Navigating transplants in blood cancer: Dr James Morton’s guide for patients and families

[00:02:36] Kate: In this episode, our host, Maryanne Skarparis, sits down with associate professor Dr. James Morton for an in-depth look at bone marrow transplant in the treatment of leukaemia and related blood cancer. Dr. Morton shares what led him to specialise in transplant medicine and reflecting on the early experiences that sparked his interest in how donor immune systems can contribute to curing blood cancer. He explains the key considerations that are involved in assessing whether a patient is suitable for transplant, including things like age, overall fitness, and the risk of the cancer returning. Maryanne and Dr. Morton explore topics such as graft versus host disease, donor matching through HLA typing, and the advances in post-transplant care aimed at reducing complications. 

Dr. Morton provides valuable advice about fertility preservation before undergoing intensive therapies, and they discuss the emerging cellular therapies like CAR T-cell therapy. Throughout their conversation, they emphasised the importance of clear communication and support, not only for the patient, but also their families and carers navigating the complexities of blood cancer treatment and transplant recovery.

So, whether you are considering a transplant, supporting someone through this journey, or seeking to understand these treatments better, this episode offers essential insights into one of medicine’s most sophisticated treatments.

[00:04:07] Maryanne: Welcome to Talking Blood Cancer. I feel very excited today. I have here with me Associate Professor James Morton. Welcome, James, to our Talking Blood Cancer podcast.

[00:04:17] Dr James Morton: Thanks, Maryanne.

[00:04:18] Maryanne: In the month of May this year, we’re going to be looking at the topic of transplants in your role as a transplant physician. Can you tell me a little bit about what was your interest to step into that area?

[00:04:31] Dr James Morton: So it came back from my time as a registrar at the Royal Brisbane Hospital in the 1990s. And the Royal Brisbane had a transplant unit from 1988 and got me reading a lot of the literature about transplants. I think the thing that fascinated me about bone marrow transplants, which at that time were predominantly donor transplants that we were doing, was this idea that the new donor immune system may have this role in curing leukaemia. And I found that fascinating. And patients who otherwise eventually would have their leukaemia relapse and die could be cured with a bone marrow transplant, albeit with risks. And so that’s really where my fascination with bone marrow transplants began and why on finishing my training at the Royal, I went to Seattle to do a fellowship at the Fred Hutchinson Cancer Center in bone marrow transplantation.

[00:05:21] Maryanne: How wonderful, and aren’t we lucky that we’ve got brains like yours that can further study in that area because transplants have come a long way over the years, haven’t they?

[00:05:31] Dr James Morton: They have and they haven’t, I think what’s changed is that we are much better at doing them so that the toxicity is less. Back in that time, the age limit for a bone marrow transplant of that type so, and we’re talking about donor transplants here, I think it’s important to understand, the age limit back then was 40 to 45. And we’re now transplanting very successfully people who are 70 or 75 and sometimes even older. So the first thing that’s really changed is the age of the patients that make them eligible for these procedures. And I think the second thing that’s changed dramatically is donor availability. So in those days, the main donor source was a brother sister donor. Now, we have smaller families now so, on average, patients had maybe a 30 percent chance of finding a donor. The next step that happened was the use of unrelated donors, and we got very good at unrelated donor transplants so that the outcomes of unrelated donor transplants were similar to sibling donor transplants.

Now we’ve got the third step, which is what we call haploidentical transplants, which means a person’s children can be their donor or for a child, their parents can be a donor. And I think the fourth thing that’s happened is the era of what we call post-transplant cyclophosphamide. So for a long, long time, the traditional preventative strategy for graft versus host disease was with cyclosporine and we give four doses of methotrexate. The story of the timing of those methotrexate doses was fascinating and rather arbitrary because it was designed in such a way that in the original dog studies back in Seattle, because their model was the dog, that was where they did all their initial work. They didn’t want to come in and give doses on the weekend. So there are all these kinds of historical things that have stayed on. But anyway, largely, that’s been replaced by post-transplantation cyclophosphamide, which has allowed us to broaden our donor pool even wider. We’re starting to almost look at going the full step, where if you’re 60 and your sibling’s 60 and you’ve got a child who’s less than 30 or an unrelated donor less than 30, they may be the preferred donor because the donor age is now emerging as one of the most important variables on outcome.

