Cord Blood Banking: an OB’S Perspective

Cord Blood Banking: an OB’s Perspective

BY JORDAN H. PERLOW, MD

Cord blood as a source of stem cells doesn’t have the drawbacks of hard-to-match bone marrow— or pose the ethical conundrum of embryonic stem cells. What kind of advice should you give patients who ask about banking it after delivery?

Compliments of CORD BLOOD

Cord blood banking: an ob’s perspective By Jordan H. Perlow, MD

one marrow and periph- we stay up-to-date on the scientific age time span from the search for a eral blood have been the advances in this area and the poten- bone marrow donor to transplant B traditional source of tial conflicts and dilemmas they exceeds 4 months. During that wait- stem cells. But now the transplanta- pose for our patients. ing time, patients with these serious tion of hematopoietic stem cells The use of bone marrow—the illnesses may significantly deterio- from umbilical cord blood is becom- traditional source of these stem rate, become unsuitable for trans- ing the preferred treatment for more cells—has been fraught with draw- plantation, and ultimately succumb and more malignant, benign, and backs, primarily relating to the lim- to their disease. In fact, some 9,000 inherited disorders. We obstetricians ited availability of such cells. In Americans die each year waiting for are uniquely positioned to collect fact, for the 7,000 patients seeking a stem cell transplant; sadly, one these potentially life-saving cells for allogeneic bone marrow stem cells third of them are children. Umbilical this purpose every time we deliver a annually in the United States, the cord blood may hold the remedy to baby. So it’s prudent and practical search for an appropriate matched this tragedy. for us to learn about this vital med- donor can prove difficult at best. ical technology and to educate our Overall, only 25% will find a suit- The premise behind patients as well. Moreover, the direct able match, with ethnic minority cord blood banking marketing of cord blood banking patients at greatest risk of failing to Umbilical cord blood banking con- services to our patients requires that be appropriately matched.1 The aver- sists of the collection, processing, and cryopreservation of the remain- Dr. Perlow is Associate Director, Maternal-Fetal Medicine, Good Samaritan Regional Medical Center, ing blood within the umbilical and Phoenix, Ariz., and Partner, Phoenix Perinatal Associates, Obstetrix Medical Group of Phoenix, Phoenix, Ariz. He is also Associate Clinical Professor, Department of Obstetrics and Gynecology, University of placental circulation following the Arizona School of Medicine, Tucson, Ariz. birth of a child and typically prior to

2 TABLE 1 Diseases potentially treatable with umbilical cord blood stem cell transplants

Acute leukemias Lymphoproliferative disorders Histiocytic disorders Acute biphenotypic leukemia Hodgkin’s disease Familial erythrophagocytic Acute lymphoblastic leukemia Non-Hodgkin’s lymphoma lymphohistiocytosis Acute myelogenous leukemia Prolymphocytic leukemia Hemophagocytosis Acute undifferentiated leukemia Histiocytosis-X Phagocyte disorders Chronic leukemias Chediak-Higashi syndrome Inherited erythrocyte abnormalities Chronic lymphocytic leukemia Chronic granulomatous disease Beta thalassemia major Chronic myelogenous leukemia Neutrophil actin deficiency Pure red cell aplasia Juvenile chronic myelogenous leukemia Reticular dysgenesis Sickle cell disease Juvenile myelomonocytic leukemia Liposomal storage diseases Congenital (inherited) immune system Myelodysplastic syndromes Adrenoleukodystrophy disorders Chronic myelomonocytic leukemia Gaucher’s disease Absence of T & B Cells SCID Refractory anemia Hunter’s syndrome Absence of T Cells, Normal B Cell SCID Refractory anemia with excess blasts Hurler’s syndrome Ataxia-telangiectasia Refractory anemia with ringed sideroblasts Krabbe disease Bare lymphocyte syndrome Maroteaux-Lamy syndrome Common variable immunodeficiency Stem cell disorders Metachromatic leukodystrophy DiGeorge syndrome Fanconi’s anemia Morquio’s syndrome Kostmann syndrome Paroxysmal nocturnal hemoglobinuria Mucolipidosis II (I-cell disease) Leukocyte adhesion deficiency Severe aplastic anemia Mucopolysaccharidoses Omenn’s syndrome Myeloproliferative disorders Niemann-Pick disease SCID with adenosine deaminase deficiency Acute myelofibrosis Sanfilippo’s syndrome Severe combined immunodeficiency Agnogenic myeloid metaplasia Scheie’s syndrome disease (SCID) (myelofibrosis) Sly syndrome, ß-glucuronidase deficiency Wiskott-Aldrich syndrome Essential thrombocythemia Wolman disease X-linked lymphoproliferative disorder Polycythemia vera Other malignancies Other inherited disorders Breast cancer Cartilage-hair hypoplasia Ewing sarcoma Glanzmann’s thrombasthenia Neuroblastoma Lesch-Nyhan syndrome Renal cell carcinoma Osteopetrosis Platelet abnormalities Amegakaryocytosis Congenital thrombocytopenia Plasma cell disorders SCID—severe combined immunodeficiency disease Multiple myeloma Plasma cell leukemia Waldenström’s macroglobulinemia placental delivery. Within this “left- sors, which then produce B-lympho- worldwide with more than 45 differ- over” blood, traditionally discarded cytes, T-lymphocytes, natural killer ent malignant and nonmalignant with the placenta as medical waste, cells, and plasma cells, as well as diseases and to treat patients with lies a rich source of hematopoietic myeloid stem cells that give rise to severe combined immunodeficiency stem cells; undifferentiated cells that the erythrocytes, platelets, neu- syndrome through gene therapy have the capacity to differentiate into trophils, monocytes, eosinophils, techniques (Table 1).2-7 In my view, the various components of the basophils, and macrophages. appreciating the advantages of cord hematologic and immune systems. For more than a decade, banked blood stem cells over bone marrow These pluripotent stem cells can dif- cord blood stem cells have been stem cells (Table 2) casts each deliv- ferentiate to form lymphoid precur- used to treat thousands of people ery we attend in a new light. It

