Stem Cell Tourism on the Rise

New Hampshire Public Radio, August 13, 2009

In any commercial endeavor, caveat emptor must be the consumer's guiding principle, and the medical profession is no exception to this rule. Now, as patients in increasing numbers continue to travel outside of their own countries in search of stem cell therapies that are only available in foreign lands, increasing problems and dangers are being reported.

Last month, for example, police in Hungary arrested four people in a raid that was conducted on a suspected "guerilla" stem cell clinic. According to a report in Reuters at the time, the clinic was charging patients as much as $25,000 per treatment with illegally obtained embryonic and fetal stem cells which were derived without authorization and without safety testing. Such a report is merely one instance of numerous similar events that are being reported with increasing frequency. In response to the escalating prevalence of such incidents, in December of last year the International Society for Stem Cell Research issued a new set of cautionary guidelines for patients.

According to Dr. Insoo Hyun, associate professor of bioethics at Case Western Reserve University School of Medicine in Cleveland, Ohio, "Stem cell research is progressing so rapidly and has sparked a lot of interest in translational research including among patients in hope for therapies. At the same time, legitimate science is speeding ahead and getting to the point where there needs to be more of a roadmap to take the basic knowledge to clinical applications." It was nearly a year ago when Dr. Hyun predicted it is "only a matter of time" before someone is physically harmed by bogus stem cell therapies somewhere in the world. According to Dr. Paul Sanberg, professor of neurosurgery and director of the University of South Florida Center for Aging and Brain Repair in Tampa, "We clearly need guidelines for around the world to make sure that appropriate research is done before clinical work is undertaken in patients. We see desperate patients all the time and want to make sure that any therapies they take come from responsible research groups." Similarly, Dr. Darwin Prockop, chairman of Genomic Medicine and director of the Institute for Regenerative Medicine at the Texas A&M Health Science Center College of Medicine, adds, "There is tremendous confusion about the two types of stem cells, embryonic stem cells and adult progenitor stem cells. The difference is monumental, and needs to be clarified." Although there do exist a number of clinics around the world which actually offer legitimate, scientifically based adult stem cell therapies, there also exist a number of clinics which do not offer anything of scientific legitimacy, even though they fraudulently purport to be legitimate.

Authored by a task force composed of stem cell specialists from 13 countries, the guidelines that were issued last year address, among other topics, questions of ethical review, quality and safety, voluntary informed consent of participants in research projects, careful monitoring of volunteers, and caution in using stem cell therapies outside of a research context. Hopefully, the ethical principles which are at the very essence of such guidelines will be given serious attention and consideration by stem cell researchers throughout all countries of the world, at least eventually. So far, however, such is not the case.

In addition to the need for ethical guidelines, there is another lesson to be learned from the increasing number of bogus stem cell clinics that are springing up around the world. Namely, the necessity and urgency of consumer-patient guidelines also highlights the necessity and urgency for formal, official government approval of those adult stem cell therapies which have already been proven to be safe and efficacious, so that more clinics that offer such therapies will be allowed to open in their native countries, such as the United States, instead of having to locate themselves overseas in foreign countries where they are competing against the clinics that offer bogus therapies. In other words, an updated revision of the FDA approval process, so that it is directly relevant to stem cell therapies, would allow more adult stem cell therapies to be available throughout the U.S. to more patients with various diseases and injuries, who could therefore benefit from such therapies, but for whom such therapies are not yet available within the United States. The current FDA approval process, which was designed decades ago with the specific goal of testing safety and efficacy in pharmaceutical drugs, is in many ways neither relevant nor logical when applied to the testing of stem cell therapies. Such a topic is highly complex and could constitute an entirely separate publication unto itself. Suffice it to say that a swifter, more precise and more modernized FDA approval process which is specifically tailored to stem cell therapies is desperately and urgently needed in the U.S., as is its equivalent in other countries.

As Dr. Hyun explains, "Most of the time, stem cell products are presenting entirely novel products that are unpredictable in humans. Unlike drugs, you can't just create a batch and put them on the shelf and expect they will be the same. We need uniform quality control and manufacturing. And if they're embryonic or pluripotent stem cells, they could form unwanted tissues or tumors. So, we have to be very careful about following up and monitoring patients."