That is, we’re much better off having a young donor than an old donor. So from where we would only do sibling transplants back when I started, we’re now sort of evolving into the situation where we have donor choices, and we can look at other variables to optimise the outcome, such as the age of the donor, because often now we’ve got more than one donor option available to our patients.

[00:08:04] Maryanne: Can I just ask you to explain that a little bit, I loved how what you’ve just shared there, but for the layman, when you have in front of you a patient who has an acute leukaemia or is requiring a bone marrow transplant, what are the physical reasons that make them eligible for transplant in the first place and then what are the considerations? I know you’ve captured that very quickly. But what are the key considerations in an approach to next steps with regard to trials and actualists?

[00:08:37] Dr James Morton: I think the first decision is always the patient and the patient’s disease. Now back in the 1990s, acute myeloid leukaemia, as an illustration, all we really had available prognostically was the cytogenetics and patients would fit into three groups, good, intermediate and bad risk, and that’s their risk of it coming back. And the people with good risk disease, we wouldn’t recommend a transplant for them unless their disease were to come back. People with bad risk disease, we would recommend a transplant as soon as they were into remission. And there was always debate about the intermediate risk group and judging risks and benefits, because a transplant carries risks and I’ll talk about those in a moment. 

[00:09:16] Maryanne: Good.

[00:09:17] Dr James Morton: What’s happened now is we have much more information about different leukaemic types because of the improved genetic analysis that we can do at the point of diagnosis. We also now have tools to evaluate minimal residual disease (MRD). So, the first step is deciding, does a patient need a transplant now? Or are we going to try and cure them with the chemotherapy because their genetics point to that possibility? Or are we going to treat them and monitor MRD and do the transplant if the MRD starts to go up? So that’s evolved a lot and that’s deciding whether a transplant is needed. 

The second thing is, we have to look at the age and fitness of a person. So currently where we sit at the moment is if someone’s under 70, this is the Royal Brisbane, it will be different in different transplant years, but if a patient’s under 70 and has a reasonable disease of fitness and they have a donor, a good indication we’ll accept them for a transplant. Between 70 and 75, we make a slightly different decision based on scores that predict the risks of complications of the transplant, and that’s under review. So you’ve got to look at the fitness of the person, the organ function of the person, the infection history of the person, and evaluate what are the risks versus the benefits of a transplant. And I just want to go back to a little bit about the risks. 

[00:10:36] Maryanne: Good.

[00:10:36] Dr James Morton: So when we have a lung, or a heart, or a kidney transplant, we’re worried about the person rejecting the new organ. However, when we have a bone marrow transplant, it’s the other way round. We’re worrying about the new organ, which is the new bone marrow, rejecting the patient. And that’s because when you have a transplant of bone marrow, you also acquire that person’s immune system. And that immune system, when it starts growing inside you, can recognise you as foreign and attack you. And that’s called graft versus host disease. 

[00:11:07] Maryanne: Okay.

[00:11:08] Dr James Morton: And one of the amazing things that’s been found over the years is if people get a little bit of graft versus host disease, their risk of the leukaemia relapsing after the transplant goes down. It would be lovely if we had a dial, and people have tried various techniques to create dials over time. And our techniques to create dials remain very suboptimal. 

But the transplant has risks because of that rejection process from the new immune system on the patient, and that’s called graft versus host disease. Anywhere between 30 and 50 percent of patients will develop graft versus host disease, depending on matching and many other factors. And those people who do that, the majority, we can turn that off with drugs that suppress the immune system, but that creates risks of infection. So when we see a patient for a transplant, we’re looking at the disease they have, what’s the chances that it can be cured, what’s the chances that it will relapse, and what are the chances they’ll have an adverse outcome from the transplant. And we take all those variables in together to determine what’s the best recommendation for that person in terms of the timing of the transplant. Is it a now thing? Is it better off to see if we can fix their leukaemia with treatment and defer the risks of a transplant?

[00:12:25] Maryanne: With time considerations, James, is that always available to people like yourself, specialists, or when you are making a decision with regard to looking at the many variables, is there a time urgency?