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TABLE 2 becomes a unique and potentially from his newborn sister, who was life-saving opportunity to facilitate Advantages of cord blood HLA identical.11 Several years later, the banking of cord blood. 8 stem cells over bone in 1991, the successful treatment of The premise for banking cord marrow a patient with cord blood stem cells blood is the fact that cord blood for juvenile chronic myelogenous stem cells are the progenitor cells Significantly reduced risk leukemia represented the first use of that can reconstitute the blood and of graft-versus-host disease this cord blood-derived therapy for immune systems. These cells are Greater immunological naiveté malignant disease. Since then, the particularly abundant in cord use of cord blood stem cells has blood—with concentrations nearly Painless, noninvasive, risen dramatically. It’s estimated that risk-free retrieval 10 times greater than that found in more than 3,000 patients have now bone marrow—and are more prolif- Essentially unlimited supply been treated with cord blood stem erative. Unlike the risks inherent in Technically simple collection process cells—and 400 to 500 new patients bone marrow transplants, they can Immediate availability for clinical use receive treatment annually. be collected safely without maternal In a large study of 562 patients or neonatal risk following delivery.8- Superior proliferative capacity who received unrelated cord blood 10 When infused, cord blood stem Significantly lower cost transplants, Rubinstein and col- cells migrate to the bone marrow Lower risk of infectious complications leagues concluded that cord blood where they engraft and develop into banking was a useful source of allo- the cell lines of blood and immune Greater HLA mismatch tolerance geneic hematopoietic stem cells for system components mentioned HLA—human leukocyte antigen these patients, who did not have a above. Thus, conditions whose related histocompatible donor.4 pathophysiology emanates from advantages to using stem cells from They noted acceptable rates of abnormal cells originating from cord blood compared to bone mar- engraftment and survival. An hematopoietic stem cells may bene- row. Primary among these are the accompanying editorial pointed out fit from therapy with stem cells from significantly lower risks of a serious that the results confirmed previous banked umbilical cord blood. This complication of allogeneic stem cell work, indicating that reproducible applies whether they’re malignant transplantation known as graft-ver- stem-cell engraftment can be (leukemia) or nonmalignant (sickle sus-host disease (GVHD). This con- achieved in patients with neoplastic cell anemia) conditions, or diseases dition, resulting from an unfavor- disease using stem cells derived (solid tumors) whose treatment able reaction of T cells in the graft to from cord blood.12 Furthermore, the (chemotherapy and/or radiation) Human Leukocyte Antigens (HLAs) editorial continued, the reduced risk destroys the patient’s healthy in the recipient, is a leading cause of of GVHD with cord blood allows an marrow stem cells and thus requires morbidity and mortality among increase in the permissible degree of “rescue therapy” with stem cell stem-cell transplant patients. Studies histoincompatibility between the transplantation. also suggest significant advantages donor and the recipient.12 HLA-typ- to receiving stem cells from a related ing for histocompatibility is the Acceptability and advantages donor, particularly if the source of method of determining whether a reported in the literature these cells is umbilical cord blood. collection of stem cells is suitable A growing body of research on the The first transplant of stem cells for transplantation into another per- clinical outcomes of patients treated from cord blood took place 14 years son. The HLA system has been used with cord blood stem cells suggests ago in Paris. A 5-year-old child suf- for this purpose. There are six major not only the acceptability of this fering with Fanconi’s anemia was antigens of this type and a match of approach for both adult and pedi- transplanted with stem cells using five or six of the six is considered atric patients, but the significant cord blood that had been banked optimal, with a high likelihood of

