A second chance after relapse: why NHS England must review its stem cell transplant policy

DKMS, Anthony Nolan and Leukaemia UK call for a fairer approach to second stem cell transplants after relapse

For many people with blood cancer, a stem cell transplant can offer the best chance of long-term survival. But sometimes, even after a transplant, the disease can come back.

An allogeneic stem cell transplant gives healthy stem cells from a donor to a patient after treatment such as chemotherapy or radiotherapy, helping to replace damaged or diseased bone marrow and rebuild the patient’s blood and immune system. This is different from an autologous transplant, where a patient receives their own stem cells.

For patients whose disease returns after a first allogeneic stem cell transplant, a second donor transplant may offer another chance. However, under NHS England’s current policy, patients are only routinely eligible for a second allogeneic stem cell transplant if their disease relapses more than 12 months after their first transplant.

This means that patients who relapse within a year are generally excluded from an NHS-funded second transplant under this policy, even if they respond well to further treatment, return to remission, and are otherwise clinically fit.

DKMS, Anthony Nolan and Leukaemia UK believe this rule no longer reflects modern transplant medicine. We are calling on NHS England to review the policy and consider a fairer, evidence-led approach that allows specialist clinicians to assess patients based on their individual circumstances.

How did the current policy come about?

In 2016, NHS England announced that second stem cell transplants were “not currently affordable”. Following a major campaign led by Anthony Nolan, access to second transplants was preserved, and in 2017 NHS England introduced a policy allowing some patients to receive a second allogeneic stem cell transplant for relapsed disease.

That was an important step forward. However, the policy included strict eligibility criteria.

Under the current policy, patients must:

be in complete remission
have relapsed more than 12 months after their first allogeneic stem cell transplant
be clinically fit to undergo treatment

Why does the 12-month rule matter?

A second stem cell transplant is not suitable for every patient. It is a complex and high-risk treatment that requires careful assessment by specialist transplant teams.

However, the current policy means some patients may be excluded because of when their disease returned, rather than because of their overall clinical situation.

For example, a patient who relapses at 11 months may be excluded, while someone who relapses shortly after 12 months may be considered. Yet clinical decision-making is rarely that simple.

Some patients who relapse within 12 months may receive further treatment, return to remission, remain physically fit, and have no other curative option available. In those cases, clinicians should be able to consider whether a second transplant is appropriate based on the full picture, not a fixed timeline alone.

What has changed since 2017?

Stem cell transplantation has changed significantly since the policy was introduced.

There have been advances in donor matching, conditioning regimens, supportive care, infection management, graft-versus-host disease management and post-transplant monitoring. Clinicians are also now better able to assess which patients are most likely to benefit from a second transplant.

Rather than relying on time since first transplant alone, transplant teams can consider factors such as remission status, measurable residual disease, disease biology, genetic risk, co-morbidities, previous transplant complications, donor availability and response to further treatment.

Recent evidence suggests that outcomes after second transplant have improved over time, particularly when patients are carefully selected. Relapse timing remains important, but it should be considered as one factor within a broader clinical assessment, not as a rule that automatically excludes patients.

What are we calling for?

Michael Gallagher, Policy and Public Affairs Manager for DKMS UK, said: “At DKMS, we know that finding a matching donor is only one part of giving someone with blood cancer the best possible chance. The policy that determines whether a patient can access a second transplant also needs to keep pace with medical progress.

“The current NHS England policy can rule patients out if they relapse within 12 months of their first transplant, even where further treatment brings their disease back under control and they are otherwise fit enough to be considered.

“A second transplant is not right for everyone. But decisions should be based on individual clinical circumstances and the latest evidence, not a fixed timeline alone.

“Together with Anthony Nolan and Leukaemia UK, we are calling on NHS England to urgently review this policy and move towards a fairer, risk-stratified approach for patients who may have no other curative option.”

What now?

We will continue to raise this issue with NHS England, clinicians, policymakers and parliamentarians to help ensure patients are assessed using modern evidence and individual clinical need.

We recognise that discussions around relapse and treatment options can be deeply personal and difficult. If you have any questions, or if you or a loved one have been affected by the current policy, please contact Michael at Michael.Gallagher@dkms.org.uk.