After three months of induction chemotherapy with vincristine ^[1], doxorubicin ^[2] (Adriamycin), and dexamethasone ^[3] (Decadron), I was ready for my stem cell transplant.

From the time I was diagnosed, all I kept hearing about was the stem cell transplant.  It seemed like the holy grail of treatment, and even as a physician I was somewhat mystified by the process.

Since I was fairly young (47) and otherwise in good health, there was no question that I was going to get a stem cell transplant.

The stem cell transplant used in the vast majority of multiple myeloma patients is an autologous stem cell transplant.  “Auto” meaning we are using our own cells.  An allogeneic transplant means the cells come from another donor and is rarely used as frontline treatment for multiple myeloma.

Part of the aura is the name “transplant.”  This to me created misconceptions about the procedure, conjuring up images of surgeons with masks and gowns implanting things.

Instead, the whole process goes like this:

First they give a medication to stimulate the body to produce hematopoietic stem cells, which are the cells that are the precursors to the different components of our blood, red blood cells, white blood cells, plasma cells, and platelets.  Once these cells have been produced, they are harvested by circulating your blood through a machine by a process call plasmapheresis and then stored.

A high dose of chemotherapy is then given, with the intent of completely destroying the bone marrow and wiping out as many of the cancer cells as possible.

The stored stem cells are then given back like a blood transfusion to jump-start the bone marrow to begin producing healthy cells. Resetting the hard drive is how some have described it.

The process is really all about the ability to deliver a higher dose of chemotherapy than would otherwise be possible to kill the cancer cells and then have a way to “rescue” the bone marrow and restore the immune system.

It is one more tool in the armamentarium, but not the Holy Grail.

For me, the process began with preparing to take time off.  I had never really taken any time longer than a one-week vacation from work.  This required a change of mindset.  I was going to be out of work for at least 2 months, and there was nothing I could do about it.

My wife and I took a short vacation as a “last hurrah” before the stem cell transplant.

Upon our return, I had an outpatient procedure to place a large catheter in my chest to be used for harvesting the stem cells.

I was then given Neupogen ^[4] (filgrastim), the drug to stimulate the production of the stem cells, as a shot twice a day for five days.  Because it is stimulating the bone marrow, the Neupogen causes a strange throbbing bone pain.   Tolerable but enough to know it’s working.

The harvesting part is fairly easy, two days of hanging out hooked to the plasmapheresis machine.  Fortunately the harvest was successful, and enough cells had been obtained for more than one transplant if needed.

Since I was still relatively healthy and lived fairly close to the hospital, we elected to have the transplant done as an outpatient.  This meant traveling back and forth to the hospital everyday.

The week following the harvest, I received two days of chemotherapy infusions with melphalan ^[5] (Alkeran), and then came the long awaited “day zero” or transplant day.

The nurse came in with a little IV bag of yellowish fluid, attached it to my catheter, and over 30 minutes the bag was infused.  “That’s it?” I thought.  “That was a big anticlimax; some transplant.”

It’s what comes next that you can’t prepare for.  Over the next few days the effects of the chemotherapy start to kick in: incredible fatigue, nausea, diarrhea, and mouth sores that cause difficulty swallowing.

After the transplant, it takes 10 to 14 days for the cells to “engraft” or find their way to the bone marrow and start to function.   During that time, the white blood cell count and, therefore, the immune system go to almost zero.  This is the critical time.  With no defenses, any type of infection can be catastrophic.  We were constantly admonished by the nurses to check for fever several times a day, and anything over 100.5 °F required immediate return to the hospital, anytime of day or night.  I was at the hospital most of the time anyway.

Barely able to get out of bed, we drove to the hospital daily to receive whatever was needed that day to keep me going: IV fluids for hydration, blood transfusions, platelet transfusions, usually with me trying to sleep through it.

I almost made it.  On day 9, I spiked a temperature and was admitted to the hospital.  Thankfully it was nothing serious.  The engrafting process itself can sometimes cause a fever.

The good news is that it does have an end.  On day 11, I started to engraft.  My white blood cell count was starting to turn around and creep up.  Recovery from that point is pretty steady.

Most of the nasty symptoms such as diarrhea and mouth sores resolve with engrafting.  The fatigue takes longer to resolve, but I was able to return to work in just under two months.

Next month I will write more about dealing with the fatigue and my time after transplant.