What Happens After a Stem Cell Transplant?

You may need to stay in the hospital for about two to six weeks during your stem cell transplant. Some patients may have complications resulting in staying longer than 6 weeks. The pre-transplant process starts with getting high doses of chemotherapy.

"Chemotherapy is the standard and is administered intravenously, but the difference is that in another type of cancer, these chemotherapies can be given as an outpatient. In this case, patients need to be in the hospital" Dr. Javier Pinilla, head of the Lymphoma Section at Moffitt Cancer Center, tells SurvivorNet.

Because of very high dose chemotherapy, you may experience serious side effects from low blood count.

"The drop to very low counts can predispose to very bad infections called neutropenia or febrile neutropenia. Also, very typically they have low levels of red cells that will require [them] to have blood transfusions as well. Low platelets predispose to bleed in, for which also they would require platelet transmission. That’s the reason why patients doing this phase need to stay in the hospital because of the high risk of infection, bleeding, and obviously the fact that they don’t really have enough production of these cells until this bone marrow starts to recover." Dr. Pinilla explains. He also noted that are other common side effects like nausea, diarrhea, and rashes.

“Since the chemotherapy eradicates most of the cells of the bone marrow during this process obviously patients have a high risk of infections, and they have to be very well monitored in the hospital,” he adds.

After a few days of rest following chemo, the donor stem cell will be given to you through a central line, much like getting a blood transfusion. A central line (or central venous catheter) is like a peripheral intravenous (IV) line but it is typically much longer than a regular IV and goes all the way up to a vein near the heart or just inside the heart. The transplanted donor stem cell will enter the body through the blood and will grow into healthy new blood cells. You will be awake during the entire time, and the process is not painful.

What is Monitoring Like Afterwards?

During the recovery period, your cells start to engraft, or simply start to grow and make new blood cells. It usually takes 2 to 6 weeks to start seeing normal blood counts. During the first few weeks, while you are in the hospital, the transplant team will visit you on a regular basis and watch closely for the following side effects of stem cell transplantation:

• Low numbers of red cells, white blood cells, and platelets are common during the post-transplant period. You may need daily transfusions of red cells and platelets.
• Your immune system will become weaker. Your doctor will monitor for infection.
•  Graft-versus-host disease (GVHD): "Graft" means to the donor stem cells and "Host" is the person who gets the transplant. This is one of the most fatal complications of transplant and can also be lifelong. This can happen when the donor's immune cells that kill cancer cells also attack your healthy cells. GVHD can occur early in the post-transplant period, but chronic GVHD may happen months to years later after the transplant. You will be started on medications to minimize the risk of GVHD, and your transplant team will closely monitor you for signs and symptoms of GVHD.
• You may experience loss of appetite because the mouth sores or sore throat or upset stomach.
• Graft failure or rejection: This means that the stem cell transplant does not work. It can make a person very ill, and your blood count may recover very slowly.
•  In addition, your transplant team will help you go through any feelings of anxiety, depression, or stress.

How Long Will I be Immunocompromised?

At least the first 6 weeks after the transplant is the critical period when you are at high risk to get serious infections. Pneumonia is one of the most common bacterial infections. Viral and fungal infections can also be an issue. You may be given preventative medications to protect against the infection until your blood counts reach a certain level.

You may still get an infection even after your white blood cell count reaches an optimum level. It may take up to 6 months to a year after the transplant for the immune system to work back to normal. It can take even longer for patients with GVHD since they will be on medication to suppress immunity for a long period of time. It is important to note that some patients may be immunocompromised indefinitely.

SurvivorNet’s sources tell us that a covid vaccination is recommended.

Recovery Period and What Life is Like?

Transplant care does not end even after you are discharged home from the hospital. You and your caregiver will be given instructions to

• Care for your central line to prevent infection
• Maintain healthy diet
• Avoid being near disturbed soil, bird droppings, or mold
• Maintain a germ-free environment and frequent hand washing
• Call the transplant team if you feel sick

Your transplant team will be monitoring you every few days for complications. After several months if things are going well, blood counts return to normal and your immune system works well, your doctor may decide to have less frequent visits. Since you will be taking a lot of medicines and need to have frequent doctors visit, caregiver and family support are crucial to meet these ongoing needs at home.

What is it Like in a COVID and Post-COVID World?

Patients with CML who underwent stem cell transplantation may be at a higher risk of developing severe COVID infection. They often have abnormal or low levels of immune cells that fight viruses. When it comes to performing daily activities, CML patients should continue to use caution as per CDC guidelines. If you get sick with a COVID infection, talk to your doctor for treatment options.

According to the American Society of Hematology (ASH), no change has been proposed for CML treatment as a result of the COVID-19 pandemic. With proper precaution, stem cell transplant still remains an option. Your doctor may also offer you remote testing, telephone, and telehealth encounters to minimize patient travel and exposure. Even though we are in a much different place than we were in the spring of 2020, your doctor may still advise you to continue to follow CDC guidelines after a stem cell transplant.

What is the Mechanism for Success

A targeted therapy called tyrosine kinase inhibitors (TKIs) have come a long way over the past several decades and can cause remission for a long period of time for patients with CML. As such, stem cell transplants are not done as often as they used to be prior to the availability of TKIs. However, the success rates for transplants are quite high, and currently has the best-documented curative track record for selected patients with CML.

In general, younger people tend to respond better to treatment. The major barriers to a successful stem cell transplant are GVHD and disease relapse. According to the report from ASH, the CML may come back in about 30% to 70% of patients undergoing stem cell transplantation.

Your doctor will continue to check BCR-ABL (mutated gene) PCR in the blood every three months for at least the first three years during the post-transplant period to make sure cancer has not come back.

Who Receives TKI After the Stem Cell Transplant?

During the follow-up period, your doctor may want to start you on TKI. However, we currently lack data and uniform guidelines to support how soon you need to be started on TKI. Several reports suggest that it is safe and effective to start TKI during the early post-transplant phase.

"We often after transplant will give TKI just to give that added push to keep people into remission,” Dr. Eric Winer, Director of the Adult Leukemia Institute at Dana-Farber Cancer Institute, says. Although post-transplant TKI therapy is used widely, more studies are needed to explore the best TKI dose, duration of treatment, and timeframe to start the TKI.

Questions to Ask Your Doctor

• What is the evidence on TKI use after transplant?
• Should I also consider nutritional supplements after the transplant?
• Am I at high risk for infections?
• Will my health insurance cover my stem cell transplant?
• What are the common side effects of the chemotherapy I will receive?

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