Bridging Pediatric Neuro-Oncology and Autologous Transplant Care

How can integrating neuro-oncology and stem cell transplant teams lead to better patient outcomes and satisfaction?

At most medical institutions, a child diagnosed with a brain tumor begins care with a neuro-oncology team, which handles the diagnosis, initial discussions with the family and chemotherapy. If the patient needs intensive chemotherapy with a stem cell transplant to treat their disease, the team hands care off to a separate bone marrow transplant (BMT) team. Once the patient is ready for transplant, the BMT team completes the stem cell harvest, administers high-dose chemotherapy, delivers the stem cells and monitors the patient during their recovery post-transplant. Afterwards, the patient returns to the neuro-oncology team. This handoff process can create a fragmented care experience for families and patients. Through the Neuro-Oncology Program at Children’s Hospital Colorado, the team does things a little differently.

“For families, the usual approach can feel disjointed, especially if there isn’t a lot of collaboration between the two teams or if teams or patients are coming from different locations,” says pediatric neuro-oncologist Jean Mulcahy Levy, MD.

By contrast, Children’s Colorado’s care model — led primarily by Dr. Mulcahy Levy, advanced practice provider Shelby Winzent-Oonk and Rajeev Vibhakar, MD, PhD, MPH/MSPH — keeps both the brain tumor and the transplant care within a single, interdisciplinary team, providing a coordinated path from diagnosis to post-transplant recovery.

“One of the best things for our families is our ability to have their neuro-oncologist be a major driver in their care throughout,” Dr. Mulcahy Levy says. “The patients really like the continuity of that.”

Children’s Colorado is one of the only programs in the nation that provides this level of collaborative expertise in brain tumor and stem cell transplant care.

“We’ve always been in the forefront of pushing the limits on what we can do,” Dr. Vibhakar says. “We are unique nationally.”

Coordinated pediatric neuro-oncology care

The Children’s Colorado team was designed to include doctors and care team members who are cross-trained in bone marrow transplants, cellular therapy and neuro-oncology. Dr. Mulcahy Levy, Nicholas Foreman, MD, and Dr. Vibhakar are the primary physicians for the program, but there are also physician assistants, nurses and other coordinators who are trained in these fields to provide expert support to families.

Dr. Vibhakar points out that in most hospitals, patients and families must communicate with two completely different sets of providers. Sometimes, Dr. Vibhakar says, those two teams can interpret the same information slightly differently.

“The neuro-oncology team doesn’t have the expertise of the transplant site, so they can’t address transplant complications that happen after the fact,” Dr. Vibhakar says. Similarly, the BMT team doesn't always have the neuro-oncology expertise needed to recognize or manage neurological changes that may occur in a patient.

Built on decades of innovation

The hospital’s neuro-oncology autologous transplant  began in 1997 when Nick Foreman, MD, performed one of the first brain tumor transplants in a pediatric patient. Over time, Dr. Foreman collaborated with the founder of the Bone Marrow Transplant Program at Children’s Colorado, Roger Giller, MD, to build a program that allowed the neuro-oncology team to handle transplants itself. This has had noticeable impacts on patient care.

“If we have oversight over all of those processes, then it's easier to manage issues that arise,” Dr. Vibhakar says. “We can really create a plan that’s more individual and specific to that patient rather than not knowing exactly what happened on the transplant side.”

Dr. Mulcahy Levy says that what makes the biggest difference in success rates is the team’s collaborative knowledge: “It really expands what we offer, the safety with which we can offer it and how much further we can get with the therapies that we provide.”

Unique autologous stem cell transplant outpatient care options

Another feature that sets the program apart is that some autologous stem cell patients can receive treatment and recover on an outpatient basis — a rare option for pediatric neuro-oncology patients. For these select patients, who are otherwise healthy and have strong familial support systems, outpatient transplant recoveries result in far less time in the hospital without any sacrifice in the level of safety and effectiveness.

According to Dr. Vibhakar, this model is not only good for the patient’s mental health and well-being, but it also yields positive outcomes.

“We have lower complication rates, we have lower infectious disease rates, lower adverse outcomes, lower therapy-related deaths — all of those things over 25 years of the program,” Dr. Vibhakar says about this outpatient option.

While outpatient options require more hands-on coordination and intensive follow-up from the child’s care team, the benefits are significant. Families report higher satisfaction, and the data shows better outcomes — including fewer complications, lower infection rates and shorter engraftment times.

The outpatient model is a more labor-intensive method for the program’s physicians, nurses and coordinators that requires increased training for recovery. Still, it represents the unique, patient-centered approach that prioritizes safety and effectiveness at every stage of treatment.

Expanding collaboration across care teams

The team is now moving into the CAR-T cell therapy space, which is an expansion of the Neuro-Oncology Program. Dr. Vibhakar explains that the team will continue to train the next generation of young faculty members in new techniques like these, while also ensuring they continue to have a broad level of expertise.

Although it is rare to find medical doctors with such an interdisciplinary knowledge of care, Dr. Vibhakar says it’s necessary for the program’s unique systems to continue.

“It’s a critical component of the care we provide,” Dr. Vibhakar says. “I think it's incumbent on us to train the next set of people.”