Clinical Decisionmaking In Hematopoietic Stem Cell Transplantation

Hematologic malignancies are particularly amenable to the beneficial effects of HSCT due to their relative sensitivity to cytotoxic chemotherapy and radiation, as well as their susceptibility to immunologic effects that are associated with allogeneic HSCT. The intent of HSCT for the treatment of malignancy is to have a significant impact on survival and to potentially cure the disease. The curative intent of HSCT is imperative, as the procedure is associated with a significant degree of morbidity and mortality as compared to other forms of therapy. As such, the decision to employ HSCT is based primarily on the inherent risk of the disease itself versus the potential benefit and inherent risks of the various forms of HSCT being considered. This decision takes into careful consideration many factors, including the specific disease, the available alternative treatment options, the disease state (remission, sensitivity to chemotherapy), patient age and performance status, and availability of a stem cell source. Once it is determined that a patient could potentially benefit from HSCT, the decisions as to what type of transplant (allo-geneic vs autologous vs syngeneic), what type of conditioning regimen, and the timing of the transplant (first complete remission vs first relapse) need to be made. These decisions are primarily based upon the aforementioned factors and supplemented by the amount of risk that the patient (and physician) is willing to accept.

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