4 TABLE 3 Private and public umbilical cord blood banking options*

Private options Price: Successful Samples initial banking cost/ Company Phone Web address transplant(s) stored yearly storage fee

California Cryobank 800-400-3430 http://www.cryobank.com 0 5,000+ $1,015/$115 Cord Blood Registry 888-267-3256 http://www.cordblood.com 28 60,000+ $1,740/$95 CorCell 888-326-7235 http://www.corcell.com 21 8,000+ $1,750/$95 Cryo-Cell 800-786-7235 http://www.cryo-cell.com 5 70,000+ $1,110/$115 Cryobanks Intl. 800-869-8608 http://www.cryo-intl.com 12 8,000+ $1,299/$95 LifebankUSA 877-543-3226 http://www.lifebankusa.com 11 20,000+ $1,395/$95 ViaCord 800-998-4226 http://www.viacord.com 11 50,000+ $1,650/$125 *Data accurate as of July 2004. Selected public options Company Phone Web address Where collected

Cryobanks Intl. 800-869-8608 http://www.cryo-intl.com Samples from all states accepted; Registration by 35 weeks required Life South Community Blood Centers 352-334-1000 http://www.lifesouth.org Local Florida and Alabama hospitals only Alberta Cord Blood Bank 780-492-2673 http://www.acbb.ca/ Collections throughout Canada Red Cross Blood Services, San Diego 858-514-1664 http://www.redcross.org Collections at Palomar Hospital only StemCyte Inc. 626-821-9860 http://www.stemcyteinc.com Collections at Southern California hospitals University of Colorado 303-372-2673 Collections at Denver area hospitals Bonfils Cord Blood Services 303-363-2350 Collections at selected Colorado hospitals only Hawaii Cord Blood Bank 808-983-2265 Collections at selected island hospitals successful engraftment and survival. HLA mismatched for at least two or successful stem cell transplantation However, even with lesser degrees of more HLA antigens. The incidence can take place in adults. matching, successful transplants of of severe GVHD was low, neutrophil Studies of children have consis- stem cells from cord blood have engraftment was 90%, and survival tently shown the acceptability and occurred.3 rates were encouraging, given the advantages of using cord blood. Laughlin and colleagues recently life-threatening nature of these dis- Kurtzberg studied 25 patients, reported on 68 adults suffering from orders. The authors concluded primarily children receiving cord life-threatening hematologic disor- that HLA-mismatched cord blood blood from unrelated donors who ders who received stem cells from from unrelated donors can restore were partially HLA mismatched. banked cord blood from unrelated hematopoiesis in adults undergoing Excellent engraftment was noted, donors.3 After undergoing intensive myeloablative therapy and is associ- as was minimal risk for severe chemotherapy or total-body irradia- ated with acceptable rates of GVHD. GVHD.13 Other researchers reported tion, all patients received transplants This study and others suggest that the outcomes for 113 children of HLA-mismatched cord blood. even with the relatively small sam- requiring stem cell transplants for a The vast majority of patients were ple volume of banked cord blood, variety of serious illnesses.14 All

