Procedure 26

CLINICAL PRIVILEGE WHITE PAPER
Bone marrow transplantation
Background Bone marrow transplantation (BMT) is a medical procedure used to treat a broad range of diseases that include • malignant diseases such as leukemias and lymphomas • nonmalignant diseases such as aplastic anemia • inherited diseases such as thalassemia, sickle-cell anemia, and congenital immunodeficiencies • solid tumors such as breast, ovarian, and testicular cancer Bone marrow is a spongy tissue found inside bones. It contains stem cells that produce the body’s blood cells. These blood cells include white blood cells, which fight infection; red blood cells, which carry oxygen to and remove waste products from organs and tissues; and platelets, which enable the blood to clot. When the stem cells in the bone marrow malfunction, they produce abnormal blood cells. Physicians use large doses of chemotherapy/radiation to destroy abnormal stem cells and abnormal blood cells. Such therapies kill these cells but also destroy normal cells found in the bone marrow. Similarly, when aggressive chemotherapy is used to treat cancer, it also destroys healthy bone marrow. BMT enables physicians to use chemotherapy/radiation by allowing replacement of the diseased or damaged bone marrow after the chemotherapy/radiation treatment. Bone marrow harvesting and the bone marrow transplant are relatively simple procedures. For harvesting, a needle is inserted into the donor’s pelvic bone and the bone marrow is extracted. For the transplant, which is similar to a blood transfusion, the bone marrow is delivered to the patient intravenously and the stem cells find their way to the bone marrow to produce new blood cells. Types of bone marrow transplant include the following: • Autologous. In this type of transplant—the most common type performed— patients serve as their own donors. The stem cells are taken from the patient and returned to the patient. • Allogeneic. In this type of transplant, the stem cells are obtained from a closely or completely matched individual. This is usually a brother or sister of the patient, but may be an unrelated volunteer donor who is genetically similar to the patient. • Syngeneic. In this type of transplant, an identical twin serves as the donor. Identical twins are perfectly compatible donors, so there is no risk of rejection or other immune reactions.
A supplement to Briefings on Credentialing 781/639-1872 1/02

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Allogeneic patients receive additional medications to prevent and control graft-versus-host disease (GVHD). cord blood. and/or pediatric hematology/oncology. the society has published the policy statement Guidelines for Training. patients are very susceptible to infection and excessive bleeding. In addition. Involved specialties Medical oncologists. Cognitive skills Physicians performing stem cell transplantation should have specific training and documented competency in each of the following cognitive skills: • Indications for blood and BMT • Documentation and reporting of patients on investigational protocols 2 A supplement to Briefings on Credentialing 781/639-1872 01/02 . the ASBMT states that all physicians performing peripheral blood. which can be a life-threatening complication. Until the transplanted bone marrow begins to produce normal blood cells. and marrow transplantation must be licensed and should be board-certified in hematology.Bone marrow transplantation Procedure 26 Management of complications is the most difficult part of the BMT process. immunology. In these guidelines. medical oncology. The training should be conducted in a program compliant with the ASBMT Guidelines for Clinical Centers and accredited by the Foundation for the Accreditation of Hematopoietic Cell Therapy (FAHCT) or an equivalent accreditation program. To help accomplish this objective. The overall goal for training in blood and marrow transplantation is to ensure that physicians carrying out these procedures are competent in the use of high-dose therapy for the treatment of malignancy or bone marrow failure. physicians performing hematopoietic cell transplants must receive specific training in the cognitive and procedural areas listed below. The two to four weeks immediately following transplant are the most critical because the highdose chemotherapy/radiation has destroyed the patient’s bone marrow and damaged the body’s immune system. hematologists. and immunologists Positions of societies and academies ASBMT A primary objective of the American Society of Blood and Marrow Transplantation (ASBMT) is to ensure the highest quality of medical practice in hematopoietic progenitor cell transplantation.

acute and chronic GVHD . including use of donor registries • Methodology and implications of human leukocyte antigen typing • Understanding of chimerism analysis • Knowledge of leukapheresis procedure • Management of ABO (i. If allogeneic transplantations are not performed within the primary training program. ASBMT policy requires a minimum of one year of clinical experience in both inpatient and outpatient settings.fungal disease .hemorrhagic cystitis .terminal care patients Procedural skills Physicians performing stem cell transplantation should be proficient in the following procedures: • Bone marrow harvest • Skin biopsy • Stem cell product infusion Method of training Although it is recognized that training may take several forms.neutropenic fever .e. additional training at a second center is necessary.Bone marrow transplantation Procedure 26 • Understanding the role of the Institutional Review Board and ethical conduct in clinical trials • Pretransplantation patient education • Identification and selection of stem cell source.veno-occlusive disease of the liver .cytomegalovirus infection and disease .late complications of blood and marrow transplantation • Management of . blood types)-incompatible hematopoietic progenitor cell products • Administration of high-dose chemotherapy • Diagnosis and management of .pain .thrombocytopenia and bleeding .nausea and vomiting .other viral infections in immunocompromised hosts .chemotherapy and radiation therapy–induced toxicities .interstitial pneumonia .. A supplement to Briefings on Credentialing 781/639-1872 01/02 3 . That experience must include primary responsibility for the care of patients receiving both allogeneic and autologous transplantations.

