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Cord BloodBanking:

Cord BloodBanking:

an OB’s PerspectiveB Y J O R D A N H . P E R L O W , M D

Cord blood as a source of stem cells doesn’t havethe drawbacks of hard-to-match bone marrow—or pose the ethical conundrum of embryonic stemcells. What kind of advice should you give patients

who ask about banking it after delivery?

Compliments of

B one marrow and periph-eral blood have been thetraditional source of

stem cells. But now the transplanta-tion of hematopoietic stem cellsfrom umbilical cord blood is becom-ing the preferred treatment for moreand more malignant, benign, andinherited disorders. We obstetriciansare uniquely positioned to collectthese potentially life-saving cells forthis purpose every time we deliver ababy. So it’s prudent and practicalfor us to learn about this vital med-ical technology and to educate ourpatients as well. Moreover, the directmarketing of cord blood bankingservices to our patients requires that

we stay up-to-date on the scientificadvances in this area and the poten-tial conflicts and dilemmas theypose for our patients.

The use of bone marrow—thetraditional source of these stemcells—has been fraught with draw-backs, primarily relating to the lim-ited availability of such cells. Infact, for the 7,000 patients seekingallogeneic bone marrow stem cellsannually in the United States, thesearch for an appropriate matcheddonor can prove difficult at best.Overall, only 25% will find a suit-able match, with ethnic minoritypatients at greatest risk of failing tobe appropriately matched.1 The aver-

age time span from the search for abone marrow donor to transplantexceeds 4 months. During that wait-ing time, patients with these seriousillnesses may significantly deterio-rate, become unsuitable for trans-plantation, and ultimately succumbto their disease. In fact, some 9,000Americans die each year waiting fora stem cell transplant; sadly, onethird of them are children. Umbilicalcord blood may hold the remedy tothis tragedy.

The premise behind cord blood banking

Umbilical cord blood banking con-sists of the collection, processing,and cryopreservation of the remain-ing blood within the umbilical andplacental circulation following thebirth of a child and typically prior to

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

Dr. Perlow is Associate Director, Maternal-Fetal Medicine, Good Samaritan Regional Medical Center,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 ofArizona School of Medicine, Tucson, Ariz.

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placental delivery. Within this “left-over” blood, traditionally discardedwith the placenta as medical waste,lies a rich source of hematopoieticstem cells; undifferentiated cells thathave the capacity to differentiate intothe various components of thehematologic and immune systems.These pluripotent stem cells can dif-ferentiate to form lymphoid precur-

sors, which then produce B-lympho-cytes, T-lymphocytes, natural killercells, and plasma cells, as well asmyeloid stem cells that give rise tothe erythrocytes, platelets, neu-trophils, monocytes, eosinophils,basophils, and macrophages.

For more than a decade, bankedcord blood stem cells have beenused to treat thousands of people

worldwide with more than 45 differ-ent malignant and nonmalignantdiseases and to treat patients withsevere combined immunodeficiencysyndrome through gene therapytechniques (Table 1).2-7 In my view,appreciating the advantages of cordblood stem cells over bone marrowstem cells (Table 2) casts each deliv-ery we attend in a new light. It

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TABLE 1

Diseases potentially treatable with umbilical cord blood stem cell transplants

Acute leukemias Acute biphenotypic leukemiaAcute lymphoblastic leukemiaAcute myelogenous leukemia Acute undifferentiated leukemia

Chronic leukemiasChronic lymphocytic leukemiaChronic myelogenous leukemia Juvenile chronic myelogenous leukemia Juvenile myelomonocytic leukemia

Myelodysplastic syndromesChronic myelomonocytic leukemiaRefractory anemia Refractory anemia with excess blasts Refractory anemia with ringed sideroblasts

Stem cell disordersFanconi’s anemiaParoxysmal nocturnal hemoglobinuriaSevere aplastic anemia