5 Answering patients’ questions about cord blood banking What is cord blood? Umbilical cord blood, also known as placental blood, is blood that flows in the circulation of a developing fetus in the uterus. After the baby’s birth, the leftover blood in the umbilical cord and placenta—which is a rich source of stem cells—is often discarded as biologic waste. What are hematopoietic stem cells? These stem cells are “progenitor” or immature unspecialized cells of the hematopoietic system that have the potential to later develop into more spe- cialized cells—in fact to differentiate into all of the components of the blood and immune systems. During the 1980s, researchers found that cells in cord stem cell donors were HLA-identical blood were similar to the hematopoietic stem cells found only in bone marrow. siblings, but the patients who received stem cells from cord blood What is stem cell preservation? were half as likely as those receiving Stem cell preservation consists of collecting the aforementioned “leftover” bone marrow transplants to develop umbilical cord blood from the placenta and umbilical cord after the baby is delivered and the cord is cut—which poses no risk to either the newborn or GVHD. In another study, which the mother. This blood containing the stem cells is then sent to the “bank,” looked specifically at stem cell which processes the sample and ultimately preserves the cells by freezing transplantation to treat pediatric them in liquid nitrogen. leukemia, children who received Who should consider umbilical cord blood banking? HLA-mismatched cord blood from I personally believe you should inform all prospective parents of their options an unrelated donor also had a lower for “banking” their baby’s umbilical cord blood for potential future use as risk of GVHD than recipients of stem-cell therapy. This opportunity is limited—obviously it will no longer HLA-mismatched marrow from an exist once a baby is delivered—so it gives the couple a chance to determine if unrelated donor.15 These findings any relatives who currently have a disease might wish to pursue cord blood speak to the preference and benefits stem cell therapy. Parents should also find out about any family history of dis- of using unrelated or related cord ease that may increase the risk for other family members. For patients like blood stem cells, if available, rather these, private cord blood banking may offer an opportunity to store the than unrelated or related bone mar- potential cure of these diseases. Some patients may choose to bank cord blood row, in the event a stem cell trans- in the absence of “risk factors,” given the small but potential need for these plant becomes necessary. cells in the future. In an important study, Gluckman How likely is it that families of patients with no history of disease and colleagues addressed the issue will ever need stored stem cells? of “order of preference” of cord It’s estimated that the likelihood that a need for cord blood stem cells will arise blood sources.16 They obtained and within a family is no more than 1/1,500 Another option is to consider public banking of cord blood as a way to help others with serious diseases find a cure. reviewed information on 143 cord This is available at no cost to the patient through Cryobank International blood stem cell transplants, giving (1-800-869-8608; www.cryo-intl.com). attention to the source of the stem cells. It turned out that 78 cord How are stem cells currently being used to fight diseases, including cancer? blood recipients were related to the More than 3,000 patients with at least 45 diseases have now been treated using donor, while 65 other recipients cord blood stem cells. These include malignant diseases like leukemia and were not. Patients in both groups lymphoma, as well as neuroblastoma and retinoblastoma. An important—and were being treated for a variety of less well recognized—fact is that a multitude of nonmalignant diseases are also diseases, both malignant and non- being treated using cord blood. These are primarily inherited disorders of the malignant. Gluckman found that blood and immune systems and genetic diseases affecting metabolism in many patients who received their cord ways. These therapies using cord blood stem cells are not “experimental” but blood from a relative were signifi- 1,2 are considered “mainstream” approaches to treatment. cantly less likely to develop severe What are the possibilities for the future? GVHD and were more than twice as Promising research is ongoing into using cord blood to treat such diseases as likely to be alive 1 year later. The stroke, Alzheimer’s, multiple sclerosis, lupus, diabetes, and other auto- researchers noted significantly immune diseases. These future opportunities for treating such serious worse outcomes for the group illnesses are based on the plasticity of cord blood stem cells, and the potential receiving cord blood from unre- for them to be directed into other cell types, such as nerve, heart, liver, lated donors—even in the group with no HLA mismatches—again suggesting the benefits of receiving

