Outpatient bone marrow transplant (BMT) strategies, as reviewed by
Dix and Geller, have evolved for various reasonsfrom social to
medical. If high-dose approaches are to become a viable treatment for
common cancers, such as breast cancer, the refinement of transplants
to a kinder and gentler approach is essential.
Preference for Outpatient Treatment
The outpatient BMT approach was developed primarily to support the
patients preference to be outside the hospital. Many patients
find their time in the hospital to be one of the most
burdensome portions of traditional inpatient-based stem-cell
transplant procedures. Patients will tolerate the chemotherapy,
extensive monitoring, and antibiotic treatment, but prefer the
privacy, personal dignity, and freedom afforded by an outpatient BMT approach.
Patients undergoing a stem-cell transplant tend to be very
sophisticated, learn a great deal about their disease and treatment,
and prefer to be intensively involved in the therapeutic decisions
and provisions of their care. In addition, the patients family
often feels much more empowered in an outpatient setting, where they
sense a greater involvement.
The Caregivers Role
There is little doubt that the caregivers abilities are a
critical component of a successful outpatient BMT approach. While
some clinicians have found this to be limiting, in our experience,
nearly every family, regardless of socioeconomic background, was
capable of providing adequate caregiver supportif prepared in
advance and well trained. Furthermore, when patients learn early on
that they will soon be in need of a caregiver, they often show a
remarkable ability to arrange satisfactory coverage. Indeed, the
commitment of individuals and their family and friends is often a
major determinant of the general well being of the patient, as well
as the success of the transplant procedure.
Outpatient vs Inpatient Setting
Indeed, in our hands, the patients quality of life in the
outpatient setting appears to be far superior to that in the
traditional inpatient approach. Perhaps one of the most intriguing
difficulties encountered among the now thousands of outpatient
transplant patients is that they often do not want to be readmitted
to the hospital, preferring instead to manage their symptoms and
discomfort (if any) by themselves or their caregivereven if
they are quite symptomatic. Their satisfaction with their medical
care is higher when performed in the outpatient arena than when
confined to a hospital bed.
Of interest, one of the major concerns of physicians about the
outpatient transplant approach is the perceived potential risk for
the patient. Traditionally, patients have been hospitalized, and the
wisdom of having aggressively treated patients who were febrile and
neutropenic as outpatients raised concern for some physicians.
However, when outpatient transplant programs are carefully
established and managed, the patients risk is minimal. In fact,
for many institutions, the outpatient transplant program represents
one of the lowest-risk propositions for a hospital. We have found our
infectious risks to be substantially lower among outpatients compared
to inpatient treatment for matched patients.
Optimal Outpatient BMT Programs
Perhaps the most critical element of the outpatient BMT strategy is
the development of the integrated inpatient-outpatient team. A major
determinant of success is the ability to offer 24-hour, 7-day
coverage that provides the patient with a secure environment.
Many decisions regarding the particular characteristics of an
outpatient BMT program are related to the logistic and financial
considerations that help optimize the program for the patient. For
example, in our program, we have minimized the use of home health
care personnel since finding that the daily cost associated with its
use generally outweighs its cost-effectiveness. Most of this care
either can be rendered by the caregiver, or is of such a nature that
it can be most efficiently provided in the outpatient clinic by a
dedicated team member.
We have utilized a nearby apartment or hotel as a patient residence
during outpatient BMT treatment and have generally not used the
patients home. A major consideration for not employing a
home-based treatment strategy relates to the transportation policies
of most emergency medical technician (EMT) teams. If the BMT patient
becomes critically ill and ambulance transport is required, the
patient generally will be taken to the nearest hospital. However, for
patients in the midst of a transplant procedure, the EMTs
designated hospital may not be the hospital in which the patient is
undergoing the procedure. The critical early hours after an emergency
event weigh importantly in our recommendation for housing the patient
nearby the primary transplant center. Further, the home environment
often places the patient back into his or her home role, potentially
presenting additional stress.
The success of an outpatient BMT approach has been facilitated by the
prophylaxis against neutropenic infection to minimize
hospitalization. Contemporary oral antibiotic programs have been
particularly useful, and in our program, readmissions for febrile
events are now rare. Our decision to admit or closely observe
patients during the initiation of antibiotic therapy is based on our
desire to carefully assess the early course of febrile, neutropenic patients.
Furthermore, because septic patients will generally display their
most significant symptoms early in their course, we find that an
observation period of 4 to 6 hours in the outpatient clinic or a
brief overnight admission facilitates patient comfort and safety.
This provides a means of observingr the patient but cost-effectively
utilizes available personnel, clinic, and inpatient space.
Care should be taken in modifying the high-dose chemotherapy regimens
in order to facilitate the outpatient approach. The underlying
strategy of using dose-intensive therapy is aimed primarily at
treating the disease. In our experience, even minor modifications in
the treatment regimen may result in either significant modifications
to efficacy or changes in the toxicity profileboth of which may
profoundly affect outcome.
In our experience, the success of a treatment regimen is determined
primarily by the amount of mucositis produced. The regimen of
cyclophosphamide, Platinol, and BCNU (CPB) produces no mucositis.
In our program, this effect, among others, causes CPB to be a
preferred approach for outpatient transplants for both breast cancer
On the other hand, regimens containing thiotepa (Thioplex), mephalan
(Alkeran), or other agents that produce mucositis, generally show
inferior results in the outpatient setting. This is because the
mucositis often requires admission for pain control,
hyperalimentation for fluid and nutritional support, and parenteral
antibiotics to treat the more serious infectious complications
associated with mucosal breakdown.[3-7]
In conclusion, patient preference, generally superior medical
results, and economics all favor outpatient BMT approaches
William P. Peters, MD, PhD
Roy B. Baynes, MD, PhD
Lucy Cassells, MD
Roger Dansey, MD
Jared Klein, MD
Caroline Hamm, MD
Chachada Karanes, MD
Steve Abella, MD
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prophylactic ciprofloxacin and rifampin and empiric once daily
vancomycin and aminoglycoside for neutropenic fever after high-dose
chemotherapy and autologous bone marrow support. J Clin Oncol
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