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Curing cancer in Jerusalem.


There are many reasons to makea pilgrimage to Jerusalem. This beautiful ancient city houses the spiritual treasures of the three major monotheistic religions. Global inter-faith cooperation is nowhere more evident than at the large hospitals of Jerusalem. We went to Jerusalem to meet with Dr. Shimon Slavin, renowned for curing leukemia victims with bone marrow transplants. Not only is having this procedure done far less expensive in Jerusalem than it is in most countries, but Jerusalem also is a marvelous setting to restore one's body and soul.

Jerusalem is indeed a city of surprises. Thecamels and the old city wall right out of the Bible are a striking contrast to the state-of-the-art, world-class operating rooms. From riding a camel near the Garden of Gethsemane and on the Mount of Olives on a beautiful sunny day, it is only a few minutes to the site of the internationally known bone marrow transplant program headed by Dr. Slavin. The Reverend Peter Michael and I made an appointment with Dr. Slavin at the Hadassah University Hospital to televise a story about a bone marrow transplant being done for a young leukemia patient from Buenos Aires, Argentina.

Marcello Elnagar, 31, had come toJerusalem from Argentina with his sister, Christina, who would donate bone marrow for her brother. Marcello has chronic myeloid leukemia, a disease for which the average survival time is about three years. Marcello had been diagnosed in February. He was still in excellent physical condition, and having the transplant before his disease proressed improved his chances for a complete cure. His radiant sister seemed joyous at the opportunity to donate bone marrow for him. It was fortunate for Marcello that her bone marrow was a perfect match--the odds that it would be were only 25 percent, and there were no other siblings from whom to get matched bone marrow. Christina, a newlywed, told us she was waiting to start a family until the bone marrow transplant had been completed.

Before the transfusion could begin,Marcello had been treated to eradicate cancer cells, for the recipient's immune system must be entirely eradicated or it will recognize the transfused cells as foreign and reject them.

After Marcello received bone marrowfrom his sister, all blood cell types in his body were her cell types, having developed in Marcello's body out of donor stem cells from his sister. All circulating blood cells as well as cells constituting the immune system (lymphocytes) develop from the stem cells.

Bone marrow transplantation, amedical procedure rapidly coming into greater use, involves infusion of normal bone marrow cells into a patient, as in a simple blood transfusion. Bone marrow transplantation, or BMT as it is abbreviated, has the potential to treat many life-threatening disorders in patients who cannot be cured by conventional therapy. Bone marrow is an amorphous, blood-like tissue located inside the spongy part of the bone. Its many kinds of cells are all produced by the stem cells. Properly functioning bone marrow is important because it produces: red blood-cells that bring oxygen to all body tissues; a variety of infection-fighting white blood cells, including lymphocytes and antibody-forming cells; platelets that retard bleeding; and various other cells that protect against foreign pathogens and toxic agents as well as serve other functions.

Bone marrow transplantation isused to treat an incredibly large number of cancerous and noncancerous conditions. Acute leukemias, chronic myeloid leukemia, Hodgkin's and non-Hodgkin's lymphomas are the most common cancers treated with bone marrow transplantation. The procedure permits administration of several therapeutic agents in high, otherwise lethal doses. High-dose chemotherapy often coupled with radiation therapy is given in an attempt to eradicate all malignant cells. The patient is then rescued with normal bone marrow cells obtained from a normal donor or with treated cells from the patient himself. If any residual cancer cells of host origin have survived the heavy preparatory regimen of chemotherapy and radiation, the new donor-type immunological system can potentially react to destroy them.

Bone marrow transplants can alsobe the key to treating such genetic diseases as thalassemia major, in which the bone marrow produces abnormal red blood cells. The only known way to cure thalassemia major, a disease similar to sickle cell anemia, is to destroy the patient's own marrow and put in new bone marrow cells that will produce normal red blood cells. The thalassemias are a very complex, very common group of inherited diseases. Worldwide, 180 million or more people carry at least one gene with the thalassemia. In areas where the genes are most common, such as the Mediterranean basin and Southest Asia, millions of people have an actual disease, having inherited at least one gene from each parent. Most thalassemia diseases are mild, but a small fraction are referred to as thalassemia major. In all cases, untreated thalassemia major patients eventually die from the disease or from complications of the frequent blood transfusions they must receive, but BMT can totally cure the disease, especially if the transplants can be made in the first few years of the patient's life.