Myeloproliferative disordersAcute myelofibrosisAgnogenic myeloid metaplasia

(myelofibrosis)Essential thrombocythemia Polycythemia vera

Lymphoproliferative disordersHodgkin’s disease Non-Hodgkin’s lymphomaProlymphocytic leukemia

Phagocyte disordersChediak-Higashi syndromeChronic granulomatous diseaseNeutrophil actin deficiencyReticular dysgenesis

Liposomal storage diseasesAdrenoleukodystrophyGaucher’s disease Hunter’s syndrome Hurler’s syndrome Krabbe diseaseMaroteaux-Lamy syndrome Metachromatic leukodystrophyMorquio’s syndrome Mucolipidosis II (I-cell disease)Mucopolysaccharidoses Niemann-Pick diseaseSanfilippo’s syndromeScheie’s syndrome Sly syndrome, ß-glucuronidase deficiencyWolman disease

Other malignanciesBreast cancerEwing sarcomaNeuroblastoma Renal cell carcinoma

Histiocytic disordersFamilial erythrophagocytic

lymphohistiocytosisHemophagocytosisHistiocytosis-X

Inherited erythrocyte abnormalitiesBeta thalassemia majorPure red cell aplasiaSickle cell disease

Congenital (inherited) immune systemdisordersAbsence of T & B Cells SCIDAbsence of T Cells, Normal B Cell SCIDAtaxia-telangiectasiaBare lymphocyte syndromeCommon variable immunodeficiencyDiGeorge syndromeKostmann syndromeLeukocyte adhesion deficiencyOmenn’s syndromeSCID with adenosine deaminase deficiencySevere combined immunodeficiency

disease (SCID)Wiskott-Aldrich syndromeX-linked lymphoproliferative disorder

Other inherited disordersCartilage-hair hypoplasiaGlanzmann’s thrombastheniaLesch-Nyhan syndromeOsteopetrosis

Platelet abnormalitiesAmegakaryocytosisCongenital thrombocytopenia

Plasma cell disordersMultiple myelomaPlasma cell leukemia Waldenström’s macroglobulinemia

SCID—severe combined immunodeficiency disease

becomes a unique and potentiallylife-saving opportunity to facilitatethe banking of cord blood. 8

The premise for banking cordblood is the fact that cord bloodstem cells are the progenitor cellsthat can reconstitute the blood andimmune systems. These cells areparticularly abundant in cordblood—with concentrations nearly10 times greater than that found inbone marrow—and are more prolif-erative. Unlike the risks inherent inbone marrow transplants, they canbe collected safely without maternalor neonatal risk following delivery.8-

10 When infused, cord blood stemcells migrate to the bone marrowwhere they engraft and develop intothe cell lines of blood and immunesystem components mentionedabove. Thus, conditions whosepathophysiology emanates fromabnormal cells originating fromhematopoietic stem cells may bene-fit from therapy with stem cells frombanked umbilical cord blood. Thisapplies whether they’re malignant(leukemia) or nonmalignant (sicklecell anemia) conditions, or diseases(solid tumors) whose treatment(chemotherapy and/or radiation)destroys the patient’s healthy marrow stem cells and thus requires“rescue therapy” with stem celltransplantation.

Acceptability and advantagesreported in the literature

A growing body of research on theclinical outcomes of patients treatedwith cord blood stem cells suggestsnot only the acceptability of thisapproach for both adult and pedi-atric patients, but the significant

advantages to using stem cells fromcord blood compared to bone mar-row. Primary among these are thesignificantly lower risks of a seriouscomplication of allogeneic stem celltransplantation known as graft-ver-sus-host disease (GVHD). This con-dition, resulting from an unfavor-able reaction of T cells in the graft toHuman Leukocyte Antigens (HLAs)in the recipient, is a leading cause ofmorbidity and mortality amongstem-cell transplant patients. Studiesalso suggest significant advantagesto receiving stem cells from a relateddonor, particularly if the source ofthese cells is umbilical cord blood.

