white blood cells, or stem cells—whichever is required to cure the particular disease. A patient or donor undergoing stem cell harvest is then injected with a stimulating factor called “filgastrim” (Granulocyte Colony Stimulating Factor or GCSF). At a higher dose, it encourages stem cells to come out of the bone marrow and start drifting through the bloodstream for easier harvest. Then, these stem cells are collected from a vein. From simply “bone marrow transplant”, the treatment was renamed as “peripheral blood stem cell transplantation".
“We do not get the stem cell directly from the bone marrow,” said Dr. Lopez. “Using the apheresis machine, we already get and collect stem cells through the peripheral blood. So it takes several hours, maybe three hours or so, until we reach a certain number of stem cells for the treatment.”
Haploidentical stem cell treatment in PH
Hematopoietic stem cell transplant is classified into two types. One is autologous, meaning the stem cells are collected from the patient. This is offered to patients with myeloma or lymphoma. On the other hand, diseases such as leukemia and aplastic anemia are treated with the second type: allogeneic HSCT or those collected from a donor’s stem cells.
“Decades ago, several institutions abroad did a study comparing chemotherapy versus autologous versus allogeneic in acute myelogenous leukemia patients, and it basically showed that allogeneic HSCT upfront is better than chemotherapy and autologous,” he said.
Of these two types, allogeneic seems to be a serious problem in the Philippines because of the difficulty in donor search. Initially, patients can only rely on a fullmatch stem cell donor to proceed in transplantation. A full-match could be compatible 25 percent of the time. There are cases that “one can have seven siblings, and may not even have a match within those seven, and that has happened to one of my patients,” shared Dr. Lopez, adding that having no stem cell match, the option would be “the donor bank which we don’t have here in the Philippines.” No doubt, it will potentially increase expenses to scout for stem cell donors abroad. From the foreign donor bank, the shipment alone would cost to an estimate of $30,000-$40,000. These digits equate to P1.5-P2 million and would probably force one to crash the bank only to extend one’s life.
In October 2013, St. Luke’s Global City launched the first mismatch stem cell transplantation, saving more Filipinos struggling with blood disorder. With mismatch stem cell, a patient no longer has to find a complete match to undergo treatment, no matter how many mismatches occur. One can find a mismatch donor 95% of the time amongst family members. Even a parent could be a donor to a child and vice versa. This is done through a regimen concocted by Johns Hopkins University. High doses of cyclophosphamide are given on the third and fourth day after the infusion of the stem cells. Cyclophosphamide reduces the post-treatment complication of stem cell patients by selectively killing cells that trigger graft versus host disease. Survival data and complication rates are also similar to a complete match sibling or unrelated donor transplant.
St. Luke’s Global City pioneered haploidentical HSCT in the Philippines, with 17 stem cell patients of various malignant blood diseases, several of which have already passed the threeyear survival mark. Dr. Lopez usually tells his patients: “Pass your three-year mark; if you pass your three-year mark and you’re still alive, then that’s pretty much it. You most likely survived your leukemia.”
Hope at a price
For leukemia patients, haploidentical HSCT is better performed when a patient is in first remission or early in the stages of their disease, not during relapse or as a last resort. The survival rate is better, overall.
St. Luke’s Global City doctors share their optimism with their Filipino patients, believing that getting cured of their disease does not always equal to emptying the wallet.
“For me, that’s the heartbreaking thing, in truth, and I’m trying to find ways on how we can help the average Filipino,” Dr. Lopez said. “The issue for me are those who have spent a lot for the initial treatment of leukemia, and have very little resources left for the transplant.”
There are several variables which could spike or lower the medical cost of stem cell transplantation. “When I searched the net, I was surprised to find out that some articles were quoting P4 million to P5 million for a HSCT. Patients will be discouraged. From our experience in St. Luke’s Global City, the range of a HSCT is somewhere between P1.6 to P2 million, or even less,” Dr. Lopez clarified.
He broke down the eight cost variables for the stem cell transplant: age (pediatric or adult), weight, conditioning regimen, number of stem cell harvests, units of blood transfusions given, intravenous antibiotics for infections, length of stay in the isolated hepa-filtered positive pressure room, and the need for intravenous nutrition. Dr. Lopez shared that he had some patients in the recent past who went through complication-free procedures, resulting in a lower or average overall hospital bill.
It is expected that the “cost of living” for blood cancer patients could end up costing a fortune. This is a normal financial stigma for most Filipinos who struggle with the disease; however, it should not hinder patients from asking for professional assistance and getting treatment. With a readily available family member who is a full or partial matched donor and with the cost of the transplant contained, a patient can breathe freely when undergoing this revolutionary treatment at St Luke’s Medical Center.