19 Jun 2026

A Second Chance at Life

A blog series: Why the NHS Must Rethink Access to Second Stem Cell Transplants?

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 1:

By Dr Heather A. Damian, PhD  

For many people diagnosed with blood cancer, a stem cell transplant is not just a treatment – it is their best chance to survive. But what happens when that first transplant doesn’t work, or the disease returns?

For a small but significant group of patients, a second stem cell transplant can be lifesaving. Yet in England and Wales, access to this potentially vital procedure is restricted by an outdated policy (set in 2017) that no longer reflects scientific advances, clinical practice, or patient need.

This blog, sets out why updating the policy in line with patients need is urgently required and how Leukaemia UK, Anthony Nolan and DKMS are working together to achieve this. The three charities have come together to urge NHS England to update this policy as soon as possible.

Why might someone need a second transplant?

A donor stem cell transplant (SCT) – also referred to as an allogenic or allo-HSCT – replaces damaged or diseased bone marrow with healthy donor cells The bone marrow contains blood stem cells and is the factory producing all the blood cells needed, forming your oxygen carrying system to your immunity. Allo-HSCT is one of the few treatment options with a curative intent for blood cancers like leukaemia.

However, an allo-HSCT is not a simple procedure; replacing a patients whole immune system is a difficult procedure that can come with significant side effects and sometimes doesn’t succeed at all. Some patients:

• Relapse after their first transplant, usually due to some residual disease surviving
• Do not achieve full remission
• Experience complications that limit long-term success e.g. graft-versus-host disease (GvHD)

In some cases, a second transplant may be the only remaining option with a curative intent.

Data from NHS England which was used to inform the current policy, suggests that over a 10 calendar year period (2000-2009, inclusive), 184 patients underwent a second allo-HSCT for relapsed disease, primarily for acute myeloid leukaemia (AML 51%, CML 14%, lymphoma 7%, myeloma 2% & MDS 25%).

This equates to 184 patients over a 10-year period, or approximately 18–19 patients per year undergoing a second allogeneic stem cell transplant. Of these, around 123 patients over the same period (approximately 12 per year) had a first remission lasting longer than 12 months before relapsing and proceeding to a second transplant.

Before undergoing a stem cell transplant, patients must receive intensive preparatory chemotherapy, which can place significant strain on the body. As a result, some patients with additional co-morbidities or poor overall health may not be considered suitable candidates, as they may not safely tolerate the conditioning treatment required ahead of transplant.

The current policy

Access to second stem cell transplants in England is governed by a commissioning policy introduced in 2017 under NHS England’s specialised services. We will explore this process further in the following blog of this series.

At the time, there was a real risk that second transplants would no longer be funded at all. Thanks to a strong, collective campaign run by Anthony Nolan, access was preserved but with limitations.

In order to be eligible for a second transplant on the NHS, patients must meet three specific requirements:

• Patient is in complete remission
• Patient relapses over 12 months, after first allo-HSCT
• Patient is clinically fit to undergo treatment

The point currently in review is the “12 month rule”. This restriction acts as a hard cut-off for patients but medicine rarely works in absolutes. Some patients who relapse after a transplant can go back into remission with further treatment. However, these treatments are often only temporary. For many people with leukaemia, a donor stem cell transplant (allo‑HSCT) remains the only option that offers a chance of long-term survival. Despite this, patients with cancer can be ruled out of a second transplant if their disease returns within 12 months of their first transplant. This means that even patients who are otherwise well and fit for treatment may not be able to access the only potentially life-saving option available to them.

So, what has changed since 2017?

In short, a lot. Over the last decade, stem cell transplantation has evolved significantly. Advances in donor matching, conditioning regimens, supportive care, infection management, and patient selection have all contributed to improved outcomes and increased survival rates following a transplant. Clinicians now have a far greater understanding of which patients are most likely to benefit from a second stem cell transplant, allowing decisions to be based on a much more nuanced assessment of risk and potential benefit than was possible in 2017.

At the same time, risk assessment tools have become considerably more sophisticated. Rather than relying on broad time-based criteria alone, clinicians can now evaluate a range of factors including remission status, measurable residual disease (MRD), co-morbidities, genetic risk, donor suitability, and overall patient fitness. Emerging treatments and transplant strategies [including maintenance therapies, donor lymphocyte infusions (DLI), targeted therapies, and CAR-T integration] are also improving relapse prevention and long-term survival prospects.

Crucially, the evidence base surrounding second stem cell transplants has grown substantially. Recent international studies consistently demonstrate improved outcomes over time and support a more personalised, evidence-led approach to decision making. Collectively, these developments suggest that the current NHS England policy no longer reflects modern clinical practice or the realities of contemporary transplant medicine.

Internationally, healthcare systems have adapted:

• Germany uses detailed risk stratification models
• France applies a shorter six-month threshold
• Countries including Sweden, Finland, Australia and Canada are incorporating updated evidence into practice

In contrast, England’s policy has remained static.

The result? A system that may exclude patients who could benefit. Simply because they fall on the wrong side of an arbitrary timeline. And not only this but it has resulted in a system which now also excludes patients who are unable to access treatment unless they have the benefit of a private healthcare provider or can self-fund – contributing to health inequality. Some patients are able to get a secondary stem cell transplant through a private healthcare provider, when rejected by the NHS. However, there are more patients in England who cannot afford this and this has resulted in either private fundraising or having to accept no further action.

It is clear that this policy is no longer fit for purpose and requires an urgent update to ensure leukaemia patients do not fall through the cracks in our healthcare system. We believe decisions around second stem cell transplants should be based on the patient’s individual situation, rather than a set timeframe. That’s why Leukaemia UK,  Anthony Nolan and DKMS will keep working together to push NHS England to update its policy on second stem cell transplants.

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