"Our first bone marrow transplantsare now over three years old," Dr. Slavin said. "The patients develop normally, receive no blood transfusions, no medications--as a matter of fact, they have no need to see a doctor at all." Dr. Slavin suggested that sickle cell anemia and other inherited blood diseases are potentially treatable with BMT. He told us of a patient who suffered from both leukemia and sickle cell anemia. A bone marrow transplant simultaneously cured both his leukemia and his sickle cell anemia.

Bone marrow donors are usuallygenetically matched siblings. When BMT is indicated, the patient, all siblings, and preferably both parents should be tissue-typed. If a patient has no matched donor in his family, a search for a suitable unrelated donor through computerized international data banks should be considered. The Hadassah University Hospital has a computer bank of the tissue types of volunteers who can be consulted by any patient anywhere in the world, Dr. Slaving told us with pride.

A strong patriotic spirit was apparenteverywhere in Israel--among young and old. Each time the telephone rang during our interview, Dr. Slavin excused himself to answer it, and we noted that this eminent physician was xeroxing material for us himself. After the third interruption, he apologized, explaining that his secretary had been drafted for military service. He wasn't complaining. Doctors, too, are conscripted. No able-bodied person seems to be exempt.

"There is no shortage of volunteersfor bone marrow transplants," Dr. Slavin said, "just a shortage in funds to pay for the labor to do the tissue typing of those who volunteer to give bone marrow, should a patient need their particular type of marrow."

Dr. Slavin explained that theHadassah's doctors prefer to take bone marrow using epidural anesthesia in adult donors. The extraction procedure entails a needle-size puncture on each side above the buttocks. From the two sites approximately two pints of bone marrow are aspirated. "It's a quite simple medical procedure," Dr. Slavin explaineD. "The risk is minimal, and the procedure is painless." The patient commonly experiences some weakness, as after blooddonation. Marrow donors return to unrestricted activity within days.

The Hadassah staff also performsautologous transplants, in which patients serve as their own bone marrow donors. The procedure eliminates the graft-versus-host problem that can lead to bone marrow rejection, but it has certain drawbacks.

"The problem is to obtain bonemarrow cells that are free of tumor cells," Dr. Slavin explained. One new "clean-up" method designed to get rid of all tumor cells uses a metallic powder coated with a chemical that adheres to cancer cells but not to normal bone marrow. The powder is mixed with the bone marrow; then, a magnet separates out the tumor cells. After cleaning, the healthy bone marrow can be frozen inliquid nitrogen by a process called cyropreservation until needed. A few minutes before use, the frozen marrow is thawed in a body-temperature water bath and infused into the patient.

Cryopreservation of bone marrowis recommended for patients with certain cancers who have been brought into complete remission by intensive chemotherapy but who are at significant risk for relapse of the disease. Examples are children who have lymphoblastic leukemias, lymphomas, or solid tumors such as neuroblastoma or Ewing's sarcoma and who have no genetically mathced siglings. The bone marrow must be taken at an early stage in the first remission in preparation for possible later relapses. Transplants after the first remission are much less likely to succeed. Patients with cancers not treatable by BMT can benefit by preserving their own bone marrow for "rescue" following high-dose chemo or radiation therapy.

In Israel the cost of preservingbone marrow is about $4,000, including hospitalization and maintenance of the fronzen marrow. Special purging procedures may raise the price to $6,000. "The Hadassah University Hospital can now safely eliminate several types of leukemia, lymphoma, and other cancer cells from bone marrow without harming the normal stem-cell function," Dr. Slavin said.

