09 Sep 2026

A Second Chance at Life

A blog series: The evidence behind the change

A second stem cell transplant can offer some patients another chance at survival after if their disease returns after the first. However, under a 2017 NHS policy, access is restricted by strict eligibility criteria, including a requirement that relapse occurs more than 12 months after the first transplant. Below we will explore this policy and the question of why some patients might not receive a second transplant? And in turn explore the significant advances in transplant medicine since then, and why many believe these rules no longer reflect modern clinical practice.

Part 2:

By Dr Heather A. Damian, PhD  

In our last blog, we explored why some people might need a second allogeneic stem cell transplant (HSCT2), we outlined the current NHS England policy, and highlighted growing concerns that the existing 12-month eligibility rule no longer reflects modern clinical practice.  

We also touched on how transplant medicine has advanced significantly over the last decade, with improvements in donor matching, supportive care, disease monitoring and a better understanding of which patients are most likely to benefit from a second transplant. 

Here, we will take a closer look at how approaches to HSCT2 differ internationally and what the latest research tells us about outcomes, patient selection and evolving clinical practice. And why patients deserve decisions based on today’s evidence; not yesterday’s rules. 

What has changed since the NHS policy was introduced?

When NHS England developed its current policy in 2017, advocated for at the time by Anthony Nolan, it was based largely on evidence reviewed in 2015. Since then, a much larger and more modern body of evidence has emerged. 

Over the past decade, numerous international studies have demonstrated that outcomes following HSCT2 have steadily improved, reflecting advances in transplant techniques, donor selection, supportive care, measurable residual disease (MRD) monitoring and more personalised patient selection.[i,ii] 

Across adult patient groups, recent evidence shows survival rates of approximately 30–40% in carefully selected patients, with outcomes continuing to improve year-on-year [i,ii,iii,iv]. This shows that around one in three carefully selected adults now survive long-term after a second transplant. While it isn’t the right treatment for everyone, it can offer something no other treatment can: a genuine chance of long-term survival. 

For people with relapsed acute myeloid leukaemia (AML) and acute lymphoblastic leukaemia (ALL), a second transplant can represent a potentially curative option and, in some cases, act as a bridge to additional curative therapies such as CAR-T treatment [ii]. For patients with AML, this is particularly crucial, as following a relapse these patients can be left without any other viable treatment options.  

For patients like Ruth Wake, this policy has already had devastating consequences. After relapsing nine months after her first stem cell transplant for AML, Ruth, 58, was told that because of the NHS England policy, once her temporary treatment stopped working, she would go into palliative care, despite her clinicians believing a second transplant was worth pursuing. It soon became clear there were no exceptions and no appeal process.  

Speaking on the decision, Ruth said: “Even a convicted murderer gets a right of appeal and I get nothing. The decision was made by people who never even met me, they were just going on historical data that I subsequently found out had been drawn up in 2017. I also discovered that there was new research since that time indicating that second transplants had a higher chance of working than previously believed.” 

Determined to fight for change, Ruth worked with her MP, Sir Gavin Williamson, while Leukaemia UK, Anthony Nolan and DKMS pressed those with the power to make change happen in England for an urgent review of the national policy. 

Despite this, Ruth had accepted nothing would change in time for her, so she started the process to secure funding from her company medical insurance to pay for a second transplant privately at the Royal Marsden in London.  

Ruth underwent the transplant in January 2026. The treatment was successful and she is currently recovering. Ruth continued: “To be given the news you’ve relapsed is bad, but then to find that decisions have been made on data that is way out of date and not reflective of today’s patient doesn’t make sense. I know there are no guarantees that my leukaemia won’t come back again, but this gives me extended time with my family when otherwise I would have had nothing.”

So, what is important in a second haematopoietic stem cell transplant? 

From all the evidence a clear consensus can be drawn that successful outcomes are influenced by a combination of clinical factors rather than by one fixed time point. 

