Standardizing haematopoietic cell transplants in China

This expert consensus statement is an opus magnum written by 19 Chinese leaders in blood disorders, especially in hematopoietic cell transplants. The statement covers almost every category of neoplastic and nonneoplastic conditions and many aspects of transplants including appropriate recipients, donors, pretransplant conditioning regimens, graft types and graft-versus-host disease (GvHD) prevention. It also gives us a snapshot of what is going on in transplants today in China. First, why should we be interested in what is going on in China? For many reasons, China is one of the world’s oldest civilizations and the most populous nation. One in every five humans is Chinese. Prominence of China on the world stage is growing rapidly including in science and medicine. And our Chinese colleagues have done more HLA-haplotype-matched transplants than everyone else combined, so there is much to be learned from their experience. As the authors indicate, almost 20% of all transplants worldwide are being done in China including 40% of HLA-haplotype-matched transplants. Wow. It would be impossible for me to comment on the entire content of this document; it might also take a lifetime. Instead my focus is on some key concepts and illustrate these with examples. First, the typescript is an expert consensus statement. As such, we might ask ourselves what exactly these words mean. There are many definitions of consensus. For example, the Oxford English Dictionary defines consensus as a general agreement derived from the Latin consens, to agree. Note that there is no implication a consensus is correct. For example, there was consensus amongst Western religious leaders in the Middle Ages that the world was flat, an idea already known to be wrong in the Western Han Dynasty (西漢). Also, before Copernicus and Galileo, there was Western consensus that the Earth was the centre of the Universe, a notion disproved by Chinese astronomers in the Shang Dynasty (商; Fig. 1). The most important variables in analyzing the validity of consensus statements and guidelines is how they were developed and the quality of evidence on which they are based. The development process can range from friends or colleagues around a table over drinks late one evening to a highly structured, evidence-based reiterative process such as the RAND-Delhi expert consensus panel process [1, 2], more on the quality of evidence below. Although consensus statements and clinical practice guidelines are intended to provide guidance to clinicians, they differ. A consensus statement is developed by an independent panel of experts, usually multi-disciplinary, convened to review the research literature in an evidence-based manner to advance understanding of an issue. In contrast, a clinical practice guideline produces statements informed by a systematic review of the evidence. Although consensus statements address topics in which the evidence base is less extensive compared to clinical practice guidelines, their development should still be methodologically rigorous and transparent. Organizations such as Appraisal of Guidelines for Research and Evaluation [3], Institute of Medicine (now National Academy of Medicine) [4], Guidelines International Network [5] and Oxford Univ. Centre for Evidence-Based Medicine developed [6] criteria to ensure objective, scientifically valid and consistent standards for development and reporting of high-quality guidance documents. In trying to analyze the typescript by Huang and colleagues, we are hampered by the lack of details on the consensus process used. Hopefully, the authors will publish these in a supplement. As for the content, there are too many recommendations to discuss each in detail. However, there are several recurrent themes which have perplexed transplant experts for several decades: (1) who Correspondence: [email protected] Haematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London SW7 2AZ, UK