[00:12:38] Dr James Morton: If there’s a time urgency, that generally means the person’s got limited time before their leukaemia comes back, and so we’re wanting to get on with that person’s transplant. But in people where this is their chance of being cured without a transplant. This is their chance of being cured with a transplant. This is the complication risk. This is where balanced decisions are made. And we have a lot more information now available than we did in the 1990s to help us in our communications with the patient determine what’s their best approach in going forward.

[00:13:08] Maryanne: Okay. Good, from my perspective, I’ve seen the introduction of haplo’s a lot more of recent times. Can you talk a little bit more about, I know you quickly touched on haploid and what are the considerations there?

[00:13:21] Dr James Morton: So I think the best way to explain that is how do we choose a donor. So we do tissue typing, which looks at various genes that we have and looks for a match with our donors. That’s called HLA typing and we now do that at a molecular level to try and identify the best match of donor. Now for a brother or sister, we can do that at a lower level, but for an unrelated donor, we do it at a molecular level, and that’s how we identify the best donor for a person to have a transplant. And if they don’t have a compatible sibling, and they have a rare tissue type and often that happens with people from particular ethnic backgrounds, to give an illustration. Say you’re from Fiji, but your mother’s Fijian Indian, and your father’s Fijian Polynesian. That brings together mixes of different HLA but also haplotypes. So the haplotypes follow the ethnicity, so where you have an unusual ethnic background, it can be quite hard to find a matched donor on the registry. 

And so, we used to say for a caucasian person, about 70 percent could find a donor on the registry, but for other groups, and particularly of mixed ethnicity, it was much harder to find a donor. Now, that was based on full matching. What has now happened is that they have been able to do half-matched transplants, so with a much greater degree of mismatching. The greater the degree of the mismatch, the more likely the new immune system is going to grow in your body and recognise you as foreign. And so, much greater risks of graft versus host disease. But some groups in America started working that by giving a few days after the transplant a high dose of cyclophosphamide. And the idea was that when you gave back the marrow or stem cells, and we probably need to explain to your audience peripheral blood stem cells versus marrow, but when we give back the donor cells, cells capable of recognising the patient will get excited and start to grow really fast. And that makes them very sensitive to a whack of the cyclophosphamide because that’s a chemotherapy agent that hits lymphocytes, particularly dividing lymphocytes. So those donor cells capable of recognising the patient and targeting them get killed selectively by that big dose of cyclophosphamide afterwards.

And so from moving from the old-fashioned preventative strategies of cyclosporine and methotrexate to this high-dose cyclophosphamide has meant we’re able to overcome that barrier of mismatch. And so we’re able to transplant people across the mismatch because of that technique. And that’s meant we’ve been able to do haploid transplants. We’re also much more safely able to do mismatched unrelated donor transplants where there’s small disparity between the donor and the patient. So it’s broadened the donor pool to the point where virtually everyone has a donor. And there may be subtle differences in outcome with different donor choices, but the outcomes are pretty similar now, whether you have a brother, sister. You have a matched unrelated donor, you have a mismatched unrelated donor, or you have a half-matched family member. And that essentially means we have much greater options for our patients who need a transplant. And that’s why you’ve seen this emergence of haplo transplants.

The other reason is that point you made of time. Now let’s say you’ve got a disease where there’s a limited window of opportunity to do the transplant while the person’s still in remission. It may be that you’re able to get a haploid donor because it’s one of your kids, you can twist their arms, inheritance is on the line, you’d be able to get that donor much faster than you can get a registry donor. That’s why we’ve seen this proliferation now of this choice of a haplo donor, because these new techniques have meant the outcome is very similar to a brother sister or matched unrelated donor. And as I’ve said, it’s now got to the stage where the selection may well start to look at what’s the youngest donor we’ve got, because age is increasingly an important variable in terms of outcome, now that these newer techniques are available.

[00:17:28] Maryanne: So in that space of post-transplant, is there anything that you’d like to share that you feel the listeners might benefit from with regard to their anxieties in conversations in having haplo unrelated match?