At the crux of the problem, at least for people who reside in the U.S., is the fact that the U.S. FDA has designated each person's own cells in their body to be "drugs". A prime example of the implications of such an official government stance maybe be seen in the biotech company Regenerative Sciences, which found itself at the center of this important controversy when, in July of 2008, the company's founding CEO, Dr. Centeno, received a letter from the U.S. FDA stating that the autologous adult mesenchymal stem cells processed with Regenexx, the company's proprietary product, are considered to be "drugs" since they are intended for therapeutic use. According to the FDA letter, "These cells are considered drugs because the therapeutic claims shown on your website demonstrate that they are intended for use in the diagnosis, cure, mitigation, treatment or prevention of disease in man." The letter concluded by stating, "Please be advised that in order to introduce or deliver for introduction a drug that is also a biological product into interstate commerce, a valid biologics license must be in effect. Such licenses are issued only after a showing of safety and efficacy for the product's intended use. While in the development stage, such products may be distributed for clinical use in humans only if the sponsor has an investigational new drug (IND) application in effect as specified by FDA regulations... The mesenchymal stem cells utilized in your Regenexx procedure are not the subject of an approved biologics license application (BLA) nor is there an investigational new drug application (IND) in effect. Therefore, your implantation of the mesenchymal stem cells for which a valid license or IND is not in effect appears to violate the Act and the PHS Act and may result in the FDA seeking relief as provided by law."

Regenerative Sciences responded by posting the following notice on their website, which was most recently updated on March 31, 2009: "Last summer we got a letter from the FDA stating that they felt that our Regenexx medical procedure was actually the manufacturing of a new drug. The letter made no sense, as what we're doing is practicing medicine. We kindly wrote back stating our position and then we didn't hear back for more than half a year. Recently, the FDA has again asserted that they believe we are manufacturing a drug. They haven't given any credible rationale for why they believe this, as what we're doing with adult stem cells is no different than the average fertility clinic that grows embryos in culture for re-implantation. The fertility clinic is not regulated as a drug manufacture facility. The fertility specialists fought that fight and won."

This is a critically important issue, since it illustrates the frustration that many, if not all, adult stem cell scientists in the U.S. feel, as it this stance by the FDA which poses an insurmountable, not to mention entirely illogical, hindrance to the availability of adult stem cell therapies in the United States. For anyone who has ever wondered why it is that adult stem cell therapies are available in ordinary clinics in most countries outside of the U.S., but only in a limited number of FDA-approved clinical trials within the U.S., here's your answer: the FDA considers each person's own autolgous adult stem cells to be a "drug", and therefore those stem cells are subject to the same multi-year, multi-million-dollar clinical trial process through which all pharmaceutically manufactured drugs must pass before being considered legally marketable within the United States.

The statement on the website of Regenerative Sciences continues: "ASCTA (American Stem Cell Therapy Association) is a physician organization that was formed in opposition to the FDA's position that adult stem cells are drugs. This group heralds a much bigger movement than what we're doing here with the Regenexx procedure. We've found literally an outcry by patients with chronic diseases that the FDA would stand in their way of getting safe stem cell work performed by their doctors. We agree that there are hundreds of likely unsafe stem cell outfits around the globe injecting God-knows-what into whoever has the will to pay. All the more reason for an organization to step to the forefront to establish physician-run guidelines for safe lab practices and clinical oversight... The pre-clinical research on adult stem cells is much stronger than embryonic stem cells... When I've posed the question to numerous doctors and experts in the field, are your own stem cells drugs? They look at me like I'm crazy, and often reply 'Of course my stem cells aren't drugs!' Why would the FDA take the position that your cells are drugs... The ASCTA physician group will be getting out its lab practices guidelines meant to hold new adult stem cell practices to the highest standards to protect patients. Our goal is clear and it's worth fighting for: Safe Stem Cells Now!"

