Marking 25 Years of Progress in Blood and Marrow Transplantation

Doris R. Brown, MD, PhD

Professor, Hematology and Oncology

Director, Blood and Marrow Transplant Program

Wake Forest Baptist Medical Center

Comprehensive Cancer Center

A few years ago, the world celebrated the life and contributions of E. Donnall Thomas, MD, who a little more than 40 years ago pioneered blood and marrow transplantation as a modality of care in the treatment of blood cancers. Blood and marrow transplant (BMT) was initially conceived as a process whereby damaged or diseased hematopoietic stem cells— cells responsible for healthy blood and immune function—are replaced with healthy stem cells from a donor (allogeneic transplant).

BMT as therapy for patients with leukemia was a novel concept worthy of the 1990 Nobel Prize in medicine, awarded to Dr Thomas for the discovery of a cure for leukemia and other blood cancers. The first BMT for a patient with leukemia was in 1968 and the first BMT using an unrelated donor was in 1979. Fast forward to 2015, when the National Marrow Donor Program (NMDP) has grown to an organization that has facilitated more than 50,000 transplants and includes almost 12 million volunteer donors.

While major accomplishments in BMT were being made around the country, the first BMT program at Wake Forest Baptist came into view, a vision brought to life by David D. Hurd, MD. In 1989, Dr Hurd moved to Winston-Salem from his faculty position at the University of Minnesota to start the Wake Forest Baptist Medical Center BMT Program.

The Wake Forest program was the second in North Carolina, extending a new level of care to the western half of the state. In the early 1970s, investigators had demonstrated successful cryopreservation of bone marrow and the ability to use frozen bone marrow from the patients themselves (autologous transplant) to engraft and reconstitute hematopoiesis, promoting recovery from intense chemotherapy treatment of blood-related cancers.

As the world was awakening to the accomplishments in the field of BMT, the first patient to receive an autologous transplant at Wake Forest was successfully treated in May 1990. Then, within months, the first allogeneic transplant patient was cared for at Wake Forest. Dr Hurd spearheaded the initiative to begin a volunteer marrow donor collection center, and the center became an NMDP transplant center in full swing by 1995.

During the past 25 years, the BMT program at Wake Forest has transplanted more than 2000 patients from North Carolina, Virginia, West Virginia, Tennessee, and South Carolina. Our David D. Hurd, MD, founder of the blood and marrow transplant program at Wake Forest, still treats patients at the center and serves as a professor of Hematology & Oncology. catchment area is extensive, capturing part of the underserved Appalachian area. As Dr Hurd and colleagues developed a BMT program that transplants more than 100 patients annually, they also met with the demographic challenges of a rural versus urban population, and socioeconomic and ethnic diversity.

These are issues that affect access to healthcare, including the complex delivery of transplant care that continues many months after the definitive treatment. The NMDP still recognizes this region on a widely viewed “heat map” of areas where the numbers of transplants performed do not match what would be expected given the population. Although there is still work to be done, the center has established a quality program under the leadership of Dr Hurd,, raising the standard of care in the region.

Since 1990 there have been major changes in patient demographics, graft sources, and conditioning regimens. Research has expanded availability of transplant through implementing alternative stem cell sources, introducing modifications in intense therapy to improve tolerance and modulate the immunotherapy of the transplanted cells, and making transplant safer with contributions from the fields of molecular tissue typing and infection detection, prevention, and treatment. For patients of all ages, the survival of BMT has never been better. Cures are more attainable for patients transplanted earlier in the course of their disease, in remission, and with posttransplant modulation of minimal residual disease.

As Wake Forest Baptist Medical Center’s Comprehensive Cancer Center prepares to celebrate 25 years of providing stem cell transplant care, we have more and better therapy than ever. With advancements made in cellular therapy opening doors for patients with blood-related cancers, it is a good time to reflect on the history and the success of our program. We see a vibrant future providing opportunities in the treatment of blood cancers with cellular therapy and stem cell transplant.

The BMT program participates in clinical trials sponsored by the BMT Clinical Trials Network (BMT-CTN), representing a collaborative effort of the Center for International Blood & Marrow Transplant Research, the NMDP/Be The Match campaign, and multiple transplant centers across the United States. These efforts meet a critical need for multi-institutional clinical trials focused on improving survival for patients undergoing stem cell transplant.

Clinical research in stem cell transplant and cellular therapy is a cornerstone of our program, creating access for our patients to these opportunities. Through our affiliation with the BMT-CTN, we offer patients the opportunity to participate in clinical trials to determine the optimal care of older adults with myelodysplastic syndromes. We’ve partnered with the pharmaceutical industry to explore the role of pretreatment and early access to transplant for patients with myeloproliferative disorders, and we participate in cooperative group and pharmaceutical trials that create access to cellular therapy interventions through novel treatments for refractory diseases.

Key research initiatives include advancing optimal donor selection, identifying key transitions in immune reconstitution, and implementing novel therapies in the management of transplant complications including graft-versus-host disease. We offer alternative donor transplants from haplo-identical donors for patients lacking a conventional donor. Access to haplo-identical transplant protocols is particularly important for ethnic or racial groups underrepresented in the donor pool of the NMDP.

Through participation in clinical research, the future looks bright for providers and patients as we help define new treatments with fewer toxicities and better outcomes.