Studies consistently show that patients are more likely to benefit from a second transplant if: 

• They are in remission at the time of transplant,  

• They are physically well enough to tolerate treatment,  

• They have favourable disease characteristics. [ii,v]  

Although a longer interval between first and second transplant is associated with better outcomes, evidence suggests there is a sliding scale of risk, rather than a sharp divide at exactly 12 months. [ii,iv,v]

In other words, there is little evidence to suggest that a patient who relapses at 10 months has fundamentally different prospects from someone who relapses at 13 months. Previously we touched on how tools such as MRD, donor lymphocyte infusion (DLI), maintenance therapies, targeted treatments and CAR-T therapy are further improving long-term survival for many patients.[vi] 

This shows how transplant practice has evolved substantially since the NHS policy was introduced in 2017 and supports moving towards a more personalised, evidence-based assessment rather than relying on a fixed 12-month exclusion criterion. 

At the heart of this issue is a simple principle. Rather than asking: 

“Did the patient relapse before or after 12 months?”

It should be: 

“Based on today’s evidence, could this person benefit from a second chance?” 

Importantly, this is not about offering second transplants to everyone. There is limited evidence that patients receiving a transplant with active disease can achieve durable survival – these outcomes are consistently poorer than those achieved in remission. Second transplantation remains a high-risk procedure and will not be appropriate for every patient. Instead, it is about ensuring that each patient is assessed using the best available evidence and their complete clinical picture, rather than being automatically excluded because they relapsed before an arbitrary threshold. 

That is why the policy must change. Every eligible patient deserves an individual clinical assessment, informed by modern evidence and clinical expertise, instead of being automatically ruled out by a one-size-fits-all rule.

How does England compare internationally?

Through research and our partnership with DKMS and its international clinical networks, we have gathered information from several countries to better understand how second transplants are commissioned elsewhere and how those approaches compare with England. 

Internationally, many countries operate differently. In Germany and across the wider European transplant community, European Society for Blood and Marrow Transplantation (EBMT) – derived risk stratification models are used to assess transplant suitability based on factors such as remission status, comorbidities, disease biology and patients’ individual circumstances, rather than a single binary cut-off. [v,vi,vii,viii]  

In France, guidance from the Société Francophone de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC) supports consideration of second allogeneic transplant where remission duration following the first transplant exceeds six months, reflecting a more flexible approach than the current NHS England 12-month criterion.[ix,x]  

Meanwhile, international collaborative groups continue to shape modern transplant practice. The 2022 European Leukaemia Net (ELN) recommendations, developed by an expert panel representing 11 countries including Germany, France, the Netherlands, Spain, Australia, Japan, China and Taiwan, suggest that treatment decisions are guided by individual patient risk factors rather than a single criterion. The guidance highlights the importance of MRD assessment, genetic and molecular risk profiling, patient fitness, donor selection and multidisciplinary decision-making when considering intensive therapies such as stem cell transplantation. Together with advances in reduced-intensity conditioning, relapse prevention strategies and post-transplant monitoring, these developments reflect a broader international shift towards personalised, evidence-based care. [xi] 

Building the case for change 

Through the clinical networks and relationships held by Anthony Nolan, Leukaemia UK and DKMS, we began engaging directly with transplant specialists across the UK in 2025 to better understand whether there was both a clinical need and professional support for updating the current policy. 

Following further discussions in early 2026 with the Blood and Bone Marrow Transplant Clinical Reference Group (CRG), there was broad recognition that the policy should be reviewed.  

Together, we agreed to begin the process of seeking change. 

However, it also became clear that policy reform would not happen overnight. NHS England is operating within a challenging environment, with ongoing organisational changes, pressures on specialised commissioning, and significant financial constraints across the health service. Updating a national commissioning policy requires extensive evidence review, expert consultation, clinical governance and consideration of resource implications. 

Despite these challenges, we believe patients deserve a policy that reflects the best available evidence and modern clinical practice. 

If you agree, please add your name to our petition and help amplify our voice.

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References:

[i] Shouval R, et al. Outcomes after second allogeneic hematopoietic stem cell transplantation for acute myeloid leukemia relapse: a registry analysis from the EBMT Acute Leukemia Working Party. Blood. 2024. doi:10.1182/blood-2024-xxxxxx.