6 Answering patients’ questions about cord blood banking (cont.) and pancreas cells, or the ability of the body to direct cord blood stem cells to damaged or diseased organs where a therapeutic reparative process will occur. Can stem cells for one sibling be used for another? Privately banked stem cells of a family member can be used for other members of the family if the “matching” is acceptable. Fortunately, compared to the traditional source of stem cells—bone marrow—cord blood cells can be used with less precise matching. Receiving stem cells from a relative also con- fers a greater likelihood of survival and a reduced likelihood of severe trans- stem cells from a related source, if plant-related complications. Mothers, siblings, and other relatives to the new- available. born contributing the cord blood have all been recipients of cord blood stem cell transplantation. Patient options and counseling Can the cells be donated to anyone outside of the family? Patients may decide to bank their Typically, privately banked stem cells are called upon to treat a family member child’s umbilical cord blood pri- with a known need or who develops a need in the future. Several children have now been treated using their own banked stem cells who had no specific risk fac- vately or publically—in those com- tors to begin with—but who later developed unexpected life-threatening diseases munities that offer it. But because that proved treatable with them. private cord blood banks can be Are any genetic diseases helped by using stem cells? pricey—their services ranging from Yes; in fact, sickle cell anemia is being cured using cord blood stem cell trans- roughly $300 to $1,500 initially, plantation. Many other inherited diseases have been similarly treated. with subsequent ongoing annual Fanconi’s anemia has been cured with cord blood transplantation and was the storage fees of $50 to $100— very first disease cured using cord blood stem cells in 1988. Rarer diseases, encourage patients to research their such as severe inborn errors of metabolism, have been treated in this manner various options (Table 3).The (Table 1). Internet is a good place for them to Is collection a difficult process? start gathering information to dis- No. Collection is relatively straightforward and is done after the infant is cuss with you. Patients considering delivered and the umbilical cord is cut. It requires about 3 to 5 minutes before private umbilical cord blood bank- the placenta delivers. ing shouldn’t shy away from ques- If a patient is considering private cord blood banking and trying to tioning prospective cord blood choose a company, what questions should she ask? banks about the number of success- Some suggested questions are: ful transplants they’ve performed, if 1. How long has the company been established and working in the field of they are accredited by the American cord blood banking and stem cell research and how many samples do they Academy of Blood Banks for stem have in storage? cell storage, and how long they’ve 2. Is the facility approved by the American Association of Blood Banks been in business. The issue of (AABB accreditation)? whether a cord blood bank has had 3. Has the company had successful cord blood stem cell transplants? This is stored samples used in successful critical, as a successful transplant essentially validates the companies’ methodology and procedures for collection, processing, and storage. transplants is significant—as it In my opinion, a prospective customer of a private “family” cord blood serves to validate the methodology bank can feel more confident regarding their “investment” if the company is of that bank’s collection, processing, well established (>5 years), has thousands of banked samples, is accredited by and preservation techniques. the AABB, and is involved in hematopoietic stem cell research with respect to Although for several years the investigating current and future stem cell applications. marketing of private cord blood banking was aimed at motivating parents to store their child’s cord including parents and siblings. In Estimates have varied considerably, blood in the event that child should fact, using a child’s own blood stem ranging from one in 1,000 to one in develop a pediatric leukemia, it is cells may not be preferable when 200,000 for use by age 18.17-19 The more appropriate that patients treating blood malignancies, as a chance that a banked umbilical approach the option of cord blood lack of graft versus leukemic effect cord blood sample would be used banking as a potential “family may diminish the likelihood of suc- for anyone within a family has been resource,” where cord blood stem cessful treatment. calculated at one in 1,400. Given cells serve to treat diseases that How likely is a person ever to these odds, the question is whether occur among family members, need a stem cell transplant? we should encourage patients to