[00:17:44] Dr James Morton: The first thing I want to just talk about is bone marrow and stem cells, if I can just address that question because it confuses people. Now in the old days, the way we used to collect the bone marrow from the donor is we would take the donor to theatre, and we would harvest a litre to a litre and a half of their bone marrow to give back. And then in the 1990s, we started using growth factors. So that’s the GCSF, and we would give the donors GCSF, and the GCSF would mobilise those cells from the bone marrow into the blood. And then we could collect those cells by washing the blood. And we call that a peripheral blood stem cell transplant. When we do a bone marrow transplant or a peripheral blood stem cell transplant, we are doing a transplant of bone marrow stem cells. So they are the same thing. There’s some differences in them around the type of cells that are there, but the fundamental idea is this is a transplant of bone marrow stem cells. It also includes the donor’s immune system. So just to clarify for that for people, because they get concerned that they’re having a bone marrow, not a stem cell transplant, or having a stem cell, not a bone marrow, they are essentially the same thing. It’s just how we collect those bone marrow stem cells. That’s the first thing. 

Now, the second thing, and Maryanne, we badly need to update this, but many years ago, we did a talk and we called it The Nuts and Bolts, and there’s a video of it on YouTube, and it needs to be updated. But it’s a really neat video, and as part of all my patients’ consent processes, I get them to go and watch that video, because it explains to them the transplant process. And it has some interviews from some patients who are now much older than they were when they did that. I think it was 2008 or 2009 that we did that. And it’s just a really good way to go over the process of having a transplant and what’s involved. So that you understand the stages and very importantly, your family understands the stages because it is a procedure that has risks.

You do get conditioning therapy, which is the drugs we give before the transplant and the conditioning therapy has two purposes. It’s to try and diminish the leukaemia to the lowest possible levels and it’s to suppress your immune system so you don’t reject that new bone marrow coming in. You then have a period of time before those stem cells start to grow, so during that time blood counts can be very low, and you can need transfusions, just like your leukaemia treatment. You can get side effects on other parts of the body, because the conditioning therapy can have effects on the lining of the mouth, or you get a sore mouth, a sore gut, that sort of thing. And then, around that two week point, the blood counts start to come in and all those things get better and then you enter the phase of risks of graft versus host disease, where your treating team will monitor you very closely for that, and if you develop features of graft versus host disease, they might do some diagnostic tests to confirm that. We’ll start you on treatment accordingly, and then you get out of hospital, followed as an outpatient. 

Traditionally, we follow patients locally for around the first 100 days, and then after that, they go home and may come back to the hospital. We’ll see them over the internet or through their local doctor. 100 days comes from the time when there were very few transplant units around the world. So people would travel all over the world to Seattle, for example, to get their transplant. They knew at that time that once you got through that first hundred days, your risks of acute problems diminished, and so it was safe to return home. But graft versus host disease can be an acute and chronic thing, and there are people who are long-term survivors who have significant complications as a consequence of that graft versus host disease. So it’s very important to be fully informed and it’s very important for your family and your friends to be fully informed about what’s going on and that there are risks, but this is my chance of a cure. That’s why we do it.

[00:21:26] Maryanne: Absolutely, people who will be attracted to listening to this conversation, James, often will ask for, and I did reach out to one of our haematology nurses who is in the transplant section down in Tasmania to just ask her, what did she feel were some, key questions that she often gets in that space.

[00:21:44] Dr James Morton: Depending on their disease, their conversations would’ve been held fairly early in the piece regarding the treatment of their disease. So whenever I’ve got a young male patient who I’m treating. It’s one of the first questions we talk about it. And in fact, any male patient is, do they want to preserve their fertility? Do they want to have their sperm stored? So for example, today I started a young fellow aged 30 on treatment for lymphoma with CHOP. Now probably not gonna affect his fertility, but we discussed banking of sperm. So any male patient that discussion should be had fairly early, whilst things are still viable. Now, when you’ve been sick with one of these diseases, you don’t always have the greatest viability of sperm. But we should always make the effort to bank sperm before we commence treatment if the patients want to preserve their ability to have a family. 

The second comment I make to these young fellows is don’t assume that the treatment we’re doing is rendering you aspermic and that you don’t need to use contraception because, you can get caught out. Because the treatments don’t always, render you infertile. In fact, the younger you are and the less intense treatment, the more likely you are to preserve your fertility. And fertility, it can recover a period after treatment. Now, a transplant is different because it’s a more intensive regime. The likelihood of maintaining fertility after a transplant is much lower, so one should again try and collect sperm there prior to it if they’ve not had sperm collected beforehand. Though, that may be impacted on the ability to collect it based on what treatment they’ve had before.

