Brazil Squandering Potential of National Umbilical Cord Blood Inventory

map 24 transplant centers in Brazil

Parent’s Guide to Cord Blood Foundation has heard a rumor that changes in Brazil’s public health policies will lead to the suspension of operations at all of the country’s public umbilical cord blood banks. Even if these operations are not fully suspended, already roughly half of the public cord blood banks in Brazil stopped collecting during the Coronavirus pandemic and have never resumed their operations^1,2.

This situation is deeply regrettable, considering the public resources that have been committed over the past twenty years to build the current Brasilcord network of 14 public cord blood banks distributed throughout the country. The Cancer Foundation, through an agreement with the National Bank for Economic and Social Development, has invested roughly R$ 3.5 million per bank^3,4.  The original goal was to reach an inventory of 75,000 cord blood units to guarantee a satisfactory genetic sampling of the population in Brazil⁴. However, the Brasilcord inventory had only reached 18,325 by the end of 2022⁵.

In Asian countries the cord blood inventory and number of cord blood transplants is growing, particularly in China where umbilical cord blood has been used in 30,000 therapies to date^5,6. Worldwide, researchers have found that cord blood therapy is proven to benefit neurological conditions such as cerebral palsy⁷. Yet Brazil seems to be moving in the opposite direction, neglecting advances in cord blood research and the potential benefits of their previous financial investment and existing cord blood inventory.

The main reason that cord blood has fallen out of favor in Brazil is the attitude of the medical community. In countries such as the United States, Japan, and China, cord blood transplants have proven comparable to other transplant methods in short term results, plus in the long term they yield improved overall survival and quality of life^8-11. Whereas in Brazil, overall survival after cord blood transplants has been markedly lower than with bone marrow transplants¹². The oncology centers in Brazil might improve their outcomes by consistently applying the cord blood transplant guidelines from the American Society for Transplantation and Cellular Therapy¹³. In Brazil, oncologists rely mostly on transplants from half-matched bone marrow donors (also known as “haplo” transplants), which are more convenient in the short term in cost and hospitalization time¹⁴. However, not all patients have a haplo donor in their family, or the person that could be a haplo donor may be ineligible to donate, or the potential donor is the mother that carries antibodies against the patient¹⁵. The original motivation for the investment in the Brasilcord public bank network was to cover the genetic diversity of cancer patients in Brazil⁴. Recently, researchers in Brazil have been studying ways to create a limited number of induced stem cell lines that will cover the bioversity of the population in Brazil¹⁶. But these induced cells are many years away from approval for routine use in patients, whereas cord blood transplants are already established as an unmanipulated graft source that enables treatment of patients who do not have matching donors in their family. The oncology community in Brazil has fallen into a negative cycle, where the lack of expertise with cord blood leads to unwillingness to utilize cord blood.

Moreover, cord blood banking has been dragged into Brazil’s political polarization. Transplant doctors have campaigned to convince mothers that public cord blood banking is a resource for the people, and parents should not pay to bank their child’s cord blood privately because the cord blood in private banks will never be used¹⁷. In fact, over a thousand cord blood units have been released from private cord blood banks to treat the donor child for diagnoses that include, among others, congenital heart defects, neuroblastoma, acquired aplastic anemia, cerebral palsy and autism¹⁸. In addition, units from private cord blood banks have been used to treat a sibling of the donor child for numerous conditions, including among others, leukemia, Sickle Cell Anemia, and Thalassemia Major. The cord blood that mothers in Brazil selflessly donated to the Brasilcord public banks should also be used.

Another problem in Brazil is that decision makers for public health spending like to invest in the next new thing. The Ministry of Health has recently committed R$ 100 million for a clinical study of cancer treatment with CAR-T cells¹⁹. Meanwhile they are overlooking advances in cancer treatment with cord blood. The biotech company Gamida Cell has developed an expanded cord blood product, Omisirge®, which engrafts in only 10 days (nearly a week faster than bone marrow) and has been approved by the United States FDA^20,21. Yet Brazil is not investing in the utilization of this product at the country’s cancer centers, even though five hospitals in Brazil participated in the phase 3 trial that led to the FDA approval²².

At a time when Brazil is embracing new technologies in various areas, negligence regarding umbilical cord blood is an example of how Brazil can become stuck in a cycle of ups and downs, failing to achieve lasting and consistent development. In the current situation, the medical potential of Brazil’s cord blood banking system and its inventory of donated cord blood is being squandered.