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pursue private umbilical cord blood the expense of cord blood banking, banking. and parents are often made to feel Key Neither the American College of inadequate if they choose not to points Obstetricians and Gynecologists bank cord blood. Unquestionably, (ACOG)20 nor the American Acad- parents should not be made to “feel Cord blood is a rich source of emy of Pediatrics (AAP)21,22 recom- guilty” if they are not interested or hematopoietic stem cells: mends routine private umbilical able to afford this service. This is a undifferentiated cells that can cord blood banking for all patients. particularly important point, consid- develop into virtually any type of However, I believe that only the ering the many patients for whom blood cell in the human body, and patient and her family in consulta- private cord blood banking may not which now provide a better tion with their medical care be economically feasible. It is alternative to bone marrow providers can best decide if this is important to point out though, that transplantation to treat an something of value to them. Given private cord blood banks are likely expanding list of malignant, benign, the evidence within the literature to provide free services or banking and inherited disorders. suggesting significantly improved at substantially reduced costs if a The premise for banking cord blood outcomes for individuals requiring specific need is identified and cord is the fact that cord blood stem cells stem cell transplants using related blood is likely to be used for trans- are the progenitor cells that can cord blood, I certainly would not plantation. reconstitute blood and the immune discourage a woman from pursuing Also in my experience, payors system. These pluripotent stem cells private cord blood banking if she have covered the costs of cord can differentiate to form lymphoid were so inclined, aware of the costs, blood banking for patients in whom precursors, which then produce potential benefits, and low likeli- a stem cell transplant is likely, and B-lymphocytes, T-lymphocytes, hood for need. Every individual has physicians become patient advo- natural killer cells, and plasma cells, different priorities, therefore I cates in communicating with insur- as well as myeloid stem cells that believe in educating, counseling, ance companies regarding these give rise to erythrocytes, platelets, and then allowing patients to make special needs. neutrophils, monocytes, eosinophils, an informed decision. The AAP statement, however, basophils, and macrophages. ACOG and AAP have raised a specifically says that private cord Because using cord blood stem cells number of important ethical and blood banking “should be consid- carries a smaller risk of graft- medical questions pertaining to cord ered if there is a family member with versus-host disease, it allows blood banking, including: To whom a current or potential need to for a greater degree of do the stem cells ultimately belong? undergo stem cell transplantation.” histoincompatibility between What happens if parents disagree on That contingency and the ever- donor and recipient. their use? Should cord blood be expanding list of conditions being saved routinely at all deliveries? treated with cord blood, heighten the These questions and other ethical importance of obtaining a thorough issues need continued discussion as family history during the course of we move forward with the expan- prenatal care. Patients themselves sion of umbilical cord blood bank- may be unaware of the potential ing opportunities.23 Some years ago importance in volunteering family even the Wall Street Journal criti- medical history data. Therefore, I cized private marketing practices for can’t overstate the importance of playing on the emotions of expec- questioning them directly—whether tant parents.24 The term “biological through an interview or survey—to insurance” is often used to validate identify family members with dis-

8 eases that are potentially treatable or outcomes for all patients, whether apies are being studied for diseases curable through the use of cord stem cells are obtained from related as wide ranging as diabetes, lupus, blood. The opportunity to obtain or unrelated sources. spinal cord injury, and neurologic related cord blood stem cells doesn’t disorders as diverse as stroke, multi- often knock twice. The future looks promising ple sclerosis, Parkinson’s, and I’d advise patients who anticipate Several favorable new developments Alzheimer’s.28-33 that a child or other family member are occurring in cord blood banking. New information on the differen- will need a stem cell transplant to As successful engraftment correlates tiation plasticity of hematopoietic privately bank their child’s cord positively with larger numbers of stem cells raises the probability that blood. On the other hand, I’d coun- stem cells within a transplanted sam- these cells may be converted to cell sel parents who ask about private ple, cord blood stem cell amplifica- types other than those of the blood cord blood banking as a form of tion or expansion is an in vitro and immune systems, such as skele- “biological insurance” about the process that holds great promise.8 By tal muscle, heart, liver, brain, and small likelihood that they’d ever increasing the numbers of stem cells epithelial tissues.34,35 Such an need it, the costs involved, and the within a sample, we can anticipate accomplishment could replace the successful outcomes reported with both more successful engraftment need for work with embryonic stem related cord blood, in case a need and a potentially inexhaustible sup- cells for this purpose and eliminate should one day arise. Also I would ply of stem cells from any given sam- the compelling ethical and moral present the currently fairly limited ple.25-27 The availability of greater issues associated with the use or cre- options for public donation. Public numbers of stem cells would make ation of human embryos for this donation of umbilical cord blood possible transplants in larger-sized purpose. should be without charge to the patients, multiple patients, or the patient and practitioners are encour- provision of multiple doses for a sin- Conclusions aged to learn of the resources within gle patient. At present, cord blood Privately banking a baby’s cord blood their communities. samples are used in their entirety after delivery may not be for every With 4 million births per year in and thus unavailable for subsequent patient, but obstetricians should dis- the US, a large reservoir of geneti- use. cuss cord blood banking with par- cally diverse stem cell samples could Recently, the first successful ents, or at least provide information. be collected that would otherwise be autologous cord blood transplants Advise women whose significant discarded. Undeniably, many people took place (Personal communica- family or personal history indicates a would benefit from the availability tion; Viacord, Cord Blood Registry, potential need for stem cell treat- of these samples, most especially July 2002). These were cases where ment to seek counseling with med- ethnic minorities, given their under- parents opted for private cord blood ical or surgical specialists on the representation in bone marrow reg- banking without any specific family advisability of cord blood banking istries. Cryobanks International (1- risk factors, and the stem cells were for this purpose (see “Answering 800-869-8608; www.cryo-intl.com) subsequently used to treat unantici- patients’ questions about cord blood will accept public cord blood dona- pated metastatic retinoblastoma, banking,” page 6). Another option is tions at no cost as long as collection neuroblastoma, and several cases of to contact private cord blood banks arrangements are made prior to 35 severe aplastic anemia. for advice and information on weeks’ gestation. Other public cord Expanded uses for cord blood whether a particular disease is blood banks accept donations from appear to be on the horizon. Prom- amenable to stem cell transplanta- samples only within affiliated hospi- ising areas of current research are tion. Some years ago, it was pre- tals (Table 3). Ultimately, it is hoped focusing on the use of cord blood dicted that “the collection of placen- that significant medical advances in for tissue regeneration, angiogene- tal blood will become as usual as it is transplantation biology will improve sis, and gene therapy. Stem cell ther- unusual today.”36 With greater