Physicians awarded this certificate must have been previously certified in internal medicine by the ABIM. completed the requisite subspecialty training. The ABIM also offers a subspecialty certificate in hematology. demonstrated clinical competence in the care of patients. and procedural skills). and passed the subspecialty examination. of which a minimum of 12 months must be clinical training. Requisite training requirements The ABIM requires 24 months of hematology training. provision of medical care. Physicians who are awarded this certificate must have been previously certified in internal medicine by the ABIM. Requisite diagnostic and therapeutic procedures: • Bone marrow aspiration and biopsy • Administration of chemotherapeutic agents and biological products through all therapeutic routes • Management and care of indwelling venous access catheters • Minimum half-day per week in continuity outpatient clinic Clinical competence requirements The ABIM requires substantiation that candidates for certification in the subspecialties are competent in clinical judgment. and continuing scholarship. and touch preparations of bone marrow biopsies 4 A supplement to Briefings on Credentialing 781/639-1872 01/02 . bone marrow aspirates. demonstrated clinical competence in the care of patients. completed the requisite subspecialty training. staining. and interpretation of blood smears. clinical skills (medical interviewing. examination. including preparation. the American Board of Internal Medicine (ABIM) offers a subspecialty certificate in medical oncology. professionalism. Requisite training requirements The ABIM requires 24 months of medical oncology training. medical knowledge. Requisite diagnostic and therapeutic procedures • Bone marrow aspiration and biopsy. physical examination. of which a minimum of 12 months is clinical training.Bone marrow transplantation Procedure 26 Positions of other interested parties ABIM In addition to the primary certificate in internal medicine. and passed the subspecialty examination. humanistic qualities.

medical knowledge. MD.” says Spitzer. it is a good idea for hematologists and medical oncologists who usually participate in BMT procedures to complete a transplant fellowship program. director of the Bone Marrow Transplant Program at Boston-based Massachusetts General Hospital. clinical skills (medical interviewing. such a fellowship is not required as there is no certification for BMT at this time.Bone marrow transplantation Procedure 26 • Measurement of complete blood count. and continuing scholarship. The board requires three years of full-time combined accredited training. “Physicians can receive training in harvesting stem cells and performing autologous and allogeneic transplants in their hematology/oncology fellowship programs. humanistic qualities. The ABIM also offers dual certification in hematology and medical oncology. Boston. physical examination. which must include the following: • A minimum of 18 months of prospectively designed fulltime clinical training with patient care responsibility • A minimum of 12 months in the diagnosis and management of a broad spectrum of neoplastic diseases. MA According to Thomas Spitzer. Spitzer says a physician should participate in a minimum of A supplement to Briefings on Credentialing 781/639-1872 1/02 5 . However. including platelets and white cell differential. Then the physician can become a member of a transplant team and acquire experience in the procedure by working with senior BMT practitioners without undergoing a formal transplant fellowship program. including hematological malignancies • A minimum of six months’ training in the diagnosis and management of a broad spectrum of non-neoplastic hematological disorders Massachusetts General Hospital. using automated or manual techniques with appropriate quality control • Administration of chemotherapeutic agents and biological products through all therapeutic routes • Management and care of indwelling venous access catheters • Minimum half-day per week in continuity outpatient clinic Clinical competence requirements The ABIM requires substantiation that candidates for certification in the subspecialties are competent in clinical judgment. provision of medical care. and procedural skills). professionalism.

Alternatively. For allogeneic transplants. “and we often work in concert with our transfusion medicine colleagues in the blood bank.” CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution’s policy regarding this procedure. These procedures must be in the BMT area (harvesting. In regard to the qualifications required for performing autologous transplants or allogeneic transplants. a physician would see many different kinds of patients and become better prepared for whatever problems or complications that might occur. there is more training required both in immunology and in managing complications. Spitzer adds that transplant physicians today should have experience in apheresis methods. For continued competence in BMT. autologous transplants.” says Spitzer. Basic education: MD or DO Minimum formal training: Applicants must have completed an ACGME/American Osteopathic Association (AOA)–accredited training program in medical oncology. If physicians intend to have a career in BMT. hematology. With that amount of experience. he recommends that they be competent to perform both autologous and allogeneic transplants. a letter of reference regarding competence should come from the direc- Minimum threshold criteria for requesting core privileges in BMT 6 A supplement to Briefings on Credentialing 781/639-1872 01/02 . Spitzer states that there’s a big leap in going from autologous to allogeneic. Required previous experience: Applicants must demonstrate that they performed at least 10 BMT procedures in the past 12 months. This is a whole new field that involves collecting stem cells via the blood rather than direct bone marrow harvesting. physicians should participate in a minimum of 10 procedures each year.” he says. “Physicians who have had experience in allogeneic transplants are qualified to do autologous transplants but not vice versa.Bone marrow transplantation Procedure 26 50 transplants before he or she begins to function independently. or immunology followed by completion of a BMT fellowship program or a minimum of one year of clinical experience in a FAHCTaccredited BMT program that included autologous and allogeneic transplantation. or allogeneic transplants) for which privileges are requested. “This is another skill we’ve had to learn. Note: A letter of reference should come from the director of the applicant’s BMT training program.