The first transplant of stem cellsfrom cord blood took place 14 yearsago in Paris. A 5-year-old child suf-fering with Fanconi’s anemia wastransplanted with stem cells usingcord blood that had been banked

from his newborn sister, who wasHLA identical.11 Several years later,in 1991, the successful treatment ofa patient with cord blood stem cellsfor juvenile chronic myelogenousleukemia represented the first use ofthis cord blood-derived therapy formalignant disease. Since then, theuse of cord blood stem cells hasrisen dramatically. It’s estimated thatmore than 3,000 patients have nowbeen treated with cord blood stemcells—and 400 to 500 new patientsreceive treatment annually.

In a large study of 562 patientswho received unrelated cord bloodtransplants, Rubinstein and col-leagues concluded that cord bloodbanking was a useful source of allo-geneic hematopoietic stem cells forthese patients, who did not have arelated histocompatible donor.4

They noted acceptable rates ofengraftment and survival. Anaccompanying editorial pointed outthat the results confirmed previouswork, indicating that reproduciblestem-cell engraftment can beachieved in patients with neoplasticdisease using stem cells derivedfrom cord blood.12 Furthermore, theeditorial continued, the reduced riskof GVHD with cord blood allows anincrease in the permissible degree ofhistoincompatibility between thedonor and the recipient.12 HLA-typ-ing for histocompatibility is themethod of determining whether acollection of stem cells is suitablefor transplantation into another per-son. The HLA system has been usedfor this purpose. There are six majorantigens of this type and a match offive or six of the six is consideredoptimal, with a high likelihood of

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TABLE 2

Advantages of cord bloodstem cells over bonemarrow

Significantly reduced risk of graft-versus-host disease

Greater immunological naiveté

Painless, noninvasive, risk-free retrieval

Essentially unlimited supply

Technically simple collection process

Immediate availability for clinical use

Superior proliferative capacity

Significantly lower cost

Lower risk of infectious complications

Greater HLA mismatch tolerance

HLA—human leukocyte antigen

successful engraftment and survival.However, even with lesser degrees ofmatching, successful transplants ofstem cells from cord blood haveoccurred.3

Laughlin and colleagues recentlyreported on 68 adults suffering fromlife-threatening hematologic disor-ders who received stem cells frombanked cord blood from unrelateddonors.3 After undergoing intensivechemotherapy or total-body irradia-tion, all patients received transplantsof HLA-mismatched cord blood.The vast majority of patients were

HLA mismatched for at least two ormore HLA antigens. The incidenceof severe GVHD was low, neutrophilengraftment was 90%, and survivalrates were encouraging, given thelife-threatening nature of these dis-orders. The authors concluded that HLA-mismatched cord bloodfrom unrelated donors can restorehematopoiesis in adults undergoingmyeloablative therapy and is associ-ated with acceptable rates of GVHD.This study and others suggest thateven with the relatively small sam-ple volume of banked cord blood,

successful stem cell transplantationcan take place in adults.

Studies of children have consis-tently shown the acceptability andadvantages of using cord blood.Kurtzberg studied 25 patients,primarily children receiving cordblood from unrelated donors whowere partially HLA mismatched.Excellent engraftment was noted,as was minimal risk for severeGVHD.13 Other researchers reportedthe outcomes for 113 childrenrequiring stem cell transplants for avariety of serious illnesses.14 All

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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

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

*Data accurate as of July 2004.

stem cell donors were HLA-identicalsiblings, but the patients whoreceived stem cells from cord bloodwere half as likely as those receivingbone marrow transplants to developGVHD. In another study, whichlooked specifically at stem celltransplantation to treat pediatricleukemia, children who receivedHLA-mismatched cord blood froman unrelated donor also had a lowerrisk of GVHD than recipients ofHLA-mismatched marrow from anunrelated donor.15 These findingsspeak to the preference and benefitsof using unrelated or related cordblood stem cells, if available, ratherthan unrelated or related bone mar-row, in the event a stem cell trans-plant becomes necessary.

