Inability to Give Correct Cost of Treatment/ Package Cost For Bone Marrow Transplantation

Most patients of Haematological disorders, who have been advised Bone Marrow Transplantation, (BMT) fail to understand why correct package cost for Bone Marrow Transplantation cannot be given on telephone /web inquiry or otherwise, before examining the patient and having a final diagnosis after detailed investigations.

One must understand some basic facts about Bone Marrow Transplantation, its process and the variable factors which will increase or decrease the cost of BMT for every patient.

Process of Bone Marrow Transplantation

Stage 1: Evaluating the patients for BMT (Work up)

Duration: 14 - 30 days

Patient undergoes complete medical check-up to evaluate suitability to go through the BMT procedure. This involves the following:

• Blood Tests• Chest X- ray and CT Scans• Tests to assess the condition of heart, lungs, kidneys, liver etc.• Bone Marrow Tests

Stage 2 : Preparing the patient for BMT (conditioning)

Duration : 2 - 10 days

High dose of chemotherapy or radiotherapy is given to destroy the diseased marrow and destroy the cancer anywhere else in the body. As a result, the bone marrow gets damaged. This is required to create space for new blood stem cell and also to suppress the patient’s own immune system (in case of allogeneic transplant), so that the blood stem cells are not rejected.

Stage 3: Pre-engraftment (before the transplanted blood stem cells start working)

Duration: 2 - 3 weeks

After high dose chemo-radiotherapy, the patient’s blood stem cells are destroyed and normal blood cells are not produced. The patients need to be kept in a clean room within the BMT unit in strict isolation during this time. They also need a lot of blood and platelet transfusion. Most patients get serious infections during this period and need treatment with antibiotics.

Stage 4: Post-engraftment (after the transplanted blood stem cells start working)

Early phase (First 3 months)

There are two types of white blood cells: neutrophils and lymphocytes. Neutrophils save us from acute infections and lymphocytes prevent repeated or chronic infections. Once the neutrophil count is above the critical value of 500 cells per micro litre, the patient can come out of critical isolation. This is called engraftment or the first sign that the transplanted blood stem cells are functioning. Soon after the neutrophil increase to normal or near-normal levels and if there is no other complication, the patient can be discharged home. However, regular check-up and blood tests (2-3 times a week) are required. There is also a risk of graft-versus-host disease (GVHD) at this stage.

Late Phase (3 months-12 months)

The immunity against viruses takes a very long time to recover. Even though some of the immunity is restored, the patient is still at risk of infections with viruses and fungus. This is more so if they are being treated for graft-versus-host disease (GVHD), which can become chronic and lingering. If the patient is well, the frequency of check-ups and blood tests reduce over several months.

Now that one has understood the entire BMT process, one must also understand the variable factors responsible for increasing / decreasing the cost of treatment which are as under:

1. Age of the patient: Younger the patient, lesser the cost.

2. General condition of the patient: Patients coming with bad general condition require additional investigations, drugs, disposables, blood and blood components to build them up and prepare them for stage II treatment of conditioning as explained above.

3. Body Weight: Doses of drugs are calculated as dose of drugs in mg / kg body weight or per M2, ie taking both height and weight in consideration. Therefore the costs will go up if the body weight or height is more.

4. Presence / Absence of other associated disease: A patient requiring BMT can also have diabetes, heart disease, kidney problem, lung / liver disease or any other disease. Therefore the cost of investigations, drugs, disposables, procedures like dialysis, treating in ICU and other things add on the cost which is not required for patients who do not have any other associated disease (es).

5. Need for different type of chemotherapy drugs, antibiotics / antifungal / antiviral and other drugs: Conditioning regimens as detailed in stage II require different chemotherapy drugs for different haematological disorders. Some of these drugs are manufactured in India and others have to be imported. Which are extremely expensive?

Therefore the cost will vary depending on whether drugs are imported or not.

Most patients (90%) requiring BMT are carrying bacteria / fungi / virus infections and need antibiotics / antifungal / antiviral drugs which are expensive. Some patients are resistant to these drugs and require more expensive drugs to which they can respond. Therefore the cost will further go up for these patients.

Infected patients also require additional investigations, like blood counts, blood, urine stool and other cultures and sensitivity tests.

6. Need for Blood / Blood component therapy: The requirement of blood / blood component therapy also varies from patient to patient. Higher the number of blood / blood components required, additional cost of irradiating the blood / blood components, testing and collection of blood and its storage is incurred.

7. Need for parenteral nutrition:Some patients are unable to eat or drink anything due to sores in their month and therefore require intravenous feeding with aminoacids, lipids and carbohydrates which further adds to cost.

8. Need for Total Body Irradiation (TBI), some hematologic disorders require Total Body Irradiation and therefore have to incur additional cost of Radiation.

9. Need for Cellular Therapy : In case, fully HLA matched donor is not available, stem cells for transplantation are collected from half matched family donor. Some of the cells collected from half matched family donor are likely to produce complications. Therefore magnetic separation of unwanted cells is done to get rid of them. This requires additional cost of Rs. 6-15 lacs.

Cost variation is maximum during first 3 months of treatment. After 3 months it is possible to predict the treatment costs more accurately.

10. Need for treating infections: Most patients requiring BMT are immunosuppressed and therefore are susceptible to infections and therefore incur additional cost for treating these infections.

11. Graft Versus Host Disease: In 30-50% of patients undergoing an allogeneic BMT, the cells from the donor might react against the patient’s body. This is called Graft Versus Host Disease, which increases the hospitalization days and requires additional investigations and treatment cost.

In view of the above, which patients will require how many investigations, how many days of hospitalisation, need for intensive care in ICU,drugs,disposables,blood/ blood components, dialysis,radiation,treatment for acquired infections and complications is unpredictable and therefore giving accurate cost of doing BMT package is not practical before complete evaluation of the patient and the donor. Thereafter an approximate cost can be given without taking major complications into account. There are too many variables in the process of BMT as it is not a surgical procedure, but a complicated cellular interaction taking place inside a human body. Hence, the predicted expenditure would only be an approximation.

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