The Role of Transplant in Multiple Myeloma

Keith Stewart, MBChB:We have seen trials now from Spain, one from the United States, and Birmingham, suggesting that transplant might not be required so frequently anymore, and particularly if you’re using these 4-drug regimens together, such as carfilzomib, lenalidomide, dexamethasone, and daratumumab, or as we just talked, VRd [bortezomib, lenalidomide, dexamethasone]/daratumumab. What do people think about that? Is transplant still with us? And if so, for how long? What do you think?

Thomas G. Martin, MD: The FORTE trial randomized patients to KRd [carfilzomib, lenalidomide, dexamethasone] 12 cycles, versus KRd [carfilzomib, lenalidomide, dexamethasone] 8 cycles, plus a single autologous transplant. In that study, the people who were not high risk did well whether they received a transplant or not. KRd [carfilzomib, lenalidomide, dexamethasone] in that setting might be enough, and you might not need to do an autologous transplant. However, in the high-risk population, it still was a benefit.

Natalie S. Callander, MD: We’re involved in a trial called the MASTER trial, which involves giving KRd [carfilzomib, lenalidomide, dexamethasone]/daratumumab.It’s also an MRD [minimal residual disease]-driven trial. And this has about 112 patients accrued at 6 different institutions. We can tell that the MRD negativity rate goes up, even with a 4-drug regimen, post-transplant. And it’s substantial. If we end up using MRD as a surrogate end point or to limit therapy, that’ll be very interesting. I have to put myself in the protransplant camp, it does provide benefit to patients. I am interested to see about long-term data with FORTE.

Keith Stewart, MBChB: This is [Luciano] Costa’s, [MD,] presentation of the trial right?

Natalie S. Callander, MD: Yes.

Keith Stewart, MBChB: That’s the one I meant from Birmingham. In that trial, they all get transplanted? Is that right?

Natalie S. Callander, MD: They can be transplant-ineligible. That’s allowed. But the majority of patients have gone on to transplant.

Keith Stewart, MBChB: The jury’s still out for the time being. People are still transplanting. Peter, is that the case with you?

Peter Voorhees, MD: Yes, I would say so. And going back to the FORTE trial, the transplant arm did have a higher proportion of patients with sustained MRD negativity. And sustained MRD negativity is more important than MRD negativity in 1 point in time.

Transcript edited for clarity.