In an important study, Gluckmanand colleagues addressed the issue of “order of preference” of cordblood sources.16 They obtained andreviewed information on 143 cordblood stem cell transplants, givingattention to the source of the stemcells. It turned out that 78 cordblood recipients were related to thedonor, while 65 other recipientswere not. Patients in both groupswere being treated for a variety ofdiseases, both malignant and non-malignant. Gluckman found thatpatients who received their cordblood from a relative were signifi-cantly less likely to develop severeGVHD and were more than twice aslikely to be alive 1 year later. Theresearchers noted significantlyworse outcomes for the groupreceiving cord blood from unre-lated donors—even in the groupwith no HLA mismatches—againsuggesting the benefits of receiving

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Answering patients’ questions about cord blood bankingWhat is cord blood?Umbilical cord blood, also known as placental blood, is blood that flows in thecirculation of a developing fetus in the uterus. After the baby’s birth, the left-over blood in the umbilical cord and placenta—which is a rich source of stemcells—is often discarded as biologic waste.

What are hematopoietic stem cells?These stem cells are “progenitor” or immature unspecialized cells of thehematopoietic system that have the potential to later develop into more spe-cialized cells—in fact to differentiate into all of the components of the bloodand immune systems. During the 1980s, researchers found that cells in cordblood were similar to the hematopoietic stem cells found only in bone marrow.

What is stem cell preservation?Stem cell preservation consists of collecting the aforementioned “leftover”umbilical cord blood from the placenta and umbilical cord after the baby isdelivered and the cord is cut—which poses no risk to either the newborn orthe mother. This blood containing the stem cells is then sent to the “bank,”which processes the sample and ultimately preserves the cells by freezingthem in liquid nitrogen.

Who should consider umbilical cord blood banking?I personally believe you should inform all prospective parents of their optionsfor “banking” their baby’s umbilical cord blood for potential future use asstem-cell therapy. This opportunity is limited—obviously it will no longerexist once a baby is delivered—so it gives the couple a chance to determine ifany relatives who currently have a disease might wish to pursue cord bloodstem cell therapy. Parents should also find out about any family history of dis-ease that may increase the risk for other family members. For patients likethese, private cord blood banking may offer an opportunity to store thepotential cure of these diseases. Some patients may choose to bank cord bloodin the absence of “risk factors,” given the small but potential need for thesecells in the future.

How likely is it that families of patients with no history of disease will ever need stored stem cells?It’s estimated that the likelihood that a need for cord blood stem cells will arisewithin a family is no more than 1/1,500 Another option is to consider publicbanking of cord blood as a way to help others with serious diseases find a cure.This is available at no cost to the patient through Cryobank International (1-800-869-8608; www.cryo-intl.com).

How are stem cells currently being used to fight diseases, including cancer?More than 3,000 patients with at least 45 diseases have now been treated usingcord blood stem cells. These include malignant diseases like leukemia andlymphoma, as well as neuroblastoma and retinoblastoma. An important—andless well recognized—fact is that a multitude of nonmalignant diseases are alsobeing treated using cord blood. These are primarily inherited disorders of theblood and immune systems and genetic diseases affecting metabolism in manyways. These therapies using cord blood stem cells are not “experimental” butare considered “mainstream” approaches to treatment.1,2

What are the possibilities for the future?Promising research is ongoing into using cord blood to treat such diseases asstroke, Alzheimer’s, multiple sclerosis, lupus, diabetes, and other auto-immune diseases. These future opportunities for treating such serious illnesses are based on the plasticity of cord blood stem cells, and the potentialfor them to be directed into other cell types, such as nerve, heart, liver,

stem cells from a related source, ifavailable.

