4.2.3 Haematopoietic stem cell transplantation

HSCT is an established treatment for haematological malignancies in CAYA. HSCT is reserved for those patients at greatest risk of relapse. As the understanding of the biology of leukaemia and treatment with chemotherapy and targeted therapy has improved, the indication for HSCT has reduced in some groups. HSCT is used as a salvage where primary treatment has failed.

Indications for HSCT in acute leukaemia

The indications for HSCT in acute leukaemia should be reassessed continuously by the cancer service. At this point in time, consideration for HSCT may include:

  • ALL with high-risk features – for example, hypodiploidy or induction failure
  • AML patients with high-risk features
  • mixed-phenotype acute leukaemia (MPAL)
  • infant leukaemia with poor prognostic criteria
  • relapse during or shortly after first remission
  • persistent-positive

All patients being considered for HSCT will be discussed at a leukaemia MDM.

Timeframes for starting treatment

Donor searches should begin as soon as the CAYA is identified as a potential HSCT candidate. All newly diagnosed AML, MPAL and infant leukaemia patients and all relapsed patients should be human leukocyte antigen (HLA)-typed as part of their initial investigations. Institutional practice will determine which family members should have HLA tissue typing.

Training and experience required of the appropriate specialists

Paediatric or adult haematologist/oncologists treating CAYA acute leukaemia must have training and experience of this standard:

  • Fellow of the Royal Australian College of Physicians (or equivalent)
  • adequate training and experience that enables institutional credentialing and agreed scope of practice within this area (ACSQHC 2015).

Cancer nurses should have accredited training in these areas:

  • anti-cancer treatment administration
  • specialised nursing care for patients undergoing cancer treatments, including side effects and symptom management
  • the handling and disposal of cytotoxic waste (ACSQHC 2020).

Systemic therapy should be prepared by a pharmacist whose background includes this experience:

  • adequate training in systemic therapy medication, including dosing calculations according to protocols, formulations and/or preparation.

Where no medical oncologist is locally available (e.g. regional or remote areas), some components of less complex therapies may be delivered by a general practitioner or nurse with training and experience that enables credentialing and agreed scope of practice within this area. This should be in accordance with a detailed treatment plan or agreed protocol, and with communication as agreed with the medical oncologist or as clinically required.

The training and experience of the appropriate specialist should be documented.

Health service characteristics

To provide safe and quality care for patients having HSCT therapy, health services should have these features:

  • a clearly defined path to emergency care and advice after hours
  • access to an accredited diagnostic pathology laboratory including haematology, biochemistry, flow cytometry, cytogenetics, molecular pathology, HLA-tissue typing, microbiology
  • access to blood products and a transfusion laboratory
  • access to medical imaging, including CT and MRI
  • cytotoxic drugs prepared in a pharmacy with appropriate facilities
  • occupational health and safety guidelines regarding handling of cytotoxic drugs, including preparation, waste procedures and spill kits (eviQ 2019)
  • guidelines and protocols to deliver treatment safely (including dealing with extravasation of drugs)
  • coordination for combined therapy with radiation therapy, especially where facilities are not co-located
  • an intensive care unit and other medical subspecialties including infectious diseases
  • participation in cooperative group trials for CAYA with acute leukaemia, with adequate support from clinical research associates or research nurses
  • established quality management systems at both the institution and departmental level allied health staff with experience in working with CAYA, including social work, psychology and dietetics (ideally, there should also be access to physiotherapy and/or exercise physiology)
  • specific support for Aboriginal and Torres Strait Islander patients
  • transplant

HSCT/cellular therapies centres require stem cell collection and processing facilities, a dedicated quality manager and data management system. Such sites also require additional accreditation by organisations such as NATA and JACIE-FACT.