Shortly before our arrival inJerusalem, a young Soviet immigrant to Israel, Michael Shirman, died following a bone marrow transplant. Shirman had gained world-wide attention when Soviet authorities delayed his sister's request to come to Jerusalem to donate her bone marrow. "When she came, he was already very sick," hematologist Dr. Reuvn Oor of the Hadassah Hospital told us. "His body was full of tumor and the cancer doubled its size even three to four hours. So this was a cancer that nobody could expect you could cure. But he was a very strong man and very much wanted to do it. We tried it, and from the point of view of the treatment, we had great success, because we did get rid of his tumor. His sister was a perfect match for hime. Identical. The patient went home after that, but complications followed, becuase he had been heavy treated during the long wait for his sister. His liver and intestines were damaged from the previous treatment. But from the point of view of the cancer, he died without evidence of the tumor."

We had learned about Dr. Slavinand the work being done in Jerusalem from Dr. Jan Jansen of Indiana University Medical Center's Bone Marrow Transplantation Unit. Dr. Jansen, a native of the Netherlands, is a noted authority on bone marrow transplants. He is also working to set up a matched unrelated donors bank to provide bone marrow for patients who do not have suitable relatives for donors. Most of the 60 or so bone marrow transplantation centers in the United States limit their transplants to patients who have a brother or sister with an identical tissue type, Dr. Jansen explained. "Only approximately one out of every three patients who are otherwise eligible for bone marrow transplantation have such a donor," he said. "So, at present, a large number of patients who otherwise would be candidates will never receive a transplant because they do not have a suitable donor."

Although there are about 2 milliondifferent tissue types, Dr. Jansen believes a file of 3,000 donors could provide transpaltns for as many as half the patients who have no sibling donors. "What we would do is ask volunteers if they would be willing to serve on the file," Dr. Jansen said. "The only thing they would have to do is to allow us to draw some blood from their arm, about four tubes, and we would establish the tissue type from the white cells and the blood. Then we would enter the tissue type into a computer and store it." At a cost of about $350 for each tissue typing, even a relatively small donor file could easily cost $1 million. More patients might be helped by linking the local file with others nationally and internationally.

When we returned from Jerusalem,we told Dr. Jansen and other hemotogolists about Dr. Slavin's ambitious plans to set up an international bone marrow bank in Israel. One hematologist responded, "It's a damn shame not to have every donor in the world who's been matched on the computer system. There's an awful lot of data sitting out there, but it isn't pooled." He suggested the U.S. Navy is interested in such a project and will possibly help support it.

Dr. Jansen was surprised to learnof the low cost for bone marrow traasplantation being quoted in the Hadassah Hospital in Jerusalem. Dr. Slavin had told us that the cost of $35,000 in U.S. money includes all the work for the donor and the recipient as well as the convalescence. The fee also covers all expenses plus room and board for a companion.

Dr. Slavin reported that theHadassah's bone marrow transplantation is covered by many foreign governmental and medical insurance programs. Insurers could deduce that since this procedure is capable of producing a complete cure, it would cost less in the long term than paying a leukemia patient's hospital bills for several years of critical illness, he said. Dr. Slavin pointed out that in the U.S. the average bone marrow transplant can cost from $150,000 to $200,000. "The cost of the ticket here is nothing compared to the savings," Dr. Slavin said with a grin.

A U.S. visitor feels at home in theHadassah. Many names are familiar. There is a John F. Kennedy wing on the hospital and, nearby, a Rockefeller Museum in Jerusalem. Just across the street from the King David Hotel is the most splendid Y.M.C.A. I've seen anywhere in the world. Such landmarks and the Holy Land aspects, too, make a trip to Israel for an important medical procedure seem less far-out than at first blush.

Obviously, the hospital's bonemarrow transplant unit is subsidized. Many Jewish americans contribute generously and with pride to the Hadassah. "Rich and religious Jewish families pay a lot of money to be buried on the Mount of Olives," one of our hosts observed.

Not all leukemias can be treatedwith bone marrow transplants, and bone marrow transplants are not successful in every leukemia patient. However, successful case histories make this procedure one that offers great hope.

Anyone wishing more informationon bone marrow centers in the United States and abroad may obtain names and addresses of centers by writing to the Society. Address requests to: Bone marrow Transplants, 1100 Waterway Boulevard, Indianapolis, IN 46202.
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Author:SerVaas, Cory
Publication:Saturday Evening Post
Date:Jul 1, 1987
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