Patient options and counselingPatients may decide to bank theirchild’s umbilical cord blood pri-vately or publically—in those com-munities that offer it. But becauseprivate cord blood banks can bepricey—their services ranging fromroughly $300 to $1,500 initially,with subsequent ongoing annualstorage fees of $50 to $100—encourage patients to research theirvarious options (Table 3).TheInternet is a good place for them tostart gathering information to dis-cuss with you. Patients consideringprivate umbilical cord blood bank-ing shouldn’t shy away from ques-tioning prospective cord bloodbanks about the number of success-ful transplants they’ve performed, ifthey are accredited by the AmericanAcademy of Blood Banks for stemcell storage, and how long they’vebeen in business. The issue ofwhether a cord blood bank has hadstored samples used in successfultransplants is significant—as itserves to validate the methodologyof that bank’s collection, processing,and preservation techniques.

Although for several years themarketing of private cord bloodbanking was aimed at motivatingparents to store their child’s cordblood in the event that child shoulddevelop a pediatric leukemia, it ismore appropriate that patientsapproach the option of cord bloodbanking as a potential “familyresource,” where cord blood stemcells serve to treat diseases thatoccur among family members,

including parents and siblings. Infact, using a child’s own blood stemcells may not be preferable whentreating blood malignancies, as alack of graft versus leukemic effectmay diminish the likelihood of suc-cessful treatment.

How likely is a person ever toneed a stem cell transplant?

Estimates have varied considerably,ranging from one in 1,000 to one in200,000 for use by age 18.17-19 Thechance that a banked umbilicalcord blood sample would be usedfor anyone within a family has beencalculated at one in 1,400. Giventhese odds, the question is whetherwe should encourage patients to

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Answering patients’ questions about cord blood banking (cont.)and pancreas cells, or the ability of the body to direct cord blood stem cells todamaged 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 mem-bers of the family if the “matching” is acceptable. Fortunately, compared tothe traditional source of stem cells—bone marrow—cord blood cells can beused 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-plant-related complications. Mothers, siblings, and other relatives to the new-born contributing the cord blood have all been recipients of cord blood stemcell transplantation.

Can the cells be donated to anyone outside of the family?Typically, privately banked stem cells are called upon to treat a family memberwith a known need or who develops a need in the future. Several children havenow been treated using their own banked stem cells who had no specific risk fac-tors to begin with—but who later developed unexpected life-threatening diseasesthat proved treatable with them.

Are any genetic diseases helped by using stem cells?Yes; in fact, sickle cell anemia is being cured using cord blood stem cell trans-plantation. Many other inherited diseases have been similarly treated.Fanconi’s anemia has been cured with cord blood transplantation and was thevery first disease cured using cord blood stem cells in 1988. Rarer diseases,such as severe inborn errors of metabolism, have been treated in this manner(Table 1).

Is collection a difficult process?No. Collection is relatively straightforward and is done after the infant isdelivered and the umbilical cord is cut. It requires about 3 to 5 minutes beforethe placenta delivers.

If a patient is considering private cord blood banking and trying tochoose a company, what questions should she ask?Some suggested questions are:

1. How long has the company been established and working in the field ofcord blood banking and stem cell research and how many samples do theyhave in storage?

2. Is the facility approved by the American Association of Blood Banks(AABB accreditation)?

3. Has the company had successful cord blood stem cell transplants? This iscritical, as a successful transplant essentially validates the companies’ methodol-ogy and procedures for collection, processing, and storage.

In my opinion, a prospective customer of a private “family” cord bloodbank can feel more confident regarding their “investment” if the company iswell established (>5 years), has thousands of banked samples, is accredited bythe AABB, and is involved in hematopoietic stem cell research with respect toinvestigating current and future stem cell applications.

pursue private umbilical cord bloodbanking.

Neither the American College ofObstetricians and Gynecologists(ACOG)20 nor the American Acad-emy of Pediatrics (AAP)21,22 recom-mends routine private umbilicalcord blood banking for all patients.However, I believe that only thepatient and her family in consulta-tion with their medical careproviders can best decide if this issomething of value to them. Giventhe evidence within the literaturesuggesting significantly improvedoutcomes for individuals requiringstem cell transplants using relatedcord blood, I certainly would notdiscourage a woman from pursuingprivate cord blood banking if shewere so inclined, aware of the costs,potential benefits, and low likeli-hood for need. Every individual hasdifferent priorities, therefore Ibelieve in educating, counseling,and then allowing patients to makean informed decision.

