Bone Marrow Transplants – Hope and Risk

Bone marrow transplants are a large advancement in medicine, especially in cancer treatment. If chemotherapy or radiation treatments have depleted bone marrow in a patient, replacement with fresh marrow from a donor can prolong life.

History of Bone Marrow Transplants

The first successful marrow transplant was performed by Dr. E. Donnell Thomas in 1956 in Cooperstown, NY, between identical twins. In 1958, human leukocyte antigens (HLA) were identified, paving the way for non-twin transplants, with the first coming in 1968. HLA matches can be considered in choosing a donor.

From a matching donor identified by a Danish blood bank, a New York City boy received bone marrow in 1973 in the first successful unrelated-donor transplant. With that, the method of far-flung donor searches was introduced. By 1979, the first bone-marrow registries were established. Today, even with overall best medical efforts, there is still a high “inherent risk” to a marrow transplant. When inherent risk is high, in the case of a negative outcome for a patient it may be difficult to determine whether any medical malpractice occurred.

The least risky bone-marrow transplant involves harvesting marrow from a patient’s hip for later transplant back to his or her system. Here, risk increases proportionately with age and with lack of physical conditioning (initially, bone marrow transplant was not recommended for patients older than 50). Such transplants reduce a patient’s white-blood-cell count, subjecting her to the risk of infection for two or three weeks. Transplants of marrow from a donor are riskier. A transplant-donor mismatch may cause graft-versus-host disease in the recipient. In this dangerous malady, immune-system cells from the donor’s tissue attack cells in the recipient’s body. Unfortunately, GVHD is common in transplant cases. GVHD can become chronic in a marrow recipient. It may cause liver disease. Risk can be diminished only by meticulously careful choice of a marrow donor.

The Importance of Your Doctor

Thus, choosing a donor is a crucial medical decision in a marrow transplant. Doctors are responsible in this choice. If a person needing a transplant has an identical twin, that patient should suggest the twin as a marrow donor. However, a responsible doctor may well discover reasons the twin is an unfit donor – an extreme case would be if a blood test revealed HIV in the twin. The standard of care is that every reasonable effort must be made to rule out donors who are incompatible.  This has always been a difficult task. Medical advances in testing that give doctors more opportunity to choose wisely among donors at the same time increase the responsibility doctors should avoid choosing unwisely – these advances raise the standard of care. Such advances include donor registries, donor centers, and collection centers. Doctors at such facilities have responsibility to patients in marrow transplants.

In many transplant cases, there is a chain, as it were, of multiple responsible parties. Writing on this subject, Dr. Torstein Egeland proposed guidelines to which doctors should be held in choosing a marrow donor. He writes: “Some accidents or malpractice may have life-threatening consequences. It is therefore (to be) required that all (donor and collection) centers involved should have adequate professional liability insurance…. There is a great need for international standards regarding the coverage and level of compensation…. Often, there will be a dispute between involved centers. The patient and/or his/her relatives should not be involved in these disputes, but in due time, be sufficiently compensated by the responsible party.”

Thus, transplant doctors must perform a large and increasing amount of due diligence, but finding the people in a long chain of responsibility is complicated, as Dr. Egeland notes. Ultimately, it could require assistance from an experienced medical-malpractice attorney. Some errors along the chain of responsibility are going to be attributed to “sometimes these things just happen.”

A particular case illustrates this: the surviving husband of a woman who, as a nuclear physicist, was statistically likely for myeloma had seemingly a strong malpractice case. In the case, missed diagnoses abounded. But, the husband was not awarded a verdict. Reviewing the case, a perplexed Dr. Harry S. Jacob, MD, FRCPath (Hon), wrote that “(Diagnosing, instead of myeloma) pan-hypogammaglobulinema, bony lucencies, nephrosis, bilateral carpal tunnel syndrome; what were they thinking? The medical expert for the plaintiff discovered that the ‘oncologist’ who saw the patient in a rehabilitation hospital shortly before death not only was not boarded in oncology, but also was not a credentialed internist either. In any case, it is surprising that two actual internists (rheumatologist and pulmonologist) did not suspect the diagnosis. But, the jury forgave them – despite testimony that the patient (if diagnosed correctly with myeloma) had a better than 50% chance of surviving 5 to 7 years with chemotherapy and bone marrow transplantation.”

Future Directions

“The emphasis of current research (in marrow transplants) is primarily directed at decreasing toxicity and GVHD.” However, “transplants are performed with increasing degrees of mismatch” (risk) because scientists want to “increase the pool of potential donors.”

One risk that may be mitigated in future is the toxicity of the “conditioning” phase of a transplant, which (to remove depleted marrow cells that the transplant will replace) adds chemotherapy and radiation to that already received in standard cancer treatment.  This increase in toxic treatment harms or even kills some patients. Alternatively for the future, to kill depleted marrow cells a strategy called nonmyeloablative therapy involves essentially amplifying a person’s immune system with molecules that emit radiation from their nuclei. As a result, the body can remove depleted marrow cells without absorbing external radiation – less radiation for the same medical purpose. If you have medical malpractice questions, call the experienced attorneys at Nelson MacNeil Rayfield for a free consultation.

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