Treating the whole patient

“A large part of my work involves caring for pediatric patients who are undergoing stem-cell transplants,” says Shalini Shenoy, M.D. “I like what I do, because even though a transplant is a fairly rigorous intervention, the end result can be so gratifying — we can reverse a lot of very serious disorders with it.”

Shenoy is assistant professor of pediatrics and associate director of the Pediatric Bone Marrow Transplant Program at St. Louis Children’s Hospital, which uses bone marrow transplantation — also called hematopoietic stem-cell transplantation — to cure potentially fatal blood, immune, metabolic or malignant diseases in infants and children.

This demanding area of medicine draws on hematology, oncology, immunology and pediatrics. And while Shenoy comes across as soft-spoken and compassionate, it is also clear that she has intellectual steel backing her warm personality.

This unique combination of traits seems perfectly suited for dealing with the complexity of the field while at the same time reassuring both patients and their parents during the challenging procedure.

Exploring options

The stem cells used in transplantation are found in the bone marrow and blood and have the ability to differentiate into any of several types of blood cells.

Allogeneic stem-cell transplants replace a patient’s bone marrow with stem cells obtained from donor blood, bone marrow or umbilical cord blood.

The donor stem cells lodge in the patient’s bone marrow, reconstitute the marrow and supply the patient with the healthy blood, enzymes or immune factors he or she needs.

A stem-cell transplant is often the treatment of choice for certain immune or metabolic diseases where transplant is the only option for a cure. For some cancers, stem-cell transplant is usually used only if other treatments fail or if the condition can only be cured with a transplant.

While potentially life-saving, a stem-cell transplant can be arduous. Before donor cells are given, the patients’ own bone marrow or immune systems are wiped out by chemotherapy, radiation or other alternatives, leaving them exhausted and vulnerable to infection.

After the transplant, it may take months for patients’ immune systems to return — and they must stay relatively isolated until then.

Stem-cell transplants are also highly involved procedures.

Timing, choice of medications, dosage and other elements of pre- and post-transplant protocols can have a great effect on the course of treatment, the body’s acceptance of the donor cells and the ability to cure disease.

“There are many ways to transplant,” Shenoy says, “many kinds of interventions, many subtle variations on a theme. I have to decide what would be the best approach for each patient.”

Standard protocols for stem-cell transplants can have adverse side effects.

“The transplants offer hope for children suffering from chronic or terminal diseases, but their side effects can be debilitating and often include sterility,” Shenoy says. “We are researching ways to spare children from the harsh side effects of stem-cell transplantation.”

“Dr. Shenoy’s work is having a major impact on how we approach bone-marrow transplantation in patients with non-malignant diseases,” says Robert J. Hayashi, M.D., director of the Bone Marrow Transplantation Program at St. Louis Children’s Hospital, and associate professor of pediatrics.

“By providing strategies that allow us to perform these procedures with relatively little toxicity, we can now offer this treatment modality to cure many patients who were not considered before because the risks previously were too high.”

Common team goal

Shenoy sees the medical aspect as just a fraction of what she does.

Even more of her time is spent managing follow-up and social and psychological aspects of treatment. She works closely with patients and their families and with a large team of professionals devoted to supporting the patients from the time of transplant to long after.

This team includes nurse practitioners and nurse coordinators, social workers, school liaisons, physical therapists, dieticians, chaplains and child life therapists, among others. Their mutual goal is to make sure the children they treat and their families understand the procedures, goals and risks and that the patients are supported throughout the transition back to a normal life after their lengthy convalescence.

“It’s a multi-disciplinary team,” says Yvonne Barnes, nurse practitioner for bone marrow transplant at St. Louis Children’s Hospital.

“Each person has a vital role in caring for patients. Dr. Shenoy oversees the team. Her approach is very individualized and addresses the specific needs of each child. I think the best thing about working for her is seeing her go the extra mile for each patient.”

“I like the global aspect of my practice,” Shenoy says. “In this field you care for the patient in many ways. It’s not as if I just fix them and they go home and that’s it. That’s just the start. We monitor them for many months to make sure there are no late complications and to follow their progress.

“And we do all we can to get them back into their pre-transplant routines and lifestyles once their immune systems are reestablished.”

A natural consequence of spending so much time with patients and their families is that strong relationships develop.

Shenoy gets invited to patients’ graduation parties and receives pictures of teenagers on first dates and learning to drive. She relishes hearing about the ordinary milestones reached in her young patients’ lives, because they are often so hard-won.

Importance of family

Shenoy earned a medical degree in pediatrics from Mangalore University in Manipal, India, and practiced pediatrics in India.

At that time, India offered no opportunities to branch into a subspecialty, so Shenoy decided to move to New Orleans for training in hematology/oncology.

Two years later she came to the School of Medicine.

“I think it was after I started my fellowship here that I realized I was interested in transplant, because you needed to have such comprehensive knowledge,” Shenoy says. “I was introduced to the intricacies of human immunology and transplantation in the laboratory of Thalachallour Mohanakumar and was hooked.”

Mohanakumar, Ph.D., is the Jacqueline G. and William E. Maritz Chair in Immunology and Oncology and professor of surgery and of pathology and immunology.

Shenoy is married to Surendra Shenoy, M.D., associate professor of surgery, director of the Living Donation Program and a transplant surgeon at Barnes-Jewish Hospital. He comes from a town near where Shenoy grew up, and they wed in India.

“Our interests match well,” Shenoy says. “He works in liver and kidney transplantation, and the fields overlap just enough that we can share ideas. But we try not to bring specific problems home with us.”

The couple has one son and one daughter. Their son, Ashish, was born in India before the Shenoys left for the States. Ashish is a sophomore at Stanford, but Shenoy doesn’t think he’ll pursue medicine.

“He’s interested in things like economics,” she says. “He told us in sixth grade that we could essentially stop trying to teach him, because biology was not his thing. He liked math. He liked numbers. And he was fine on his own, thank you very much.”

Their daughter, Neeti, is 10 and in the fourth grade. In contrast to Ashish, Neeti has expressed an interest in biology, but according to Shenoy, Neeti thinks she would rather take care of animals than people.

Family is definitely a central theme in Shenoy’s life.

Her approach to her practice entails building a caring network of people around her patients. And she also feels that as part of the University, she is part of a family.

“I have a lot of friends in practice out in the community,” she says. “Talking with them, makes me realize how much being at the University is like being in a family. I like the feeling of having this group I can work with. I really like that interaction.”