Opportunities for MIC BMT centers

The American Society for Transplantation and Cellular Therapy (ASTCT) has recently published in its official journal, Biology of Blood and Marrow Transplantation (BBMT), a review on the issues of access to Hematopoietic Cell Transplantation (HCT) for adults in the United States¹. This is indeed very relevant to centers in middle-income countries (MICs). HCT is a term encompassing both peripheral blood stem cell transplantation (used primarily for hematological malignancies) and bone marrow transplantation (used primarily for non-malignant diseases) (see FAQs) and refers to the most commonly performed among the top five most expensive medical procedures in high-income countries². The price tag of BMT varies widely between US (in the 300.000 to 1 milion US$ range), Europe (in the 200.000 to 500.000 US$ range) and MICs like India or Pakistan (in the 15.000 to 40.000 US$ range)^2–6 with outcomes which are not substantially different^5,7. An interesting study looking at the impact of Human Development Index (HDI) on HCT results, showed that there was indeed a correlation with worse outcomes at lower HDI but that this was primarily due to disease relapse not to transplant-related mortality, suggesting that this may not apply to non-malignant diseases and that the state of disease remission at transplant might have played a major role⁸. 

Coming back to the BBMT report, age, race, and insurance/socioeconomic status were consistently associated with reduced access to HCT. The effect of race seemed to be only partially related to unequal representation in unrelated donor registries and was observed also for autologous transplantation. Interestingly, different possible mitigators for this problem were proposed, from increasing the use of cord blood banks and partially matched related (haploidentical) donors to extending and strengthening insurance coverage, but not the option of “medical tourism”. In fact, while for orthopedic surgery up to 60%-70% of cost can be saved travelling to India, for HCT this could be over 90%, and much more in absolute terms. Moreover, in the specific case of hemoglobinopathies, the number of transplants performed currently in South Asia, and, consequently, the experience gained, is far superior to Europe and North America. The same could apply to Africa, specifically for sickle cell disease, but potentially for many other indications. This could contribute to the rebalancing of professional and financial outflows from MICs to rich countries. Lastly, internationally recognized accreditation programs are setting global standards which should reassure insurance companies, out-of-pocket payers and other financing bodies^9-11 .   

References 

1. Flannelly C, Tan BE-X, Tan JL, et al. Barriers to Hematopoietic Cell Transplantation for Adults in the United States: A Systematic Review with a Focus on Age. Biol Blood Marrow Transplant. 2020;26(12):2335-2345. doi:10.1016/j.bbmt.2020.09.013 
2. Bradley C. Top 10 Most Expensive Medical Procedures. Investopedia. Accessed November 30, 2020. https://www.investopedia.com/financial-edge/0310/top-10-most-expensive-medical-procedures.aspx 
3. Broder MS, Quock TP, Chang E, et al. The Cost of Hematopoietic Stem-Cell Transplantation in the United States. Am Health Drug Benefits. 2017;10(7):366-374. 
4. Blommestein HM, Verelst SGR, Huijgens PC, Blijlevens NMA, Cornelissen JJ, Uyl-de Groot CA. Real-world costs of autologous and allogeneic stem cell transplantations for haematological diseases: a multicentre study. Ann Hematol. 2012;91(12):1945-1952. doi:10.1007/s00277-012-1530-2 
5. Ramprakash S, Agarwal R, Dhanya R, et al. Low-cost matched sibling bone marrow transplant for standard-risk thalassemia in a limited-resource setting. Pediatr Hematol Oncol J. 2017;2(4):107-113. doi:10.1016/j.phoj.2017.12.002 
6. Sharma SK, Choudhary D, Gupta N, et al. Cost of hematopoietic stem cell transplantation in India. Mediterr J Hematol Infect Dis. 2014;6(1):e2014046. doi:10.4084/MJHID.2014.046 
7. Giebel S. Association of healthcare expenditure with results of allogeneic HSCT for adults with ALL. An analysis from Acute Leukemia Working Party of the EBMT. Presented at the: 39th EBMT Annual Meeting; April 2013. http://registration.akm.ch/einsicht.php?XNABSTRACT_ID=170053&XNSPRACHE_ID=2&XNKONGRESS_ID=179&XNMASKEN_ID=900
8. Giebel S, Labopin M, Ehninger G, et al. Association of Human Development Index with rates and outcomes of hematopoietic stem cell transplantation for patients with acute leukemia. Blood. 2010;116(1):122-128. doi:10.1182/blood-2010-01-266478 
9. Snowden JA, McGrath E, Duarte RF, et al. JACIE accreditation for blood and marrow transplantation: past, present and future directions of an international model for healthcare quality improvement. Bone Marrow Transplant. Published online March 27, 2017. doi:10.1038/bmt.2017.54 
10. Snowden JA, Saccardi R, Orchard K, et al. Benchmarking of survival outcomes following haematopoietic stem cell transplantation: A review of existing processes and the introduction of an international system from the European Society for Blood and Marrow Transplantation (EBMT) and the Joint Accreditation Committee of ISCT and EBMT (JACIE). Bone Marrow Transplant. 2020;55(4):681-694. doi:10.1038/s41409-019-0718-7 
11. 7th edition of FACT-JACIE Standards. EBMT. Accessed March 30, 2019. https://www.ebmt.org/ebmt/news/7th-edition-fact-jacie-standards-released