Likewise, the ASCTA has posted the following statement on their website: "The American Stem Cell Therapy Association (ASCTA) announced today the online publication of its mission statements and charter. The organization was formed in response to the Food and Drug Administration's (FDA) recent position that the adult stem cells found in everyone's body are drugs, a position the ASCTA opposes. This physician organization is establishing laboratory guidelines that will allow doctors to bring adult stem cell therapy to their patients more quickly. These guidelines will be similar to those used by fertility specialists in in-vitro fertilization (IVF) labs, where many of the same cell culture techniques are used."

Dr. Centeno, one of the founding members of the ASCTA, is quoted on the ASCTA's website where he states, "Many patients are dying or suffering daily with incurable diseases or problems that require major surgery. These patients should have access to basic adult stem cell therapy now. ASCTA is establishing guidelines which will allow the safe use of the patient's own adult stem cells under the supervision of doctors." According to Dr. Frank Falco, another ASCTA founding member who is also quoted on the ASCTA's website, "The FDA's position against someone using their own stem cells is taking it too far. We are talking about a person using their own tissue to treat a degenerative disorder or process safely without the use of medications or surgery. Although we agree that oversight and standards are necessary, this should be provided through a physician organization such as ASCTA rather than by a government agency."

Not all stem cells are created equal, of course, and it is vitally important that the FDA make distinctions between embryonic, fetal and adult stem cells. In this regard, the ASCTA website continues, "Adult stem cells are different than embryonic stem cells. Adult stem cells are found in the patient's body in various tissues. In order to obtain enough stem cells for treatment, they often need to be cultured, similar to today's fertility treatments. Adult stem cells have undergone much more research than embryonic stem cells and therefore are closer to real world treatments. These adult stem cells are taken from the patient's own body (autologous) and ASCTA believes that they are therefore the safest for use in treating patients." To this Dr. Centeno adds, "While the Obama administration seems to have opened the embryonic stem cell door, their FDA seems to want to slam the adult stem cell door shut."

As also stated on their website, "The ASCTA is a physician group comprised of various medical and surgical specialists whose goal is to bring safe stem cell therapy to patients by establishing laboratory and clinical guidelines." More information is available at www.stemcelldocs.org. Additionally, in April of 2009 a patient movement called "Safe Stem Cells Now!" was formed in response to the FDA's unfounded position that a person's own adult stem cells are "drugs" and therefore should be regulated in the same manner. More information is available at www.safestemcells.org. As Barbara Hanson, cofounder of www.stemcellpioneers.com, states, "Adult stem cells are cells from our own body. They are very safe. There are no moral or ethical issues. They are safer than taking aspirin and yet the FDA has classified our own stem cells as drugs that require regulation. This means that prolonged investigations, including lengthy clinical trials, will be required for each and every disease and application that adult stem cells could be used for. This could take years and years. It smells of big pharma to me and many others."

Indeed, many people feel that this stance by the FDA is purely politically and economically motivated. At the very least, it is an entirely unscientific stance, and it is merely one example of the numerous ways in which the FDA needs to update its regulations so that these regulations are relevant and applicable to stem cells, which do not fall into any of the previously existing categories for which the FDA has ever had to formulate national law in the past. Such outdated laws are precisely what is driving many of the best and most accomplished adult stem cell physicians and scientists "off-shore", to set up their laboratories and clinics anywhere at all in the world, just as long as it is outside the borders of the United States. In the end, it is the U.S. patient who suffers, since the researchers and clinicians themselves are not stopped but are merely forced to relocate to other countries. Until the FDA is able to recognize the numerous and vast differences between an autologous adult stem cell and a pharmaceutically manufactured drug, it is no wonder that adult stem cell companies and physicians are forced to set up their businesses outside of the U.S., where the scientifically ethical and legitimate must compete against the scientifically unethical and illegitimate, and where the patient-consumer is not always able to distinguish between the two.

As with any endeavor, however, in any market, consumers must arm themselves with the power of knowledge, which is their greatest defense. Especially where the quality of a product or service can make the difference between life and death, such as with stem cell therapies, it is all the more critically important that the buyer beware.