By RENEE STOVSKY
ST. LOUIS — When Hank Coors, a retired lawyer, was diagnosed with multiple myeloma in 2015, he insists he was not afraid of the disease.
"I had been treated for another cancer — plasmacytoma — in 2010, and I already knew I had a smoldering case of myeloma," says Coors, of St. Louis. When his "numbers started spiking" his original oncologist at SSM Health St. Clare Hospital–Fenton referred him for a bone marrow transplant at SSM Health Saint Louis University Hospital. Coors says he had faith in the medical care he would be receiving, but he dreaded the prolonged hospital stay usually associated with bone marrow transplants. So when he met with Dr. Nabeel Rajeh, a hematologist/oncologist at Saint Louis University Cancer Center and learned about its outpatient bone marrow transplant program, he immediately asked if he could qualify for it. The cancer center is a joint initiative between the hospital and SLUCare, the academic medical practice of Saint Louis University.
Fesler
Only 15 to 30 percent of patients are considered eligible for outpatient treatment, according to Dr. Mark Fesler, director of the bone marrow transplant program there. "First, it depends on what type of transplant is being done, since some chemotherapies have higher toxicities than others. After that, we look at factors such as comorbidities and the availability of caregivers 24/7 during treatment," says Fesler. "We also insist on patients living or staying within 30 minutes of our facility so they can be treated quickly if and when they spike fevers."
Coors fit all those criteria. He was a candidate for autologous transplantation, meaning he could donate his own blood cells prior to treatment (as opposed to allogeneic transplantation, which depends on a donor and is more involved due to immunosuppression issues). He had no other major health problems and plenty of family support — his wife, Ginny, a former physical therapist, could care for him at home. A brother, sister, and two daughters and sons-in-law were available to drive him to the center for treatments.
"I always had a bag packed and ready if I needed to be admitted to the hospital," he recalls.
Luckily, he never needed to use that bag. After three months of radiation treatments, from August through October 2015, Coors' cancer was in remission. In early November of that year, he received Neupogen injections, followed by insertion of a drug port and catheter, all on an outpatient basis. His stem cells were harvested through apheresis treatment on Nov. 10; after that he began receiving his high-dose chemotherapy treatments on a daily basis for 16 days. Once those were completed, Coors' harvested stem cells were infused into his bloodstream so that he could generate new platelets and red and white blood cells.
"The chemo was tough; I wasn't in acute pain but I didn't feel right in a major way. I had no appetite, despite homemade meals; even water didn't taste good. I wound up losing 15-20 pounds," recalls Coors. "But I'm convinced I did better in my own surroundings, getting my needs taken care of by my family."
Hank Coors chose outpatient bone marrow transplant as part of his treatment for multiple myeloma because he felt more comfortable at home being cared for by family than in the hospital for a prolonged stay. Here he chats with Stacy Bohn, a nurse at the Center for Blood and Marrow Outpatient Transplant at Saint Louis University Cancer Center, where he was treated.
Coors is also convinced that the staff at the Center for Blood and Marrow Outpatient Transplant had much to do with his positive outcome as well.
"It's very personal and comfortable there. I had the same nurse practitioner, Dan Trost, and the same clinical care nurse, Maddi O'Leary, for all my procedures — blood work, infusions, even later immunizations," he says. "Everyone was so accommodating and positive that it made the daily chemotherapy visits much more bearable."
That kind of feedback is what motivates the staff to provide the best care possible, according to Allison Appenfeller, a nurse and practice manager for the center, which includes 15 treatment rooms as well as a waiting room and family room.
"We know our transplant patients — both outpatient and inpatient — are facing an extremely difficult time in their lives, so we try to help them meet that challenge by working with a team that includes not only attending physicians and nurses but also psychiatrists, social workers and counselors," she says.
According to Fesler, bone marrow transplants were first performed in the U.S. in the late 1960s and later were used to treat a variety of cancers, including breast cancer. Today, transplants are usually recommended only for blood cancers such as Hodgkin's and non-Hodgkin's lymphoma, acute myeloid leukemia, multiple myeloma and myelodysplastic syndromes.
Saint Louis University Hospital started its transplant program in 1991. Later, studies in medical journals such as Nature and the Journal of Clinical Oncology found no difference in clinical complications or mortality rates for qualified bone marrow transplant candidates treated in an outpatient setting, as compared to an inpatient setting.
In 2012, the Center for Blood and Marrow Transplantation, led by Dr. Friedrich G. Schuening, then director of the division of hematology and oncology at Saint Louis University Cancer Center, was remodeled to accommodate outpatient bone marrow transplantation. At the time, it was one of only 10 outpatient centers nationwide. (Schuening had developed a similar program at Vanderbilt-Ingram Cancer Center prior to joining Saint Louis University in 2011.)
Ironically, Schuening himself was diagnosed with acute myeloid leukemia soon after, and became the first patient seen as an outpatient here at the facility, says Fesler. Schuening received two allogeneic transplantations in 2013 and died in March 2014.
"Unfortunately, expected first-year survival rates for allogeniac transplantations are below those of autologous transplantations mainly because of graft versus host issues — 65 percent versus 90 percent," says Fesler. "But bone marrow transplants still represent the only curative option for many of these diseases."
Today, the center remains one of approximately 30 in the U.S. to offer outpatient transplantation.
"This is mainly done as a service to our patients, who really enjoy the freedom to be away from the hospital," says Fesler. "And that fits into our mission at the center, to provide compassionate, patient-centered specialty care focused not only on outcome but also on alleviation of the anxiety inherent in the disease state, complexity of care and displacement from home."