References:

1. Grupo Ibes. Anvisa publica dados sobre Bancos de Sangue de Cordão Umbilical e Placentário. (English: ANVISA publishes data on Umbilical Cord and Placental Blood Banks.) Notícias. Published 2021-07-19
2. Ministerio da Saúde. Relatórios de produção de bancos de sangue de cordão umbilical e placentário. (English: Umbilical cord and placental blood bank production reports.) Relatórios. Last updated 2022-09-13
3. Conselho Federal de Medecina. Brasil inaugura oitavo Banco Público de Sangue de Cordão Umbilical. (English: Brazil opens eighth Public Umbilical Cord Blood Bank) Notícias. Published 2010-06-08
4. Canal Saúde. Brasil terá mais cinco bancos de sangue de cordão umbilical até 2014. (English: Brazil will have five more umbilical cord blood banks by 2014.) Notícias. Published 2013-11-03
5. World Marrow Donor Association (WMDA) 2022 Annual Report.
6. Verter F, Woon J, Lai L. Cord Blood Utilization is Booming in China. Parent's Guide to Cord Blood Foundation News Published 2023-11
7. Finch-Edmondson M, Paton M, Webb A, Ashrafi M, Blatch-Williams R, Cox J, Charles, et al. Abstract 5. Umbilical Cord Blood Treatment to Improve Gross Motor Function in Individuals with Cerebral Palsy: Results from an Individual Participant Data Meta-Analysis. Stem Cells Translational Medicine. 2023;12(S1):S6.
8. Milano F, Gooley T, Wood B, Woolfrey A, Flowers ME, Doney K, et al. Cord-Blood Transplantation in Patients with Minimal Residual Disease. NEJM 2016; 375:944-953.
9. Metheny L, Politikos I, Ballen KK, Rezvani AR, Milano F, Barker JN, et al. Guidelines for Adult Patient Selection and Conditioning Regimens in Cord Blood Transplant Recipients with Hematologic Malignancies and Aplastic Anemia. Transpl. and Cellular Therapy 2021; 27(4):286-291.
10. Matsuda K, Konuma T, Fuse K, Masuko M, Kawamura K, Hirayama M, et al. Comparison of transplant outcomes between haploidentical transplantation and single cord blood transplantation in non-remission acute myeloid leukaemia: A nationwide retrospective study British J Haematology 2022; 201(1):106-113.
11. Zhou B, Chen J, Liu T, Zhang Y, Ye Y, Ding Y, et al. ASH Annual Meeting. ASH 2023 poster 1041. Haploidentical Hematopoietic Cell Transplantation Combined with an Unrelated Cord Blood Unit for Adult Acute Myeloid Leukemia Results in Improved Survival Compared to Haploidentical Hematopoietic Cell Transplantation: Results of a Multicenter, Randomized, Phase III Trial. Oral presentation 2023-12-11
12. Tavares RdCB, Bonfim CS, Seber A, Lermontov SP, Coulturato V, Zecchin VG, et al. Hematopoietic cell transplantation in pediatric patients with acute leukemias or myelodysplastic syndrome using unrelated adult or umbilical cord blood donors in Brazil. Pediatric Transplantation 2020; 24(7):e13789.
13. Dahlberg A, Kurtzberg J, Boelens J, Martinez C, Carpenter P, Tewari P, American Society for Transplantation and Cellular Therapy Cord Blood Special Interest Group. Guidelines for Pediatric Unrelated Cord Blood Transplantation—Unique Considerations. Transpl. Cellular Therapy 2021; 27(12):968-972.
14. Sociedade Brasileira de Terapia Celular e Transplante de Medula Óssea (SBTMO). Dados TCTH no Brasil 2008-2019 (English: HSCT data in Brazil 2008-2019)
15. Shaw BE. Related haploidentical donors are a better choice than matched unrelated donors: Counterpoint. Blood Advances. 2017; 1(6):401-406.
16. de Oliveira MLM, Tura BR, Leite MM, dos Santos EJM, Pôrto LC, Pereira LV, et al. Creating an HLA-homozygous iPS cell bank for the Brazilian population: Challenges and opportunities. Stem Cell Reports. 2023; 18:1905-1912.
17. Folha de São Paulo. Entrevista Vanderson Rocha. Clínicas vendem propaganda enganosa. (English: Interview Vanderson Rocha. Clinics sell false advertising.) Newspaper Published 2010-03-15
18. Ballen KK, Verter F, Kurtzberg  J. Umbilical cord blood donation: public or private? Bone Marrow Transplantation 2015; 50:1271-1278.
19. Fundação Hemocentro de Ribeirão Preto (Hemocentro RP). Ministério da Saúde libera R$ 100 milhões para estudo clínico com célula CAR-T. cell. (English: Ministry of Health releases R$100 million for clinical study with CAR-T cell.) Notícias. Published 2023-12-23
20. Horwitz ME, Stiff PJ, Cutler C, Brunstein C, Hanna R, Maziarz RT, et al.  Omidubicel vs standard myeloablative umbilical cord blood transplantation: results of a phase 3 randomized study. Blood 2021; 138(16):1429-1440.
21. Gamida Cell. Gamida Cell’s Allogeneic Cell Therapy Omisirge® (omidubicel-onlv) Receives FDA Approval. Press Release. Published 2023-04-17
22. NCT02730299. Stem Cell Transplantation With NiCord® (Omidubicel) vs Standard UCB in Patients With Leukemia, Lymphoma, and MDS. ClinicalTrials.gov