Transplant Eligibility Criteria in Multiple Myeloma
Impressions of the case of a 51-year-old man with newly diagnosed multiple myeloma and considerations that impact candidacy for an autologous stem cell transplant.
Saad Z. Usmani, MD: Welcome to this CancerNetwork® Around the Practice program, Memorial Sloan Kettering Cancer Center edition: “Improving Outcomes in Newly Diagnosed Multiple Myeloma.”
I’m your host, Dr Saad Usmani, the chief of myeloma service at the Memorial Sloan Kettering Cancer Center in New York, New York. There is a great panel of experts who have joined me. I’d like to invite my esteemed fellow panelists to introduce themselves.
Urvi Shah, MD: I’m Dr Urvi Shah, an assistant attending physician of the myeloma service at Memorial Sloan Kettering Cancer Center.
Sham Mailankody, MD: I’m Sham Mailankody. I’m also an assistant attending physician at Memorial Sloan Kettering with a focus on myeloma and cell therapies.
Neha Korde, MD: I’m Dr Neha Korde. I’m also an assistant attending physician at Memorial Sloan Kettering Cancer Center in New York.
Saad Z. Usmani, MD: Thank you all for joining me. We’re going to be discussing strategies for optimizing first- and further-line therapies for patients with newly diagnosed myeloma at early relapse. We’ll review 2 patient cases with our panelists to illustrate how we apply recent evidence in our clinical practice to tailor therapies and improve patient-treatment outcomes. Let’s begin.
We’ll start with the evolving treatment landscape of transplant-ineligible, newly diagnosed patients and then go over a case. We have a 51-year-old man who was diagnosed with a revised ISS [International Staging System] stage II multiple myeloma. At presentation, the hemoglobin was 7 g/dL, and beta-2 microglobulin was 6 mg/dL and albumin was 3.2 g/dL. The patient had hypercalcaemia. Serum LDS [lactate dehydrogenase] levels were within normal limits. Serum creatinine clearance was 45 mL/min. The bone marrow biopsy showed 22% clonal plasma cells, and they had normal cytogenetics. Serum IgG antibodies was elevated at 5 g. Serum-free kappa light chains were 24 mg/dL, and lambda light chains were suppressed. The patient had a reasonable performance status at 1. PET [positron emission tomography]–CT showed multiple FDG [fluorodeoxyglucose] avid bone lesions in the vertebrae but no extramedullary myeloma. The patent diagnosis was classified as IgG kappa myeloma, revised ISS stage II, and he was deemed transplant eligible based on his age.
Let’s go over some of the questions. My first question will be for Dr Korde. How do you determine if a patient is transplant eligible?
Neha Korde, MD: Oftentimes, I break it down with the patient. I use a category of different things. Usually, I look at their age, but that’s not always the primary thing that I’m looking at. I look at their performance status and, specifically, comorbidities. For this patient—he’s a young patient—he’s got a good performance status and is healthy going into surgery, so he’s clearly transplant eligible. As for my older patients, it becomes a little trickier. Obviously, we have to look at the comorbidities in these patients very carefully, and age isn’t always a determinant for those patients.
Saad Z. Usmani, MD: What do you think, Dr Mailankody?
Sham Mailankody, MD: At our center we have almost everybody see a transplant doctor for a consultation before we determine if the patient is eligible. In many cases like this, the patient is clearly transplant eligible. As Dr Korde alluded to, there are patients who may be older and have comorbidities. But we’ve gotten much better with transplants, so the default status for most of our patients should be that they’re transplant eligible unless there are glaring exclusions. We also find it helpful that patients meet with a transplant doctor, in addition to their primary myeloma doctor, to get a second perspective if you will, about the role of transplant, collection, and up-front vs delayed transplant.
Saad Z. Usmani, MD: Dr Shah, when would you include the transplant physicians in this process? Many of our patients aren’t expecting this kind of event to happen in their lives. They’re in their early 50s, and we’re sharing a lot of information about their disease and all this information. When do you start introducing that idea?
Urvi Shah, MD: I definitely don’t bring it up on the first visit unless a patient has already heard about it and asks questions. It’s important to start with induction, and now that we have so many options for induction, that becomes a big conversation in itself. Once the patient has finished about 3 to 4 cycles, that’s also helpful because you know how they tolerate those cycles. This helps you determine transplant eligibility and if they tolerate it well, especially for those you’re on the fence about. At that point, I have them see their transplant doctor. It’s important that you collect, even if the patient is on the fence about surgery, to do their transplant up front because—with cell therapy available also— sometimes we need these cells to have the count recovery and to use it for reasons besides transplant.
Saad Z. Usmani, MD: That’s very important. Neha, maybe I can go to you—would your engagement with the transplant physicians be different if this patient had high-risk disease? If he had high-risk cytogenetics, would you be worried about having too much of a gap between finishing induction, getting collected, and transplant? Would you involve the transplant doctors earlier in the discussion?
Neha Korde, MD: Yeah, absolutely. I take a different approach with my patients. I like to get that seed planted early because that’s the best thing for them. If there’s this ongoing discussion about whether they’re up for it, it helps to address it as we go through the induction. But for my high-risk patients, I’m very transplant forward, so I introduce the concept to them quickly, usually at first visit. I’m pretty up front and honest in terms of why and where the data are. For instance, if you look at the most recent FORTE study data, there seems to be a benefit for high-risk patients treated quickly in terms of PFS [progression-free survival]. For high-risk patients, I’m very wary about early relapses, so I try to incorporate the transplant conversation fairly early.
Transcript edited for clarity.
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