Three Common Challenges—and Solutions—for Bone Marrow Transplant Success

CHOC’s Blueprint for Achieving Successful Outcomes for Bone Marrow Transplant Patients

Long-term survivorship and improved quality of life among pediatric cancer patients undergoing bone marrow transplants is routinely threatened by three common challenges that all pediatric oncologists face: cancer relapse, infection and graft versus host disease (GVHD). The oncology team at the Hyundai Cancer Institute at CHOC is overcoming these challenges — and delivering survival outcomes better than the national average.

“What we want for bone marrow transplant patients is for them to go through transplant without getting any infections; to have a small, controlled amount of GVHD; and for their cancer to never return and their immune systems to work fine,” says Dr. Rishikesh Chavan, pediatric oncologist at CHOC. “That would be the best-case scenario, and our team at CHOC is constantly optimizing to that.”

Dr. Chavan says this best-case scenario can be difficult to achieve because of common challenges associated with bone marrow transplants: infections, GVHD and relapse. CHOC is innovating better solutions to defeat these challenges:

  1. Preventing infections: CHOC has a robust program that covers infection prevention, infection surveillance, and timely and appropriate treatment of infections if they arise. “Post-transplant, families receive a dedicated callback number and prompt follow-up to answer their questions and triage them appropriately,” says Dr. Chavan. “If a complication occurs such as fever, patients are seen within 15 minutes of arriving to our ED and their first dose of antibiotics is administered within 60 minutes of their ED visit.” CHOC routinely monitors for infections and underlying immune status, including surveillance labs to check for viral and fungal infections. There is also a keen focus on ensuring all post-transplant patients are re-immunized to prevent infections. With the COVID-19 pandemic, telehealth checks are frequently held to see how the patient is doing and avoid unnecessary hospital visits.
  2. Preventing GVHD: “A little bit of GVHD is not bad, because it tells us the new immune system from the donor is functional and responding,” Dr. Chavan says. “In fact, patients who have Grade I GVHD have better long-term survival outcomes than patients who have no GVHD at all.” Based on the use of post-transplant cyclophosphamide, CHOC has been successful in preventing GVHD in most patients despite having more mismatched/haplo transplants. To manage more serious grades of GVHD, Dr. Chavan is starting a new clinical approach at CHOC dedicated to treating GVHD. “The clinic will utilize our tumor board team-based approach for quickly recognizing GVHD based on clinical as well as laboratory data and using that information to match patients to appropriate GVHD treatments,” he says. “This design will allow us to review what is working, what isn’t and switch treatments quickly, if needed, to help patients get better. Having this ability at our clinic to respond quickly and offer very personalized treatments is the future solution to managing GVHD.”
  3. Preventing relapse: Patients’ bone marrow is checked for engraftment studies and minimal residual disease after transplant through monthly marrows, which is essentially surveillance for relapse. If a patient is likely to relapse because they are at a higher risk of leukemia to begin with or based on their surveillance marrows, they receive donor lymphocyte infusions to support their immature immune system as well as other regimens to prevent or treat relapse. Dr. Chavan is also involved in research projects to study and mitigate potential factors that affect relapse in leukemia patients undergoing stem cell transplant and cellular therapy with a focus on regulatory T lymphocytes.

For proof that CHOC’s efforts in preventing GVHD, infections and relapse is working, bolstered by both algorithm-influenced care and a concierge-medicine approach, Dr. Chavan references patient survival outcomes from 2018 and 2019 in reports by the Center for International Blood & Marrow Transplant Research (CIBMTR). Results showed CHOC well above the national average for survival outcomes and higher than most of its cohort of transplant programs.

“A great team consists of a group of kind-hearted people who can not only detect and treat complications but also anticipate potential problems and try to prevent them, and that’s what we have here at CHOC,” Dr. Chavan says.

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the cancer specialty.

Learn how CHOC’s pediatric oncology treatments, expertise and support programs preserve childhood for children in Orange County, Calif., and beyond.

Avoiding burnout: A physician shares self-compassion strategies for provider wellness

By Dr. Rishikesh S. Chavan, pediatric oncologist and medical director of the blood and bone marrow transplant program at the Hyundai Cancer Institute at CHOC

Navigating the COVID-19 pandemic and a rapidly evolving medical landscape has put added pressure and stress on the healthcare workers braving the front lines. This is why it’s more important than ever to recognize signs of burnout in yourself and your colleagues, and essential that we as physicians practice self-compassion.

As physicians juggle their position as a healthcare provider, possibly the head of their household, and many other roles, it can be almost unnatural for physicians to think of themselves and their own needs.

But as the saying goes, you cannot pour from an empty cup. Physicians can’t do their best to care for patients and their own children at home unless they’re supporting their own comfort. I liken it to the safety instructions on an airplane – put your oxygen mask on before assisting others.

