Focus

Parents now have the option of storing stem cells from their newborn baby's umbilical cord blood, in a private bank abroad. Cynthia Busuttil takes a look at this procedure.

Life cord blood debate

Claire* is eagerly awaiting her first baby. She and her husband have already made arrangements to store their firstborn's umbilical cord blood cells.

"I consider it a form of insurance. Hopefully, I won't get to use it," she said.

Claire admitted that the procedure is relatively new, especially in Malta, but added that given the amount of research taking place in the sphere one could not exclude a big breakthrough in the future.

"What if my child has a problem in five years' time that can be treated with stem cells?"

The local agent of Smart Cells (Malta), Sylvana Brannon, said that about 100 mothers have shown interest in the procedure since Smart Cells (Malta) started operating in February.

In theory, stem cells derived from umbilical cord blood, which are "adult" as opposed to embryonic, can be used to cure a number of diseases, including certain types of leukaemia, Hodgkin's disease, Thalassemia and aplastic anaemia. However, some experts argue that science is still some distance away from delivering the spare immune system that some companies are promising.

Bioethics expert Maurice Cauchi said: "Stem cell research has made tremendous progress in the last decade and will no doubt continue to do so in the next few years. There is no doubt that great medical advances are expected to come from this source. However, it is well to bear in mind that currently the actual application of these techniques is well behind their theoretical possibilities."

Bioethics Consultative Committee chairman Michael Asciak said that in reality there was still no use for the umbilical cord stem cells. "It has to be made clear to parents that there is no particular use for them, although this does not mean that there will not be in the future."

The president of the Malta College of Obstetricians and Gynaecologists, Donald Felice, said that although the technique does have a lot of potential, at the moment there are only few specific and rare conditions that can be treated with stem cells.

St Luke's Hospital's paediatrics department chairman Simon Attard Montalto said the most likely use for umbilical cord stem cells is to treat bone marrow disorders, and there is a chance of culturing cells in vitro to create skin, which can be used for skin grafts.

But even with illnesses like leukaemia, the use is not straightforward. Dr Attard Montalto said that if a baby develops leukaemia, his own cells could not be used in the treatment as they are of the same genetic stock as the ones that developed the disease. On the other hand, the stem cells of a sibling could be very useful.

"At the moment the conditions for which the stem cells can be used preclude a lot of situations where the patient himself will be able to use his own stem cells."

Prof. Cauchi said: "The procedure is still experimental and there is no guarantee that it will be of use in any particular condition."

Moreover, he added, with the current momentum of research, there is quite a possibility of other equally-effective procedures becoming available over the coming years, rendering storage of cord blood superfluous.

Stem cells can also be obtained from the skin and bone marrow of living adults, Dr Asciak explained.

Another question that arises is for how long one can store stem cells so they remain viable. "We do not yet know whether there is deterioration over time, and whether the success rate is the same after one year and after 15 years."

Dr Felice raised a similar concern, saying nobody knows what will happen after 25 years - the time for which cells are stored.

* Name has been changed

'No-risk' procedure

An expert panel of the Royal College of Obstetricians and Gynaecologists (RCOG) said last month there was "insufficient evidence" to recommend the practice.

The British college raised concern that the health of mothers and babies could be jeopardised during the collection of umbilical cord stem cells.

But Dr Felice said the procedure is safe, and there is no risk for mother and baby. "If we did see a risk, we would object to it being done."

Moreover, cord blood is normally taken after the birth to carry out a number of tests, including checking the child's blood group. The procedure - which takes just a few minutes and includes pricking the umbilical cord with a needle attached to a sterilised bag where the blood is automatically collected - is being practised by midwives at St Luke's Hospital. However, obstetricians have refused to do it themselves in case something goes wrong after the blood is collected. In fact, the parents must sign a disclaimer before the procedure is carried out.

Mrs Brannon said the procedure only takes about three minutes, and there were complicated births where blood was successfully collected.

What are umbilical cord stem cells?

Stem cells are very early cells which have not yet developed into a particular type of cell and thus have the ability to produce all other blood cells.

Stem cells fall into two categories - embryonic and adult. The former are the subject of controversy as they entail the destruction of the embryo.

Although each person has stem cells, they decrease as one gets older. Prof. Cauchi said cord blood was a useful source of stem cells, adding that it is also a readily available source which was usually thrown away after birth.

The umbilical cord is usually discarded together with the placenta after the birth of the baby. However, parents can opt to store their baby's cord blood, which is then sent to a laboratory to extract stem cells. Companies are storing such stem cells for 25 years.

"Storage of cells from blood is a relatively easy and well-established technique and involves no ethical issue, as long as normal procedures for obtaining them do not pose extra risk for the mother or baby," Prof. Cauchi said.