[00:23:17] Maryanne: Do you find that those conversations are mainly with just the patient or do you include a spouse or a partner?

[00:23:27] Dr James Morton:  It’s very dependent on the age of the patient and the relationships they’re in. If you’re dealing with a young fellow, often his family will be involved. If it’s a fellow in a stable relationship, partners will be involved. Really it’s dependent on the individual and the relationships they have at that time.

[00:23:42] Maryanne: Is there a cost involved?

[00:23:44] Dr James Morton: No, the fertility services are really, really good in this space and they’ll generally provide the service for us very rapidly. And they’re very protective of people’s costs given the other things that they’re going through.

[00:23:57] Maryanne: Oh, that’s good to know. That’s good to know.

[00:23:59] Dr James Morton: I found the IVF providers fabulous in this space.

[00:24:03] Maryanne: Oh, that’s good. Yeah. So how do you manage the fertility of someone, of a male patient?

[00:24:09] Dr James Morton: The other thing we do is that once they get out through their transplant and they’re a year or two down the track and they’re in a situation of wanting to investigate starting a family. We’ll generally check the viability of their sperm at that time because it may recover, and so they may not need to use stored sperm if they’ve recovered after their transplant.

[00:24:25]  Maryanne: Are there any implications in using sperm?

[00:24:29]  Dr James Morton: No.

[00:24:30] Maryanne: So, we’ve talked about the male. What about a female who’s, is that a more difficult conversation to have?

[00:24:36]  Dr James Morton: Well, it’s not more difficult conversation. It’s a more complex process. So I’ve recently looked after an 18-year-old with acute lymphoblastic leukaemia and a 19-year-old with a primary mediastinal B cell lymphoma. And for both those young people, we deferred their treatment for a week or two whilst their eggs were collected. 

[00:24:55] Maryanne: Okay.

[00:24:56]  Dr James Morton: So again, the IVF people are incredibly helpful. They see them, I’ve seen a patient on Friday for their diagnosis. The IVF people have seen them on the Saturday. We give them a bit of covering steroid or something very gentle to control their disease process so those eggs can be stored. Again, it’s a bit like the situation with the boys in that you really want to get in very early. Where feasible and where the disease permits. Again, remembering that not every treatment renders patients infertile. For example, a very common situation is a young woman with Hodgkin’s disease. Now we know the fertility rate after ABVD is the same as the fertility rate of the general population.

[00:25:37] Maryanne: Okay.

[00:25:38] Dr James Morton: But, we will generally offer collection of eggs in that situation nonetheless. Okay.

[00:25:46] Maryanne:  So with the female, when they get to the decision in their life that they wanna pursue a family. Are there any detriments or things that you need to be aware of or that you look for prior to them participating, ’cause I would imagine with IVF, they have to have certain stimulating factors, does that implicate their disease?

[00:26:07] Dr James Morton: No, it doesn’t. But generally you’ll be, you want a time interval after the transplant regarding their remission status. Being in remission for a period of time, it’s often around two years that you try and encourage people to wait. Because pregnancy does have an impact upon your immune system. So I mean, you’ve got a baby inside, that’s a foreign thing. The immune system has to adjust accordingly so it doesn’t reject the baby and there have been cases of disease relapse during pregnancy in someone who’s had a transplant. So you generally delay it for a good period of time. So for a lady, you want to wait a certain period after the transplant or the period of treatment of their primary disease. Just to establish their remission duration, their likelihood of cure, before you have a pregnancy and potentially modulate the immune effects that operate in the setting of a transplant.

[00:26:57] Maryanne: Right. So tell me what other things do you feel that is necessary within this conversation when we are looking at transplants that we need to be mindful about with fertility.

[00:27:08] Dr James Morton: Just it’s a very clear discussion. Everyone understands we do everything to preserve fertility. Noting that transplantation will impact upon the fertility of the majority of patients, but not all. That at the time, they want to start a family check where their fertility is at, it may have been preserved and make sure as much as possible, you put insurance policies in place beforehand.

[00:27:29] Maryanne: Yeah, that’s very good points, James. Have you ever come across a situation when their diagnosis has been so sudden that these things haven’t been able to be put in place?

