If cord blood stem cells are the future, why aren't we saving them?

This week saw the long awaited report from the Royal College of Obstetricians and Gynaecologists (RCOG), which stated its latest position on the public and private banking of umbilical cord blood stem cells. Essentially, their stance remains unchanged from the one taken in their previous opinion paper published in 2001. The RCOG stands firm in its decision not to support commercial storage where no history of medical illness exists, but continues to back both public donation to banks such as the NHS Cord Blood Bank for non-directed use and directed donations for at-risk families. There are, however, currently only two active public banks in the UK. Given the medical advancements that have been made within the stem cell field over the past 20 years, the time has now come for the NHS to consider an improved funding infrastructure to secure access to all, says the RCOG.

Stem cells from umbilical cord blood (UCB) have been used since the first successful transplant in 1988 on Matthew Farrow, a five- year-old boy who suffered from Fanconi's Anaemia. Medical experts carried out the procedure at a hospital in Paris using the stem cells harvested from the cord blood of his newborn sister, Alison. This was to become the first of over 6,000 UCB transplants worldwide, treating disorders such as thalassaemia, immunodeficiency, inherited metabolic diseases, aplastic anaemia and acute leukaemia. Today, Matthew remains durably grafted and living proof that UCB has enormous future potential.

Cord blood advocates are keen to point out the benefits of using UCB for transplant purposes as an alternative to the traditional method of bone marrow. Unlike its bone marrow counterpart, UCB stem cells need not be an exact match and are less likely to be rejected by the recipient. Cord blood is a readily available resource, collected at the moment of delivery without pain or relative risk to mother and baby. Furthermore, stem cells collected from this routinely discarded waste product fail to raise the same moral, social and religious objections associated with the procurement of stem cells from aborted foetuses and embryos created via assisted reproductive technology. So, what reasons are being given for ignoring a resource with such great potential?

Within the public sector, the logistics of collection from multiple hospitals and subsequent cost implications involved in collection and storage are obvious reasons given against routine collection, which would inevitably draw heavily on an already cash-starved NHS. With regard to the private sector, many legal and ethical issues are raised. In spite of its potential, the RCOG purport that there remains insufficient evidence to recommend UCB collection in low-risk families. Expectant families are targeted by the use of emotive advertising literature in maternity clinics and the Internet. Critics of commercial banking argue that the costs of this service, which fall in the region of £1,200 for a 15-20 year storage term, are out of proportion in terms of the odds associated with their potential future use, currently estimated at between 1 in 20,000 and 1 in 2,700 for personal use. Furthermore, personal banking may not be deemed necessary for certain conditions as alternative resources may be available from UK and international public cord blood banks and bone marrow registries. Critics also argue that personally banked UCB may contain disorders already present in the patient at birth, but as yet undetected, and the low number of cells within a unit means they may only be used at present for transplants in children and young adults. Concerns over storage conditions and longevity of the cells are also raised.

NHS Trusts within the UK have been advised by the RCOG and the Royal College of Midwives that they do not support this practice for non-indicated patients, and that each Trust should develop its own policy on how to respond to such requests from patients. It is feared that Trusts may be subject to liability claims where the collected unit is insufficient in quantity, contaminated or mislabelled and staff may be exposed to needle-stick injury. Furthermore, the collection process, which takes place in the third stage of labour, may compromise the needs of mother and baby post-partum and other patients within the labour ward. To this end, the NHS Litigation Authority has advised that they will not provide an indemnity under the Clinical Negligence Schemes for Trusts if staff undertake this procedure.

Although opinion remains divided over the need for parents to privately bank their baby's cord blood, those on either side of the debate agree on one thing - stem cells are the future - and, in particular, UCB stem cells show great promise. Until such time as the Government fully responds to the RCOG's calls for the sufficient funding and expansion of public banks, private companies can hardly be criticised for providing a service where an alternative fails to exist.