ACOG and AAP have raised anumber of important ethical andmedical questions pertaining to cordblood banking, including: To whomdo the stem cells ultimately belong?What happens if parents disagree ontheir use? Should cord blood besaved routinely at all deliveries?These questions and other ethicalissues need continued discussion aswe move forward with the expan-sion of umbilical cord blood bank-ing opportunities.23 Some years agoeven the Wall Street Journal criti-cized private marketing practices forplaying on the emotions of expec-tant parents.24 The term “biologicalinsurance” is often used to validate

the expense of cord blood banking,and parents are often made to feelinadequate if they choose not tobank cord blood. Unquestionably,parents should not be made to “feelguilty” if they are not interested orable to afford this service. This is aparticularly important point, consid-ering the many patients for whomprivate cord blood banking may notbe economically feasible. It isimportant to point out though, thatprivate cord blood banks are likelyto provide free services or bankingat substantially reduced costs if aspecific need is identified and cordblood is likely to be used for trans-plantation.

Also in my experience, payorshave covered the costs of cordblood banking for patients in whoma stem cell transplant is likely, andphysicians become patient advo-cates in communicating with insur-ance companies regarding thesespecial needs.

The AAP statement, however,specifically says that private cordblood banking “should be consid-ered if there is a family member witha current or potential need toundergo stem cell transplantation.”That contingency and the ever-expanding list of conditions beingtreated with cord blood, heighten theimportance of obtaining a thoroughfamily history during the course ofprenatal care. Patients themselvesmay be unaware of the potentialimportance in volunteering familymedical history data. Therefore, Ican’t overstate the importance ofquestioning them directly—whetherthrough an interview or survey—toidentify family members with dis-

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Keypoints

� Cord blood is a rich source ofhematopoietic stem cells:undifferentiated cells that candevelop into virtually any type ofblood cell in the human body, andwhich now provide a betteralternative to bone marrowtransplantation to treat anexpanding list of malignant, benign,and inherited disorders.

� The premise for banking cord bloodis the fact that cord blood stem cellsare the progenitor cells that canreconstitute blood and the immunesystem. These pluripotent stem cellscan differentiate to form lymphoidprecursors, which then produceB-lymphocytes, T-lymphocytes,natural killer cells, and plasma cells,as well as myeloid stem cells thatgive rise to erythrocytes, platelets,neutrophils, monocytes, eosinophils,basophils, and macrophages.

� Because using cord blood stem cellscarries a smaller risk of graft-versus-host disease, it allows for a greater degree ofhistoincompatibility between donor and recipient.

eases that are potentially treatable orcurable through the use of cordblood. The opportunity to obtainrelated cord blood stem cells doesn’toften knock twice.

I’d advise patients who anticipatethat a child or other family memberwill need a stem cell transplant toprivately bank their child’s cordblood. On the other hand, I’d coun-sel parents who ask about privatecord blood banking as a form of“biological insurance” about thesmall likelihood that they’d everneed it, the costs involved, and thesuccessful outcomes reported withrelated cord blood, in case a needshould one day arise. Also I wouldpresent the currently fairly limitedoptions for public donation. Publicdonation of umbilical cord bloodshould be without charge to thepatient and practitioners are encour-aged to learn of the resources withintheir communities.

With 4 million births per year inthe US, a large reservoir of geneti-cally diverse stem cell samples couldbe collected that would otherwise bediscarded. Undeniably, many peoplewould benefit from the availabilityof these samples, most especiallyethnic minorities, given their under-representation in bone marrow reg-istries. Cryobanks International (1-800-869-8608; www.cryo-intl.com)will accept public cord blood dona-tions at no cost as long as collectionarrangements are made prior to 35weeks’ gestation. Other public cordblood banks accept donations fromsamples only within affiliated hospi-tals (Table 3). Ultimately, it is hopedthat significant medical advances intransplantation biology will improve

outcomes for all patients, whetherstem cells are obtained from relatedor unrelated sources.

