Tests and Eligibility Criteria for BMT in Mumbai

Who Is Eligible for a Bone Marrow Transplant?

Bone marrow transplant, or hematopoietic stem cell transplant, may be an option for some patients with blood cancers, bone marrow failure disorders and some inherited blood conditions. But simply having a disease that is treatable with BMT does not mean that transplantation is appropriate for every patient. The transplant team will assess the underlying disease, response to treatment, overall health and ability to tolerate the transplant process before recommending BMT. Pretransplant evaluation typically includes a medical history, blood tests, organ function tests, a physical exam and, for many patients, bone marrow evaluation. In Mumbai and India, patients who are advised for a bone marrow transplant or stem cell transplant should undergo an elaborate BMT eligibility assessment before the treatment plan is finalized.

What Factors Determine BMT Eligibility?

There is no single test to determine if a person is a candidate for bone marrow transplantation.

• Kind of blood cancer or blood disorder 
• Current status, risk and stage of disease
• Response to previous therapy
• Age and general physical condition
• Heart function
• Pulmonary function
• Kidney and liver functioning
• Active infection or infection not under control
• Other health conditions
• Previous chemotherapy or radiation therapy
• Type of transplant considered
• If an allogeneic transplant is required, an appropriate donor must be available.

The decision is personalized since the risks and possible benefits of transplantation vary greatly from one patient to another.

What Tests Are Done Before a Bone Marrow Transplant?

Pre-BMT testing has two primary objectives: to understand the disease status, and to determine if the recipient is sufficiently fit to undergo transplantation.

The precise investigations depend on the diagnosis, age, previous treatment and type of transplant.

1. Blood Tests

Blood tests are an important part of the pre-transplant workup

They can be used to evaluate:

• Erythrocytes

• White blood cell

• Thrombocytes

• Renal function

• Liver function

• Other disease or treatment-related parameters

Before the transplant, blood tests are used to find out about blood-cell counts and the way the liver and kidneys are working.

2. Bone Marrow Examination

Depending on the patient’s disease, a bone marrow aspiration and/or biopsy may be performed.

Before a transplant, the test can give the treating team information about the status of a blood or bone marrow disorder. Disease status prior to transplant can be particularly important to treatment planning for patients with leukemia, myelodysplastic syndromes, or other marrow diseases.

3. Heart Tests Before BMT

BMT can be a stressful process for the body and heart function may be evaluated before conditioning treatment and transplantation.

• Electrocardiogram (ECG) - checks the heart’s rhythm.

• Echocardiogram: This test provides information on the structure and pumping function of the heart.

These investigations help the BMT team decide if further cardiac assessment or treatment changes are needed.

4. Lung Function Tests

Pulmonary function testing may be done to see how well the lungs are working before transplant.

This could include measuring how much air a patient can take in and out, and how well the lungs are working. Lung assessment helps doctors decide whether the patient is likely to be able to tolerate the planned conditioning and transplant procedure.

5. Kidney and Liver Function Tests

The kidneys and liver are particularly important during BMT because the patient may be given several medicines before, during and after transplantation.

Blood tests are therefore used to evaluate kidney and liver function in the pre-transplant work-up. Abnormal results do not mean that transplantation cannot always be performed. The BMT team reviews the results in the light of the patient’s disease, treatment needs and overall health.

6. Infection Screening Before BMT

Patients undergoing stem cell transplantation are severely immunocompromised during treatment, particularly after conditioning.

But the transplant team screens patients for infections before moving ahead. Some transplant approaches may be affected by serious uncontrolled infection. Controlled infections may need specialist treatment and monitoring before transplantation.

Patients should tell the BMT team about any recent fever, infections, past major infections and any antimicrobial medicines currently being taken.

7. HLA Typing and Donor Evaluation

In an allogeneic bone marrow transplant, healthy blood-forming stem cells are taken from someone else. Potential donors are typed with Human Leukocyte Antigen (HLA). The patient’s HLA types are compared with those of the possible donor to determine if they are compatible. In general, better HLA compatibility may increase the probability of acceptance of donor stem cells. Depending on the transplant plan the donor may be a matched sibling, matched unrelated donor or other suitable donor. 

Is There an Age Limit for Bone Marrow Transplant?

There is no universal age limit which would determine whether all patients are able or unable to undergo BMT. Age is considered in combination with physical fitness, heart and lung function, kidney and liver function, other diseases, biology of disease, previous treatment and expected benefit of transplant. For some patients who are older or unable to tolerate standard high-dose conditioning, doctors might consider a reduced-intensity or non-myeloablative transplant. Chronological age should not be the sole criterion for BMT eligibility.

Can Older Adults Undergo Bone Marrow Transplant?

There is no age limit that can be generalized to all patients suitable or unsuitable for BMT. Age is considered in addition to physical fitness, heart and lung function, kidney and liver function, other illnesses, disease biology, previous treatment and expected benefit of transplant. For some patients who are older or who may not be able to tolerate the standard high-dose conditioning, doctors may consider a reduced intensity or non-myeloablative transplant. Chronological age alone should not be the sole determinant for eligibility for BMT.

What Happens After a Patient Is Declared Fit for BMT?

Once the evaluation is complete and the transplant team has determined that BMT is the right treatment, a treatment plan is finalized. For many transplants, the next big step is conditioning, which involves chemotherapy and sometimes radiation before the stem cells are infused. Conditioning prepares the patient for transplantation and, in the case of donor transplants, suppresses the immune system enough to allow the donor cells to engraft. The intensity of conditioning is chosen depending on the patient’s disease, type of transplant and medical fitness.

When Should You Seek a Second Opinion Before BMT?

A second opinion from BMT can be helpful if:

• You have recently been recommended for BMT
• You do not know the cause of a transplant
• You want the time frame of the BMT
• Several transplantation approaches have been proposed
• You have other serious medical problems
• you do not have a perfectly matched donor
• Considering a haploidentical or unrelated donor
• Your blood cancer has returned
• A transplant that has not worked before
• You want to learn about alternatives to BMT

A second opinion can look at the diagnosis, response to treatment, need for transplant, donor options, fitness before BMT and anticipated risks and benefits before a final decision is made.

About Dr. Subhaprakash Sanyal

Dr. SubhaPrakash Sanyal Director - Haemato-Oncology & BMT, Fortis Hospital, Mulund, Mumbai He is a Hematologist, Haemato-Oncologist and BMT doctor who cares for patients with blood cancers and blood disorders requiring specialist hematology and transplant care.

The BMT program at Fortis Hospital Mulund offers treatment for blood cancers like leukemia, lymphoma and myeloma, aplastic anemia, bone marrow failure and some genetic and immunodeficiency disorders.

Patients from Mumbai and India who have been advised BMT can get specialist evaluation for:

• Diagnosis review

• BMT Qualification

Investigations before transplant

• Disease status determination

• HLA and donor evaluation

• Autologous or allogeneic transplant planning

• Second opinion prior to BMT

• Planning treatment and follow-up

BMT eligibility testing is not merely used to establish whether or not a patient is able to undergo transplantation. It helps the BMT team to understand which transplant approach may be appropriate, when transplantation should be performed and how the treatment can be planned as safely as possible for that individual patient.