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awareness of the many diseases treat- for future use. Obstet Gynecol. 1997;89:300-303. 23. Sugarman J, Kaalund V, Kodish E, et al. Ethical 10. Hows JM, Marsh JC, Bradley BA, et al. Human cord issues in umbilical cord blood banking. Working Group on able with stem cells, the superiority blood: a source of transplantable stem cells? Bone Ethical Issues in Umbilical Cord Blood Banking. JAMA. of cord blood to other sources, the Marrow Transplant. 1992;(suppl 1):105-108. 1997;278:938-943. 11. Gluckman E, Broxmeyer HA, Auerbach AD, et al. 24. Chase M. Costly blood storage pitched as a hedge to potential cord blood stem cell break- Hematopoietic reconstitution in a patient with Fanconi’s expectant parents. Wall Street Journal, Health Journal, throughs of tomorrow, as well as the anemia by means of umbilical-cord blood from an HLA- April 27, 1998, B1. large untapped supply of these cells, identical sibling. N Engl J Med. 1989;321:1174-1178. 25. Ng YY, Bloem AC, van Kessel B, et al. Selective in 12. Parkman R. The future of placental-blood transplan- vitro expansion and efficient retroviral transduction of this statement seems truer today tation. N Engl J Med. 1998;339:1628-1629. human CD34+ CD38- haematopoietic stem cells. Br J Haematol. 2002;117:226-237. than ever before. □ 13. Kurtzberg J, Laughlin M, Graham ML, et al. Placental blood as a source of hematopoietic stem cells 26. About Selective Amplification. ViaCell’s Patented for transplantation into unrelated recipients. N Engl J Method for the Culture of Stem Cells. ViaCell available at: The author has spoken on the topic of cord blood Med. 1996;335:157-166. http://www.viacellinc.com/select.html. Accessed July 18, banking and received travel reimbursement and 2002. honoraria from Viacell Inc. 14. Rocha V, Wagner JE, Sobocinski KA, et al. Graft-versus-host disease in children who have received a 27. Kurtzberg J, Jroscak J, Martin PL, et al. cord-blood or bone marrow transplant from an HLA-iden- Augmentation of umbilical cord blood (UCB) transplanta- tical sibling. Eurocord and International Bone Marrow tion with x-vivo expanded cells, a phase 1 trial using the REFERENCES Transplant Registry Working Committee on Alternative replicell system. Blood. 1999;94:571a. Abstract 2547. 1. Fasouliotis SJ, Schenker JG. Human umbilical cord Donor and Stem Cell Sources. N Engl J Med. 2000; 28. Murohara T. Therapeutic vasculogenesis using blood banking and transplantation: a state of the art. Eur 342:1846-1854. human cord blood-derived endothelial progenitors. J Obstet Gynecol Reprod Biol. 2000;90:13-25. 15. Rocha V, Cornish J, Sievers EL, et al. Comparison of Trends Cardiovasc Med. 2001;11:303-307. 2. Barker JN, Wagner JE. Umbilical cord blood trans- outcomes of unrelated bone marrow and umbilical cord 29. Lewis SD. 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