[00:27:39] Dr James Morton: Correct. Yes. That happens. And again, you have to have that discussion with the patient. I can well remember another lass with primary mediastinal B-cell lymphoma, who had very unusually had Nephrotic syndrome. She was 20 or 30 litres fluid overloaded. We couldn’t wait the week or two. And we got fertility people actually visited in the hospital, had a discussion of the pros and cons, and she made an informed decision to get on with her treatment. And her fertility recovered. But wherever possible you preserve that option. But there are some situations where you can’t.

[00:28:09] Maryanne: Where you can’t. Okay.

[00:28:11] Dr James Morton: And then you know, there are the other ways of IVF down the track that can support people caught in that situation, so they can still become a parent.

[00:28:18] Maryanne: Yeah. And that’s exactly right. And we’ve both seen that happen.

[00:28:22] Dr James Morton: Managing the disease and giving them their best chance of curing them of their blood cancer is the number one most important thing at that time.

[00:28:31] Maryanne: It’s the priority.

[00:28:32] Dr James Morton: Yes.

[00:28:33] Maryanne: Yeah. Thanks James. Thanks for just capturing that. Cause I do think it’s important to look at the whole person. Where yes, you’ve got the disease, you’ve got a blood cancer, but you also have a life and you’ve got opportunities and, you know, keeping those doors open to future planning.

[00:28:48] Dr James Morton: Absolutely right.

[00:28:50] Maryanne: Is there any advice that you’d like to give for our post-transplant recovery?

[00:28:55] Dr James Morton: I’ll usually say to people that they’re going to be in hospital for four to five weeks. When they get out of hospital, they’ll be functioning at 70 to 80 percent of normal. That will gradually improve depending on complications they get. By three months, if they’re going well, they’ll be functioning at 90 percent of normal. That’s when we release the hospital’s hold on you a little bit and you start to go back to your normal life. And many people recover fully at between six and 12 months after the transplant when we start the revaccination, if they don’t have problems with graft versus host disease and the long-term effects. But there, there are definitely a small group of patients who have long-term impact upon their function because of those complications, but it’s a small number. 

[00:29:38] Maryanne: It’s a small number. That’s been really helpful because it’s an intense area. So future of transplants, is there anything you’d like to share in that space? We’ve touched on the match unrelated and the autos.

[00:29:50] Dr James Morton: I think. What we’re now moving into is the era of cellular therapy. Cellular therapy is where, I think, its simplest way of explaining to people is cellular therapy is where we try and manipulate a person’s own immune system to replicate the graft versus host disease effects on stopping the cancer coming back again. 

[00:30:10] Maryanne: Okay.

[00:30:11] Dr James Morton: So the idea of cellular therapy, which is very exciting, is that we take a person’s leukaemia or lymphoma and we find a protein on the surface of their cell that’s relatively unique. And we then insert a gene into their immune cells so their immune cells can then go and recognise that, bind to that cell and kill it. Now, this technique’s been in operation now, for about 10-15 years and the numbers have dramatically increased over the last five years, particularly in lymphomas extending into myeloma shortly. And really it’s an area of research to find out what other tumours that we can target through this new effect.

So this is the era of cellular therapy that we’re just starting. And I think it’s an area that’s very exciting. Because it’s a reprogramming of your own immune system, you’re trying to have your immune system capable of killing the cancer. But in contrast to a bone marrow transplant, you don’t have the risk of that immune system attacking you because it’s your own immune system. So we’re trying to get the immune system to do the job that a donor’s immune system does in a bone marrow transplant from a donor, but by reprogramming a person’s own immune system. 

So I guess that’s the exciting area that we’re just seeing evolve. And currently, for that treatment, we have to collect the cells here, send them over to America. They get manufactured in America and sent back. I mean, I’m super proud of what the Royal Brisbane team has done under Siok Tey’s direction, where she’s manufactured her own in-house, we call that sovereign manufacture. I think it’s very important for the future that programs like what she’s developed there are expanded upon because it’s a lot cheaper and we can invest any profits back into research in Australia and aside for your patients.

But I think this is such an exciting area of the real concept of immunotherapy, but actually re-educating our own immune system to target our blood cancer. So we’ll see how that goes. I think there’ll still be a role for donor-based transplants for a long time to come. But I do think there will be emerging indications where we may follow the choice of CAR T-cell therapy for a person rather than necessarily the risks associated with a donor-based bone marrow transplant in the future.

