Cellular Revolution
As stem cell science marches on, nurses brush up on their basics as well as the ethical aspects of the controversial treatment

By Heather Stringer
April 29, 2003

When a 45-year-old father's lymphoma relapsed during the holidays several years ago, one of his nurses knew just how lucky he was to receive another chance to live.

It was at least the second time the man's cancer had returned. Had he walked into the USC/Norris Comprehensive Cancer Center and Hospital in Los Angeles 10 years earlier, his odds of survival would have been far lower, said Sosy Keuroghelian, MN, CNS, RN, a bone marrow transplant clinical nurse specialist at Norris.

A decade ago, the man would have required surgery to remove his bone marrow, and then another surgery to have healthy bone marrow transplanted back into his body. His chances of surviving the surgeries and the lengthy recovery process would have been slim, Keuroghelian said.

But with modern technology, the man bypassed the grueling bone marrow procedures and instead received the needed treatment through blood transfusions. He checked out of the hospital just three weeks after the transfusions.

This patient's speedy recovery is largely the fruit of modern discoveries in stem cell research. While stem cell transplantation has benefited patients with diseases such as leukemia and lymphoma for the past several decades, in recent years, researchers have explored new potential treatments for a host of diseases through the use of embryonic stem cells.

Some doctors suggest that within the next five years, stem cells could be used to treat everything from heart disease to diabetes. Nurses such as Lindsay Middleton, RN, a genetic counselor with the urology/oncology branch of the National Institutes of Health, encourages nurses to prepare themselves by taking time to grasp the science that drives this technology.

"Nurses need an understanding of where stem cells are in the body, how they are obtained, how they are manipulated in the lab," Middleton said. "Nurses have always been the basic educators of patients, and in order for nurses to provide the best nursing care, they have to have a good understanding at the scientific level."

Weird science

Doctors first began taking advantage of stem cell treatments in the 1970s, when they started using bone marrow from healthy family members and transplanting it into leukemia patients, said Stephen Forman, MD, director of hematology and marrow transplantation at City of Hope National Medical Center in Duarte, Calif. The stem cells in the healthy marrow would multiply and replenish the immune system in the cancer patient.

The next medical leap came when doctors started using the cancer patient's own marrow rather than that of a donor, which lowered the rejection rate. In the 1980s, researchers found another source of stem cells: the umbilical cord blood. This led to the discovery that stem cells in the blood of people of any age could be used for transplantation.

When doctors transplanted a donor's blood-or sometimes the patient's own blood-into a leukemia patient, the stem cells would find their way to the bone marrow and start multiplying. The stem cells would eventually differentiate into platelets, red blood cells or white blood cells.

"Blood stem cell transfusions recover faster and have fewer complications," Keuroghelian said. "Survival outcomes have improved. Patients used to die during transplants due to complications, but we have really reduced that. I've seen their quality of life improve."

These improvements also are allowing doctors and nurses to treat older patients than in the past. Sharon Steingass, MSN, RN, a clinical nurse specialist at City of Hope, recently treated a man in his 70s who had lymphoma.

"Several years ago, we would have never considered transplanting because of his age," she said. "The chemotherapy and radiation would have been too hard on him, and then there is still the recovery period. Now, we could give him less chemo and radiation, and use blood for stem cells instead of marrow. Now, this man is doing well."

The next jump came in the late 1990s, when researchers began probing the potential uses of embryonic stem cells. They discovered that cells from an early fertilized egg had the capacity to develop into other tissues of the body.

"The dream was that under the right conditions, we could coax these cells to develop into liver cells, heart cells, brain cells," Forman said. "So work is being done to see if these stem cells can be used to repair brain injury from a stroke or Parkinson's disease, or even might be able to make insulin for diabetics."

Most of the time, these stem cells were from unused fertilized eggs from couples who had pursued fertility treatment, and this ushered in a moral dilemma because the eggs could represent human beings, Forman said.

"Nurses have to be very aware of the ethical aspects," Middleton said. "Patients who may need stem cell therapy may face people who are critical of the use of stem cells. Some patients themselves may be in conflict, and nurses can help them in the decision process."

Steingass believes that many people have moral objections because embryonic stem cell research has the potential to advance human cloning technology. "A lot of people have difficulty with the cloning aspect, but not the embryonic component," she said.

Both technologies take an egg, remove the nucleus and replace it with a different nucleus, Forman explained. For a diabetic, this new egg could be used to develop new pancreatic cells to reverse the effects of diabetes. But critics argue that this technology also could be used to clone human beings.

People get ready

But Forman said researchers are working on techniques that could bypass the moral issues and still take advantage of stem cell treatments. Evidence shows that cells in the brain can produce blood, and this reveals the potential that a cell in one tissue can develop into the cell of another tissue, he said.

"I'm very optimistic," Steingass said. "I know it's not going to be overnight, but I don't think you can stop science. It continues to move ahead."

Like Middleton, Steingass encourages nurses to gear up to use these treatments of the future by returning to the molecular basics they learned in nursing school. This kind of knowledge will be more important than ever as the technology moves out of the lab and into the hospital.

"In order for us to truly take care of patients, we will have to be comfortable with the molecular and genetic aspects of these treatments," she said. "We as nurses are going to have to go back to the anatomy textbooks and familiarize ourselves with what happens at the cellular levels. So many of the new treatments will require that we understand molecular things at the cellular level."

Contact Heather Stringer at heathers@nurseweek.com