Page 44 - Haematologica May 2022

D. Niederwieser et al.
the different regions showed three patterns: high (>500 teams; SEAR/WPR and EUR), intermediate (100-500 teams; North America) and low (<100 teams; AFR, EMR, Latin America). TD was similar in North America and Europe (6.0 and 7.7 respectively), between 1-2 in SEAR/WPR and Latin America and <1 in all other regions. While North America and EMR had most HCT per HCT team (93.7 and 86.6, respectively), Europe and Latin America had intermediate (57.0 and 48.2, respectively), SEAR/WPR and AFR had the lowest (27.9 and 32.7, respectively) HCT per team. It is encouraging that HCT and TR in developing regions are increasing steadily, although there are differences in indica- tions and diseases, and are closing the HCT access gap. However, the disparities in access between regions remains substantial.
Although the WBMT has established a global coverage of international transplant societies with an estimated >90% reporting, at least one very large country had incomplete reporting and lacked a national registry. With the aim of establishing such a registry, the WBMT organized a success- ful workshop to highlight the importance of coordinated reporting. Increased numbers of teams and activities in that country are now expected starting in 2016 (Xu L-P, Lu P_H, Wu D-P et al. Hematopoietic stem cell transplantation activi- ty in China 2019: a report from the Chinese Blood and Marrow Transplantation Registry Group. Bone marrow transplantation; 2021 [in press]). Therefore, the data present- edherearecertainlyanunderestimatebutareexpectedto increase further with greater completeness of reporting.14
The considerable increase seen in the SEAR/WPR and Latin American region in non-malignant disorders, hemoglo- binopathies (allogeneic HCT) and AID (autologous HCT, predominantly in multiple sclerosis), is of special interest. It is reassuring to see a worldwide trend of more patients to be transplanted in CR1 rather than later in their disease course. This phenomenon is much more evident in AML and remains constant in ALL. Lymphoma accounts for less of the increase in autologous HCT than do PCD. The indications for CML decreased only slightly in the 10 year period follow- ing the availability of successive tyrosine kinase inhibitor pharmaceuticals. However, it should be noted here that more patients were transplanted beyond chronic phase CML, and not in line with ELN recommendations.15 The changes in donor type and graft source confirm trends previously described. Frequencies of haploidentical HCT increased con- siderably to reach >10% of all allogeneic HCT throughout all regions. As a consequence, more related (matched and hap- loidentical) HCT were performed than were unrelated HCT, and the later appears to have reached a plateau. The increase of haploidentical related donors might have several reasons including lack of donors for Latin-American patients in inter- national registries, lack of local national donor registries and economic. The availability of new technologies like the post- cyclophosphamid protocol and the so called ‘Beijing Protocol’ using G-CSF/anti-thymocyte globulin and multiple stem cell sources (BM and PB stem cells)14,16 may have con- tributed to this development. Overall, CB HCT decreased consistent with the pattern seen in Europe.
There are a few limitations in this analysis. The first one relates to the reporting lag of the analysis. Logistics in obtain- ing data from 1,660 transplant centers worldwide are the main cause for this delay. While some of the regions are reporting in real time, emerging regions have not a central national or regional reporting system. In these regions, WBMT collected the information from individual transplant
centers returning the results to the regional societies for com- pleteness checking. An internet-based reporting system was developed by the WBMT and is expected to gradually bring up the survey reports to real time. An additional limitation of this analysis is the inability to provide information on utiliza- tion of HCT for specific illnesses and on information restrict- ed to first HCT. Utilization is currently being analyzed worldwide for myeloma and AML by the WBMT, but should be extended to major indications. Furthermore, infor- mation on second or third HCT is not currently available, although these account for approximately 10% of HCT in developed countries, but will be implemented with the new reporting system.
One of the challenges that the WBMT faces, is how to go beyond calculations of global HCT activity and accelerate global equity of access to HCT. The most efficient method may be to increase HCT activity/team. In fact, transplant teams have already increased their annual HCT/team by a median of 14 HCT/team since 2006. As shown in this study, 50 HCT/team are feasible even in developing countries and almost 100 HCT/team are currently being performed in North America.
Increasing team numbers might be more difficult. This is due in part to the funds allocated to local health expenditure, but also due to limitations in the infrastructure required including blood banks, intensive care units, multidisciplinary teams and microbiology expertise. Shortages and unavail- ability of medicines and lack of trained biomechanical/biotechnical technicians have also hindered HCT activities in developing countries. The WBMT has the capacity to review and analyze global HCT activity data and apply this data to support HCT activities globally. Global activity survey data has been instrumental in informing and shaping HCT support workshops in the different regions, which have been successful in fostering collaboration amongst international societies and supportive expert HCT networks globally. The WBMT, on its site, has already pre- pared a variety of documents to facilitate the establishment of new transplant programs (requirements for establishing a program, list of essential medicines, use of biosimilars to reduce costs and establishing unrelated donor registries).17–21 In addition, supervisory telemedicine is an evolving and potentially powerful tool to overcome lack of experience with collateral benefits for conventional hematology, blood banking, microbiology and virology. Devoted physicians and willing health authorities are essential for the application of such technologies and successful collaborations accompa- nied by demonstration of compliance with international standards to provide reassurance to internal and external stakeholders.22
The achievements obtained in the last decade should be an incentive to continue and even increase the common efforts to improve access and close the gap worldwide faster. This is acommoneffortofprofessionalorganizations,WHO,politi- cians and Health Authorities. The role of the WHO is essen- tial in coordinating this process among their member states.
Disclosures
No conflicts of interest to disclose.
Contributions
DN, HB, MA, KB, KF, and FRA designed the study; HB, NB, CB, NC, SC, AE,CF, SG, NH, AAH, SH, AH, MH, MI, GJ, AK, JK, NK, RPL, JWL, JMR, MP, JP, KP, AS, JAS, AS, JS, DW, NW, MK, MA, HG, YA, WS contributed data
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