Moreover, he added, transplanted stem cells obtained from one's own cord blood have the advantage of not being rejected.

The Church's view

Adult stem cells, unlike embryonic stem cells, do not pose any ethical problems, and a spokesman for the Archbishop's Curia said the Church applauded and encouraged research using adult stem cells because it was completely compatible with respect for the dignity of human beings.

The spokesman said the unexpected plasticity of adult stem cells had made it possible to use this type of cell successfully for the healing of various human tissues and organs.

"The multiple therapeutic achievements that have been demonstrated using adult stem cells and the promise that they hold for other diseases, such as neurodegenerative disorders or diabetes, make efforts to support this fruitful avenue of investigation an urgent matter."

On the other hand, the Church opposes the cloning of human embryos for the purposes of destroying them in order to harvest their stem cells, even for a noble purpose, since this is inconsistent with the motives behind human biomedical research - the respect for the dignity of human beings.

When asked whether this procedure should be made available to everyone if it is really life-saving, and not to the selected few who can afford to pay about Lm850, the spokesman said that throughout the centuries the Church had worked on the principles of justice and equity, adding that societies should strive to ensure that certain important services, especially when it comes to life-saving techniques, were, as far as possible, available to whoever needed them.

Doctors stress need for correct information

Some British doctors have expressed concern that certain firms offering the procedure are playing on parents' fears and using maternal guilt to sell their products. The Royal College of Obstetricians and Gynaecologists also warned parents to be alert to heavy marketing tactics that often include claims that cord blood can be an elixir of life for their children.

Dr Felice said that while obstetricians had nothing against the process, they were concerned parents were being led to believe that after paying Lm850 for the service, any health problems the baby might develop would be sorted out. This was far from reality, he insisted.

"Storing of umbilical cord cells should not be marketed like a commodity or in a way that gives parents a guilt complex if they do not go for it."

Dr Asciak also stressed the importance of parents being given the correct information.

Parents needed to remain open minded, Dr Attard Montalto said. "It is wrong if they are doing it under the impression that this is like a comprehensive car insurance policy, covering anything that goes wrong."

Mrs Brannon, who stored both her children's cells, said that when meeting parents she emphasises that this is not a cure for all their children's problems.

"Before I did it for both my children I did my own research. Two years ago, when I had my first baby, the main disorder for which stem cells had been used successfully was leukaemia. For me that was enough to make it worth it.

"Parents have to be aware that the probability of them needing the stem cells is very small. But they are also investing in stem cell research. And we do not know what discoveries will be made in the coming years."

Prof. Cauchi said the most telling argument in favour of storage was the fact that this was a one-off opportunity, and one either took advantage of it or it was lost forever. This, he said, was the main selling point, and one that obviously weighed most heavily on the parents. But, ultimately, they had to make up their own mind after being given all the available information.

He said there was too much direct advertising of drugs, tests, techniques and procedures by those who had a vested interest. Prof. Cauchi believes there should be stricter controls on advertising, adding that the psychological impact of such advertising must be tremendous and was bound to lead to a divisive medical practice, with expensive procedures being reserved for those who can afford them while the poorer sections of the community had to do without.

However, he does not believe the government should spend "much needed resources on these doubtful procedures".

On the other hand, Dr Felice, Dr Asciak and Dr Attard Montalto seem to agree that the government should invest in a public bank for umbilical cord cells. Dr Felice said that when the potential of the procedure becomes more secure, the possibility of opening a public bank should be discussed. "You do not need to keep samples of the whole population."

Dr Asciak explained that while private stem cell banks would not give somebody's stem cells to another person, a public bank would operate like a blood bank, with the cells being given to people who need them. He said the EU recommends public banking, although it will not stop people from going into private banking.

Dr Attard Montalto said that with a relatively closed population, Malta would not need to store stem cells for a large number of citizens. The main international research bodies have all made recommendations along these lines. While they accept and appreciate the usefulness of stem cells and support research, they have reservations about private banks but support national stem cell banks.

Just back in Malta from a visit to the laboratory in Plymouth, where the stem cells are stored, Mrs Brannon said she was in favour of public banking, adding that people should have a choice.

In its recommendations, the RCOG said it strongly supported the concept of an national health service cord blood bank and would like to see it well funded, but remained unconvinced of the benefit of personal commercial banking for low-risk families.

In 2004, the European Group on Ethics in Science and New Technologies advised the European Commission that the legitimacy of commercial cord blood banks should be questioned since "they sell a service, which has presently no real use regarding therapeutic options".

A spokesman for the Health Division said there were no plans to set up a public bank.