Case-Based Insights on Multiple Myeloma - Episode 5
Rafael Fonseca, MD: A common question that is presented to clinicians who deal with patients who have a diagnosis of multiple myeloma is, should I have a transplant? I will declare myself a believer in stem cell transplant. In 2017, for a patient who is otherwise a suitable candidate, one should consider, discuss, and—I would venture to say—try to persuade the person to go through stem cell transplant. Now, there are some reasons—personal, comorbidities, or otherwise—that may preclude a patient going through a stem cell transplant. But everything else being equal, for most of our patients, we try to go through the process of induction and stem cell transplant. It is not a must have, but it can add a significant time of disease control to a patient’s life.
In fact, one of the reasons we do transplant is that there are some very long-term outcome studies that have been done looking at survivorship post—stem-cell transplant. There’s one in particular, from 2011, that looked at 20 years of follow up post–stem-cell transplant. That’s where they found out that out of patients who were in a complete response measured by old methods, about 30% of them remained without progression at 20 years. That is 30% of about 30% of those patients who had gone into a complete response, and that’s where I came up with that 9%.
Now, with better induction therapy, maybe we’ll push that upwards. That’s where I think we can maybe cure 10% to 20% of patients, maybe even more. But for the average patient, transplant should be considered. In the United States, we push the envelope, so I wouldn’t say that age 65 is a boundary. A lot of patients who are in their 70s—sometimes even late 70s—although they have to be very fit, could be considered for stem cell transplant.
Gareth Morgan, MD, PhD: The goal of treatment for newly diagnosed patients is to get the best outcome for the patient who you’re seeing. There are clearly different tools that you can use to get to that aim. Seeing the patient as a human and adjusting the treatment for that patient becomes critical. To address the question about where do you go with autologous stem cell transplantation, it’s one of the best tools that we have for the upfront setting, and introducing new agents around that therapeutic maneuver, I believe, has given the best outcomes.
The last 1 to 2 years have seen a number of comparisons that have shown if you compare novel agents as they were at that time with stem cell transplant, the time free of disease is much better with the transplant. And so, transplant plus the novel agents is the way forward. One important thing to say at the end of that is that these have been great times for patients, where we’ve seen outcomes really improve dramatically.
Allogeneic transplantation for myeloma is one of those enigmatic types of treatments. Some people believe in it, others don’t. It’s actually quite toxic when given as a full-intensity transplant. And the mini allos, as they’re called—the less toxic approaches—although not toxic in the first 3 months, have significant mortality by a year. With the introduction of novel agents and autologous stem cell transplant, in my opinion, there’s almost not a role for allogeneic transplantation anymore because of the toxicity. This argument’s becoming even stronger as we have more monoclonal antibodies and CAR T-cell treatments. So, I think that the use of allotransplant for myeloma will become less and less prevalent.
Trasncript Edited for Clarity