[00:32:22] Maryanne: And as you said earlier, it all depends on so many variables, doesn’t it? Which pathway the patient is suggested to go to. 

[00:32:29] Dr James Morton: Yeah.

[00:32:29] Maryanne: What do you think ignited you when you first started medicine? This is a bit of a personal share, James. Can you remember the turning point when you felt that, okay, or was there an epiphany where you thought haematology is actually where I need to immerse myself.

[00:32:42] Dr James Morton: This is the sort of question you can definitely ask a doctor at 62 years of age when they’re entering that sort of back end of their career and starting to get forgetful and not able to remember why they did haematology. So I had a part-time job from the end of grade 12 ask where I work in an immunology lab.

[00:32:57] Maryanne: Okay.

[00:32:57] Dr James Morton: So over the Christmas holidays, I’d work in an immunology lab and it fascinated me when I would go to the meetings where the haematology registrars would show their slides of leukaemia and then the immunologists would report the flow cytometry. The cytogenetic people would report the cytogenetics and it just fascinated me that you could actually see the leukaemia there in a meeting, and all these other things. So, one of the really attractive things about haematology was that we treated people, but we also could see and look at the disease as part of the monitoring process. That was the first thing. 

And then, I did a term in emergency in my first year as an intern. And It was 1988 there was a particular lass that came in and she was a young lass of 18. And she’d been working at Expo and she had a life ahead of her and she came into the emergency department that night with a cough. We did a chest x-ray and she had a huge mediastinal mass. 

[00:33:46] Maryanne: Wow.

[00:33:47] Dr James Morton: And it turned out that she had Hodgkin’s Lymphoma. I was still a first year, but I followed this girl and got to know her family. And very sadly, she died. And that would be a very unusual thing these days, because our cure rate is very high. But I think that just kind of solidified things for me, that’s what I wanted to do. So, it was those experiences through university. But I’ve always remembered that young lady coming through the emergency department that night, and then her subsequent journey.

[00:34:11] Maryanne: It is often pivotal moments in life that do attract us to different things. And so over the years, as you immerse yourself deeper into the pathway of haematology and then transplants. Not every haematologist either takes up to be a transplant physician. Do you remember, was it your studies in Seattle that led you to want to go down that pathway or?

[00:34:30] Dr James Morton: I think the beauty of haematology as a career is you can go different ways. So you can be a lab haematologist, you can be a non-malignant haematologist, you can be a malignant haematologist, you can be a transplant haematologist. And some people do them all. Okay. And we’re all trained in doing them all. So I think haematology is a brilliant career to do. The malignant side of haematology is very testing because you have people in very difficult situations. And when they’re sick, you’re on call and can be very hard, but it can also be very rewarding because you see those patients and their families a lot and you get to know them very well. So it’s very different from the six-monthly or the twelve-monthly consult and you have very memorable patients. And your patients come back to see you when they’re well, and they’ve got on with their life and you’ve known them. And I’ve got patients who I saw just when I went into private practice in the late 1990s when they were diagnosed with polycythemia and then they evolved into myelofibrosis and then they started to accelerate. Had their transplant and now they’re better after their transplant off their immunosuppression and fully recovered. And I’ve had the fortune of looking after them through that whole journey. 

I had one such lady in seeing me just yesterday in her checkup five or six years after the transplant. So I’ve looked after her for almost 30 years. That’s a really special thing as a doctor and the transplantation stuff was very much born out of working with Simon Durrant as a registrar back in the 1990s. That led me to want to go to Seattle. I self-funded to go to Seattle and live there for a year and a half. The Leukaemia Foundation gave me a grant which I’ve never forgotten, buys loyalty forever. And then came back at the Royal, and still am at the Royal. I think I’ve worked at the Royal now since 1988, it’s a very, very long time and private practice, which I’ve greatly enjoyed. I’m very pleased the choices that got made. I didn’t know what I was doing back then, but I’m looking back I’m very happy.

[00:36:20] Maryanne: Well, you’re fulfilled, aren’t you?

[00:36:22] Dr James Morton: Yeah, very much so.

[00:36:23] Maryanne: Very fulfilled. It’s a passion of yours and it’s a privilege.

