Role of Transplant in Newly Diagnosed Multiple Myeloma
A brief overview of stem cell transplant’s role in the first-line treatment setting of newly diagnosed multiple myeloma.
Transcript:
Krina K. Patel, MD, MSc: Now, I’m going to come to Dr Ahmed, our one transplanter on our panel right now. With all these studies we’re talking about, these amazing response rates, these are patients who got transplants though. That’s still something that we all think, for people who are eligible, it’s what we would do. Who would you think is transplant eligible or not? What does that definition mean?
Sairah Ahmed, MD: As you alluded to earlier, eligibility is different. It’s very similar to, beauty is in the eye of the beholder. There are some institutions that are conservative and there are some institutions, like ours, who have eligibility criteria that allow most patients, I believe, to get a transplant. I think the real issues, in terms of being able to tolerate a transplant, come from organ dysfunction. So, cardiac dysfunction and pulmonary dysfunction are definitely situations where you have to weigh risk versus benefit, and potentially even transplant-related mortality, which generally in this patient population is extremely low. Given the multitude of other agents available, including now CAR [chimeric antigen receptor] T-cell therapy and bispecifics, you don’t want to have a major toxicity with transplant because these patients could potentially receive other things.
I think the one thing we don’t necessarily look at in terms of eligibility is age. It truly is just a number, but functional status is important. Is that patient able to complete their independent ADLs [activities of daily living]? Are they able to tolerate the transplant in terms of ambulation, moving around, eating and drinking, and all of those things? If they are, it doesn’t matter if they’re 60 or 90, we can get them through the transplant. Renal dysfunction is also something that is not a barrier. We transplant patients with very different renal functions, including dialysis dependent. I think you can say for those patients who are right at the edge of dialysis, that transplant could potentially lead to toxicity that would lead them to needing dialysis. I think that’s a conversation to be had. Again, now it’s a different landscape of treatment compared to 5 or 10 years ago.
Krina K. Patel, MD, MSc: With our transplant-ineligible regimens, there’s this blur. I think that’s why it was fantastic that you explained what does eligibility for transplant really mean versus who are the patients who don’t want to go to transplant, or who are the ones we’re like, well, maybe they are going to do really well with our transplant-ineligible regimens?
The MAYA study is an example with DARA-LEN-DEX [daratumumab, lenalidomide, dexamethasone] where there are patients who didn’t go to transplant, and I think they’ve had even more data recently with patients who were fit versus frail. They looked at all those data and saw that patients who were fit did way better, but the ones who were frail still did really well. Truly, not necessarily all transplant-ineligible [patients], but a PFS [progression-free survival] of 5 years. We don’t necessarily have that with all our transplant trials we’ve looked at. So, what do you talk to your patients about when they come to your clinic about transplant?
Tejo N. Musunuru, MD: The first visit usually is overwhelming for a lot of different patients because you’re talking about their diagnosis. Myeloma is difficult to understand for most patients. The next thing is their prognosis, then the different treatment options. You have, as I said, a dealer’s choice there when you’re presenting the options to them. At the end of the conversation, you also bring this stem cell transplant into the game. A lot of them are like, “Oh my God, I am done with this conversation by this point.”
So, when bringing in stem cell transplant, I usually introduce it during my first visit with them. Then…when they’re getting to that fourth cycle is when we try to send them to a transplant based on their response. I start introducing that in their second or third visit, saying, “Hey, you are otherwise fine.” Again, age is just a number to me as well. It’s their comorbidities that matter the most. Working at a satellite center, it’s easier to convince patients to get treatment once or twice a week. That’s not the problem. But trying to send them to the medical center for a transplant is where it starts. It’s like, “You think I should go to the Texas Medical Center?” And the first time they go there, we’re coming from a center where they can park, it’s free. Then they go into the building, the laboratory is on the left, the clinic is on the right. You go up 1 floor, the infusion center is there. Compared with, going to the Texas Medical Center, their first visit, the parking lot is a mile away, and then they’re trying to navigate their way into the center. I’ve had many patients, after the first visit there, saying, “Is there any way I cannot get a transplant and just continue what I’m doing? I’m doing great with these regimens, can I just continue this?” That’s a conversation I have with patients about eligibility, these are the data we have with respect to transplant.
I also tell them that 5 or 10 years ago, I probably would’ve pushed them more toward the transplant. But with the new data we have, the host of drugs we’ve had and approvals in the last 10 years, the PFS is nearing [what it is] with the transplant. So it’s your choice. These are your options, and if you want to go that route, we’ll totally facilitate that. But if you don’t want to absolutely do this, and you don’t have to make this decision now either. That’s another thing I mention to them. We can continue the maintenance and if you start relapsing based on your lab [test results], we can take that route. Most people are OK with that. There are some very highly motivated patients who would like to go. I totally encourage them, but I present them the data of both options and then let them make the choice.
Krina K. Patel, MD, MSc: I completely agree. It’s changing every day.
Transcript edited for clarity.