abim. For more information For more information regarding this procedure. Reappointment Reappointment should be based on unbiased. Applicants must be able to demonstrate their maintained competence with evidence that they performed at least 20 BMT procedures in the past 24 months. objective results of care according to the organization’s existing quality assurance mechanisms. In addition. autologous transplants. continuing education related to BMT should be required. MA 02114 Telephone: 617/724-1124 Fax: 617/724-1126 Web site: www. PA 19106-3699 Telephone: 215/446-3500 Fax: 215/446-3470 Web site: www. contact: American Board of Internal Medicine 510 Walnut Street.asbmt.org Massachusetts General Hospital Bone Marrow Transplant Program 55 Fruit Street Boston. Suite 550 Arlington Heights. These procedures must be in the BMT area (harvesting. Suite 1700 Philadelphia.org/cgi-view/homepage.Bone marrow transplantation Procedure 26 tor of BMT at the institution where the applicant most recently practiced. or allogeneic transplants) for which privileges are requested.py?dept_id=8210 A supplement to Briefings on Credentialing 781/639-1872 01/02 7 .partners. IL 60005 Telephone: 847/427-0224 Fax: 847/427-9656 Web site: www.org American Society for Blood and Marrow Transplantation 85 West Algonquin Road.

MA Managing Editor: Edwin B. for such advice.com John E. autologous transplants. Krettek Jr. or allogeneic transplants) for which privileges are requested. • Required previous experience: Applicants must demonstrate that they performed at least 10 BMT procedures in the past 12 months. additional research by physicians and counsel in local settings. Kabalin. MA The information contained in this document is general. a division of HCPro. This information. • Reappointment: Reappointment should be based on unbiased. These procedures must be in the BMT area (harvesting. The Credentialing Resource Center does not provide legal or clinical advice. continuing education related to BMT should be required. autologous transplants.. the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient’s institution is forbidden without prior written permission. DPA Executive vice president and CEO American Society of Addiction Medicine Chevy Chase.com Executive Editor: Dale Seamans dseamans@hcpro. Applicants must demonstrate their maintained competence with evidence that they performed at least 20 BMT procedures in the past 24 months. and hereby stipulate that I meet the minimum threshold criteria for this request. I understand that by making this request I am bound by the applicable bylaws or policies of the hospital. opinions. MD. Physician’s signature: _ ____________________ Typed or printed name: __________________________________________________________________ Date: ____________________ _ Clinical Privilege White Papers Advisory Board James F. or immunology followed by completion of a BMT fellowship program or a minimum of one year of clinical experience in a FAHCT-accredited BMT program that included autologous and allogeneic transplantation. Dept. an applicant must meet the following minimum threshold criteria: • Education: MD or DO. Milner. including the materials.net Richard Sheff. PhD Neurological surgeon Vice president for medical affairs Missouri Baptist Medical Center St. Alternatively. Irvine Medical Center Orange. • Minimum formal training: Applicants must have completed an ACGME/AOA-accredited training program in medical oncology. Copyright 2002 Opus Communications. Louis. • References: A letter of reference should come from the director of the applicant’s BMT training program. should not be adopted for use without careful consideration. MD Sharon Fujikawa. discussion. of Neurology University of California. In addition. hematology. FACS Urologist/Laser surgeon Scottsbluff Urology Associates Scottsbluff. Marblehead. Callahan. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. or allogeneic transplants) for which privileges are requested. AZ Beverly Pybus President The Beverly Group Georgetown. a letter of reference regarding competence should come from the director of BMT at the institution where the applicant most recently practiced. 8 A supplement to Briefings on Credentialing 781/639-1872 1/02 . PA-C Senior physician assistant consultant Phoenix Indian Medical Center Phoenix. and draft criteria set forth herein. MMS.Bone marrow transplantation Procedure 26 Privilege request form: Bone marrow transplantation In order to be eligible to request clinical privileges for bone marrow transplantation (BMT). NE Publisher/Vice President: Suzanne Perney sperney@hcpro. MD. PhD Clinical professor. CA John N. MO Michael R. MA 01945. These procedures must be in the BMT area (harvesting. objective results of care according to the organization’s existing quality assurance mechanisms. MD Practice director Quality and credentialing The Greeley Company Marblehead. Niemeyer eniemeyer@mediaone. and adaptation to local needs.