Sergio Giralt, MD
The use of stem cell transplantation has changed over the last few years, with the emergence of novel therapies and treatment strategies. But even with the FDA approvals of new agents for multiple myeloma and select lymphomas, transplant remains to be a curative and reliable strategy.
Signs of this were especially seen in results of the phase III StaMINA trial in multiple myeloma, which found that the addition of lenalidomide/bortezomib/dexamethasone consolidation or a second autologous hematopoietic cell transplant (AHCT) was not superior to a single AHCT, followed by lenalidomide maintenance.
During the 2016 OncLive
State of the Science Summit, Sergio Giralt, MD, lectured on the evolution of stem cell transplant and cellular therapies.
For community oncologists, he advises that, “Timely referral to transplant is probably the single most important thing. High-dose therapy and autologous transplant for multiple myeloma remains the standard of care.”
In an interview during the meeting, Giralt, a professor of Medicine at Memorial Sloan Kettering Cancer Center, discussed the advances in stem cell transplant and how it remains as the sole curative therapy in various hematologic malignancies.
OncLive: Please provide an overview of your lecture at this State of the Science Summit.
: I summarized what I thought were the best abstracts from the 2016 ASH Annual Meeting in San Diego in the area of stem cell transplant and cellular therapies. There were some that were really practice changing and probably the start of new eras. Sattva S. Neelapu, MD, presented the first 51 patients with relapsed/refractory DLBCL treated with a CD19 chimeric antigen receptor (CAR)-modified T-cell therapy. These were dramatic responses; people who had extensive disease achieved complete remissions.
It is still early—most of the patients were not even 3 to 4 months out of treatment. The treatment is associated with some toxicities and it probably has to be given in specialized centers. But these are people who had no viable therapeutic option. This is, really, a life-saving treatment.
There were 2 abstracts in myeloma that called to everybody’s attention. These were long awaited studies. One was presented by the Edward Stadtmauer, MD. He presented the StaMINA trial, in which 700 patients were randomized to 3 types of posttransplant consolidation: standard lenalidomide maintenance; 4 cycles of consolidation therapy with bortezomib, lenalidomide, and dexamethasone; and a tandem transplant.
To everybody’s surprise, there was no significant benefit in progression-free survival (PFS) in any of the groups. All of the groups did very well with more than 80% having 3-year survival and a 56% PFS rate at 3 years. However, none of the more intense arms were superior to lenalidomide maintenance alone after autologous transplant. Thus, in North America, we would say the standard of care remains as 1 autologous transplant followed by lenalidomide maintenance for patients with myeloma who are transplant eligible.
Interestingly, this is contrasted from the European trial, which actually showed that there was a benefit for the tandem transplant strategy. Patients who went to a tandem transplant strategy had a better PFS.
Why is there the difference between the American trial and the European trial? In the American trial, 32% of patients randomized to tandem did not get the tandem arm. Could that explain the difference? We don’t know; we need further follow-up. This question has not yet been totally answered, in that risk-adapted or response-adapted therapy with minimal residual disease (MRD) assessment will be the way we will tailor treatment for patients with myeloma to give them the longest life and best quality of life with a minimum burden of treatment.
What will the role of transplant be in the future?
That is an excellent question. Transplant remains the only curative strategy for many patients with hematologic malignancies. It is the only curative strategy in myelodysplastic syndromes (MDS), in acute leukemia for patients who failed primary therapy, and in high-risk leukemia.
However, it is toxic and it doesn’t work all the time. Relapse remains the most important cause of treatment failure. A lot of these advances will help make transplant easier and make it more effective. Lenalidomide maintenance is the best example. It doubles the remission duration after transplant and, yet, transplant is an essential component of the long-term disease-control strategy in myeloma.