[00:36:27] Dr James Morton: I’ve been doing this now for a long time, but. I still remain very enthusiastic and very interested and I’ve had some great role models over the years and I think back to the founders of the Leukaemia Foundation. So, Trevor Olsen and Ian Bunce, Trevor and Ian were role models for many things I’ve done. My office next door is Kerry Taylor, who’s been a huge haematologist for such a long time. And these are great people who I’ve got to know and work with over that time.

[00:36:54] Maryanne: It’s wonderful. Lovely privilege for you, James. With that opportunity to be in a relationship with a patient for over an extended period of time and support them with a broad range of options with regard to treatments. Do you find personally it hard if you find one of your patients who you’ve exhausted treatment options? And you’ve had this long-term relationship, do you find it difficult to then transition to the palliative care team or?

[00:37:20] Dr James Morton: So Maryanne, I don’t. And part of your job as a doctor is to facilitate the very best care and support of your patients for their best lives. And what defines that best life at different times can change. And so following that journey, and when you get to the point in the journey where there isn’t anything to do ensuring their dignity and their comfort and all that is very much part of what they ask us to do when they sign up to be looked after by them. And I don’t know that many doctors will listen to this, but I think that is part of the service that you offer. That’s part of your responsibility to your patients. I guess if you get very emotionally attached, you can’t do these things properly at times. So, that’s part of being professional and it’s part of providing that person with the most dignified pathway through their journey is very important.

[00:38:07] Maryanne: The other question that I will ask is, have you ever found yourself in a situation where you’ve had the care and the family members wanting to take a pathway of transplant because they can see that everything you presented is of value and holding on to hope, yet the patient is apprehensive. What is the messaging that you offer in times like that to try and comfort the patient to make the decision to embrace transplant.

[00:38:34] Dr James Morton: Oh, I think the decision is the patient’s decision and you’ve got to provide them with information so that they can make the best informed decision for them. Now, that’s not always the decision that others want. But it’s their decision. And I think that it’s very important that situation for everyone to understand what the offering is, what the risks are, what the complications are, so that they all have an understanding of why their loved one is making a particular decision. But that will always be the decision of the patient. You’ve just got to arm them with the right information so they can make an informed decision for themselves.

[00:39:05] Maryanne: Yeah. Good point. I love that you still use the Nuts and Bolts.

[00:39:08] Dr James Morton: Yeah, I do. It’s part of consent for everybody, but it really needs to be updated.

[00:39:12] Maryanne: It does need to be updated.

[00:39:14] Dr James Morton: And it’s got a very good framework for it. Whenever I see a new patient for a transplant, I go over everything, but I say, I get them to go home. What’s the nuts and bolts and bring back questions a week later from that video. And I think it’s a very important part of the consent process ’cause they’ve got time to digest and think and they can watch it many times over.

[00:39:31] Maryanne: Absolutely. Well, it’s a resource, isn’t it? And it is all about timing. So when people choose to open up, learn, listen, all of those sorts of things. For people who are just listening to this conversation, because we have many followers on Talking Blood Cancer. And so if you had three questions that you would encourage patients to ask, what are three considered questions that you feel. Because remember that we’re a national organisation.

[00:39:56] Dr James Morton: Yeah. So, I think the first question is, do I need a bone marrow transplant and why?

[00:40:00] Maryanne: Yes?

[00:40:01] Dr James Morton: I think the second question is, who’s the best donor for me? And I think every patient needs to leave the interview knowing what their chances are of being cured with that transplant versus the risk of complications. But those to me are the most important things.

[00:40:16] Maryanne: And would you give reassurance about those risks of complications?

[00:40:19] Dr James Morton: Yeah but at the end of the day, very important that people know, and it’s very important that they understand that it is a process with risks and some people get very sick and occasional people never leave hospital. And so we don’t want anyone going into a transplant, unaware that things can happen that are very unpleasant, not nice. And it’s uncommon, but it can happen. And it’s very important that they understand that. And it’s very important that their family understand that they understand that in their decision making.

[00:40:44] Maryanne: Thank you, James. Thanks for again giving us time here at the Leukaemia Foundation to share your knowledge and expertise. I really value what you’ve shared here this afternoon.

[00:40:54] Dr James Morton: A pleasure.