Self-compassion tactics

To avoid self-sabotage or self-destructive tendencies, one needs to feel a deep sense of love and acceptance of themselves. That’s why practicing self-compassion is so important. Here are some ways to get started:    

  • Make your own checklist Similar to a checklist one uses at the end of a shift to transition cases, make a personal one to end or begin your day. Everyone’s checklist will look different. We each classify different habits or rituals as essential. Do you need your morning coffee to function best? If you have exercised are you then your best self? For your checklist, consider elements such as:
    1. Acknowledge something that was difficult during your shift. After the feelings come up, let them go.
    2. Name three things that went well.
    3. Did you notice anyone else have a particularly hard shift? Check on them.
    4. Check in with yourself. Are you OK?
    5. Rest and recharge.
  • Relax – Identify your strategy for relaxation to help you take your mind away from the daily grind. Be aware of self-compassion versus self-indulgence. For example, watching an episode of your favorite TV show is one thing but binge watching an entire season is another. For several people, activities like bike riding, working in the garden, reading a book, practicing a musical instrument, or taking a yoga class may help establish a state of flow and provide an opportunity to go deeper.
  • Meditate – By definition, meditation means to focus on something. As you gently have a subtle focus on your heart, you can be a silent observer of your thoughts without reacting to them. An assumption that you are not your thoughts allows you to ignore intrusive thoughts and achieve a sense of peace. Sitting quietly with a guided meditation via apps such as Heartfulness, Headspace or Calm may help you get started. Studies have shown that peace and tranquility rank among the most common feelings people report after meditating, in whatever modality suits them.
  • Check in with your colleagues –Not only should we check in with ourselves, but we should check on our colleagues as well. If you see signs of burnout in a colleague, gently bring them into a conversation, or bring them a cup of coffee, and ask, “Is everything OK? Is there something that you want to talk about? Can I help you with anything?”

Interventions for physician burnout

A 2017 JAMA study found that the strongest evidence for effectiveness in combating physician burnout was organization-directed interventions, but the study noted such programs were rare. Most interventions for physician burnout put the onus back on the physician, with a focus on incentivizing physicians to participate. More effective intervention models are engrained across an entire hospital or healthcare system.

In January 2018, CHOC convened a Physician Wellness Subcommittee, composed of a group of physicians dedicated to help CHOC continue to be proactive and supportive of physicians. Its mission is “To promote physician wellness to benefit ourselves and others.”

Additionally, at CHOC, the spiritual care team offers regular “Tea for the Soul” sessions where chaplains are available to clinicians and provide a compassionate, non-anxious, non-judgmental presence to help them cope with added stressors.

CHOC leadership has taken other steps to provide additional support for its physicians and staff, recognizing the additional stressors placed upon CHOC staff during COVID-19. CHOC’s on-site daycare was set up within 72 hours, giving clinicians peace of mind that their children are safe and happy while they work. Recognizing that shopping for groceries and sundries might be challenging for staff, CHOC has set up in-house shopping resources, as well as a grab-and-go meal program and farmers market.

In the Spotlight: Rishikesh Chavan, M.D.

CHOC welcomed Dr. Rishikesh Chavan to the oncology department in January 2019. As the Medical Director of the Stem Cell Transplant and Cellular Therapy program, he works with young patients going through leukemia, lymphoma or other conditions requiring bone marrow or stem cell transplants. He attended medical school at Lokmanya Tilak Municipal Medical College in India, followed by a pediatrics residency at Tulane University School of Medicine and a Hematology/Oncology fellowship at Baylor College of Medicine. Subsequently, he served as the Medical Director of Stem Cell Transplant at Tulane University and Loma Linda University Children’s Hospital.

Dr. Rishikesh Chavan, Oncology

What are your special clinical interests?

Stem cell transplant and immunotherapy for high risk leukemias/lymphomas. I am also interested in reduced intensity stem cell transplants and gene therapy for immunodeficiencies, aplastic anemia and sickle cell disease patients.

What are some new programs or developments within your specialty?

Comprehensive whole patient care model involving psychology, nutritionists, social workers, child life specialists, pharmacists and care coordinators as an integrated team approach to improve the ease of transition between inpatient and outpatient care, to ensure patient satisfaction and compliance, and to achieve best possible outcomes—all while lowering the cost of care.

What would you most like community/referring providers to know about you or your division at CHOC?

We believe every patient coming to transplant deserves personal attention, and we strive to over-communicate with the referring providers to share updates about their patients’ health as well as
facilitate with transitioning the patients back to the referring providers as soon as the patients are ready to be followed by them.

What inspires you most about the care being delivered here at CHOC?

Healthcare delivery is going through a transformation, and CHOC is at the forefront of this healthcare transformation by bringing the latest evidence-based treatments as well as clinical trials to benefit our kids while simplifying the care they need.

If you weren’t a physician, what would you be and why?

I would be a farmer. I feel it is a skill that requires patience, selflessness and long-term thinking, and that the efforts put in by one generation are likely to benefit the next generation.

What are your hobbies/interests outside of work?

I volunteer at the local library to facilitate a Heartfulness Meditation group (a network of volunteer meditation coaches and a meditation app). I also like to spend time with my kids and dog at the park. When time permits, I try to go to the gym and play tennis. I also read a lot—nowadays audiobooks.

What have you learned from your patients?

Resilience. Given the patients we have, I can never really have a bad day. If I do feel I’m having a bad day, my patients’ situations give me perspective.