[ii] Rodríguez-Arbolí E, Othus M, Orvain C, et al. Second allogeneic hematopoietic cell transplantation for relapsed adult acute myeloid leukemia: outcomes and prognostic factors. Transplant Cell Therapy. 2024;30(9):905.e1–905.e14. doi:10.1016/j.jtct.2024.06.019.

[iii] Zhu X, Fu H-X, Liu J, et al. Outcomes and risk factors of second allogeneic hematopoietic stem cell transplantation in patients with relapsed hematological malignancy after first transplantation. Blood. 2025;146(Suppl 1):6047–6048. doi:10.1182/blood-2025-6047.

[iv] Liu Z, Yuan E, Wang Q, et al. Second allogeneic stem cell transplantation using different donors as salvage treatment for acute myeloid leukemia relapsed after transplantation. Clinical and Experimental Medicine. 2025;25:249. doi:10.1007/s10238-025-01787-9.

[v] Shimoni, A., Labopin, M., Finke, J. et al. Donor selection for a second allogeneic stem cell transplantation in AML patients relapsing after a first transplant: a study of the Acute Leukemia Working Party of EBMT. Blood Cancer J. 9, 88 (2019). https://doi.org/10.1038/s41408-019-0251-3

[vi] Jentzsch M, Grimm J, Bill M, Brauer D, Backhaus D, Goldmann K, Schulz J, Niederwieser D, Platzbecker U, Schwind S. ELN risk stratification and outcomes in secondary and therapy-related AML patients consolidated with allogeneic stem cell transplantation. Bone Marrow Transplant. 2021 Apr;56(4):936-945. doi: 10.1038/s41409-020-01129-1. Epub 2020 Nov 19. PMID: 33208914; PMCID: PMC8035074.

[vii] Hemmati PG, Terwey TH, le Coutre P, Vuong LG, Massenkeil G, Dörken B, Arnold R. A modified EBMT risk score predicts the outcome of patients with acute myeloid leukemia receiving allogeneic stem cell transplants. Eur J Haematol. 2011 Apr;86(4):305-16. doi: 10.1111/j.1600-0609.2011.01580.x. PMID: 21265883.

[viii] Shimoni, A., Labopin, M., Finke, J. et al. Donor selection for a second allogeneic stem cell transplantation in AML patients relapsing after a first transplant: a study of the Acute Leukemia Working Party of EBMT. Blood Cancer J. 9, 88 (2019). https://doi.org/10.1038/s41408-019-0251-3

[ix] Yafour N, Couturier MA, Azarnoush S, Girault S, Hermet E, Masouridi Levrat S, Schmidt A, Michallet M, Etancelin P, Guillaume T, Malard F, Sirvent A, Yakoub-Agha I, Poiré X. Seconde allogreffe : recommandations de la Société Francophone de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC) [Second allogeneic hematopoietic stem cell transplant: Guidelines from the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC)]. Bull Cancer. 2019 Jan;106(1S):S40-S51. French. doi: 10.1016/j.bulcan.2018.05.018. Epub 2018 Nov 6. PMID: 30409466.

[x] Yafour N, Couturier MA, Azarnoush S, Girault S, Hermet E, Masouridi Levrat S, Schmidt A, Michallet M, Etancelin P, Guillaume T, Malard F, Sirvent A, Yakoub-Agha I, Poiré X. Seconde allogreffe : recommandations de la Société Francophone de Greffe de Moelle et de Thérapie Cellulaire (SFGM-TC) [Second allogeneic hematopoietic stem cell transplant: Guidelines from the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC)]. Bull Cancer. 2019 Jan;106(1S):S40-S51. French. doi: 10.1016/j.bulcan.2018.05.018. Epub 2018 Nov 6. PMID: 30409466.

[xi] Döhner H, Wei AH, Appelbaum FR, Craddock C, DiNardo CD, Dombret H, et al. Diagnosis and management of AML in adults: 2022 recommendations from an international expert panel on behalf of the ELN. Blood. 2022;140(12):1345–1377. doi:10.1182/blood.2022016867.