The future looks promisingSeveral favorable new developmentsare occurring in cord blood banking.As successful engraftment correlatespositively with larger numbers ofstem cells within a transplanted sam-ple, cord blood stem cell amplifica-tion or expansion is an in vitroprocess that holds great promise.8 Byincreasing the numbers of stem cellswithin a sample, we can anticipateboth more successful engraftmentand a potentially inexhaustible sup-ply of stem cells from any given sam-ple.25-27 The availability of greaternumbers of stem cells would makepossible transplants in larger-sizedpatients, multiple patients, or theprovision of multiple doses for a sin-gle patient. At present, cord bloodsamples are used in their entiretyand thus unavailable for subsequentuse.

Recently, the first successfulautologous cord blood transplantstook place (Personal communica-tion; Viacord, Cord Blood Registry,July 2002). These were cases whereparents opted for private cord bloodbanking without any specific familyrisk factors, and the stem cells weresubsequently used to treat unantici-pated metastatic retinoblastoma,neuroblastoma, and several cases ofsevere aplastic anemia.

Expanded uses for cord bloodappear to be on the horizon. Prom-ising areas of current research arefocusing on the use of cord bloodfor tissue regeneration, angiogene-sis, and gene therapy. Stem cell ther-

apies are being studied for diseasesas wide ranging as diabetes, lupus,spinal cord injury, and neurologicdisorders as diverse as stroke, multi-ple sclerosis, Parkinson’s, andAlzheimer’s.28-33

New information on the differen-tiation plasticity of hematopoieticstem cells raises the probability thatthese cells may be converted to celltypes other than those of the bloodand immune systems, such as skele-tal muscle, heart, liver, brain, andepithelial tissues.34,35 Such anaccomplishment could replace theneed for work with embryonic stemcells for this purpose and eliminatethe compelling ethical and moralissues associated with the use or cre-ation of human embryos for thispurpose.

ConclusionsPrivately banking a baby’s cord bloodafter delivery may not be for everypatient, but obstetricians should dis-cuss cord blood banking with par-ents, or at least provide information.Advise women whose significantfamily or personal history indicates apotential need for stem cell treat-ment to seek counseling with med-ical or surgical specialists on theadvisability of cord blood bankingfor this purpose (see “Answeringpatients’ questions about cord bloodbanking,” page 6). Another option isto contact private cord blood banksfor advice and information onwhether a particular disease isamenable to stem cell transplanta-tion. Some years ago, it was pre-dicted that “the collection of placen-tal blood will become as usual as it isunusual today.”36 With greater

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awareness of the many diseases treat-able with stem cells, the superiorityof cord blood to other sources, thepotential cord blood stem cell break-throughs of tomorrow, as well as thelarge untapped supply of these cells,this statement seems truer todaythan ever before. □

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Hematopoietic engraftment and survival in adult recipi-ents of umbilical-cord blood from unrelated donors. NEngl J Med. 2001;344:1815-1822.4. Rubinste in P, Carr ier C, Schardavou A, et a l .

Outcomes among 562 recipients of placental-bloodtransplants from unrelated donors. N Engl J Med.1998;339:1565-1577.5. Diseases Treated. V iacord. Ava i lab le a t :

http://www.viacord.com/Preservation/Preservation.asp?s=DiseasesTreated&section=2. Accessed July 17, 2002.6. Kohn DB, Parkman R. Gene therapy for newborns.

FASEB J. 1997;11:635-639.7. Cavazzana-Calvo M, Hacein-Bey S, de Saint Basile

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The author has spoken on the topic of cord bloodbanking and received travel reimbursement andhonoraria from Viacell Inc.

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