Published on October 16, 2020
Stem Cell Transplant For Multiple Myeloma As First Treatment Option
With all of the new advances in treating multiple myeloma, are autologous stem cell transplants still recommended as the first treatment option? Are stem cell transplants more successful as inpatient or outpatient procedures? What is the new standard of care?
During our recent Answers Now program, multiple myeloma patients and stem cell transplant survivors Jack Aiello and Steve Albano spoke with Dr. Amrita Krishnan from City of Hope to discuss these questions. Dr. Krishnan also covered what factors make experts more or less inclined to recommend a transplant. Tune in to hear their advice and first-hand experiences.
This is Part 1 of a 3-part series. Watch all segments in the series below:
Transcript | Autologous Stem Cell Transplant for Multiple Myeloma
Myeloma Survivor Shares Their Stem Cell Transplant Story
My myeloma story began in the summer of 2011. I had been noticing increasing shortness of breath and fatigue, and I went in to see my doctor about it. And some standard blood tests revealed that I was anemic and not just a little bit anemic, but pretty far down into the moderate range. He ran some additional tests to investigate the cause of the anemia and those tests revealed the diagnosis of myeloma.
I was put on an initial induction chemotherapy regime using combinations, first of bortezomib (Velcade) and dexamethasone (Decadron), then of lenalidomide (Revlimid) and dexamethasone. I had sort of a slow response to that, but my symptoms did improve. My myeloma numbers decreased, although the induction therapy did not get me into remission. So my doctors then recommended a stem cell transplant. And I went ahead and had the stem cell transplant done at Stanford University in January of 2013. That worked very well for me. It did get me into remission and I've remained in remission since that time. I've had a great quality of life and I consider myself to have been very fortunate.
So, Dr. Krishnan, some facilities do transplants as an inpatient procedure. Some do it as an outpatient procedure, which is what I had. From the patient's perspective, which is better?
Is There a Difference Between Inpatient and Outpatient Transplants?
So we actually also opened a day hospital about five years ago. We've probably done about 500 transplants in our day hospital now. I can tell you, in terms of infection rate, it's lower in the day hospital. Patients are happier because, there's much more autonomy in terms of just being able to sleep better at night, as most people know, sleeping in the hospital is probably the hardest thing. Obviously with COVID, things changed a little bit. We have actually reopened our day hospital. We have testing now, the caregiver, as well as the patient, but it does limit the amount of activity people can do. Patients can't really go out and go for a walk, those kinds of things, the same way we could pre-COVID.
What Factors Make Doctors More or Less Inclined to Recommend a Transplant?
Yeah. And another question now. For patients who are transplant eligible, what factors might make you more inclined or less inclined to recommend a transplant for a particular patient?
So, that's a great question Steve. I think a lot of it, you're right, we're speaking to, is individualizing that decision for each patient now. So sometimes it's clear where we think transplant would be a benefit. For example, someone who hasn't gone into a complete remission after fairly intense initial therapy. We feel that transplant may offer you that opportunity to get into a deeper response, for example. But for patients who have higher risk disease, we feel that more intensive therapy beyond just standard induction therapy, again, will give them a better chance of staying in remission.
So those groups of patients, it's an easier discussion. But for other patients, for example, if you have low risk myeloma, that's gone into a deep response with just the standard therapy, which is usually Revlimid, Velcade, and Dex, it's a more nuanced discussion in terms of what is the benefit of transplant. And I can tell you, Dr. Giralt from Sloan-Kettering and myself are doing another webinar where we exactly discuss that, should I have a stem cell transplant? Our bias has been that doing transplant early gives you the longest remission. And the morbidity of it has improved as we've gotten better at doing it. But there are patients who obviously have social factors, psychological factors, many other issues who choose not to. So we certainly then encourage collecting and store [inaudible].
What Should Patients Consider When Deciding if They Should Get a Transplant?
So I'm going to ask a similar question in a different way, because the number one question I get from patients, and I've already seen two or three chat questions being asked is, the patient who gets a really good, even a complete response during induction asks, "Why should I then get a transplant?” Some also ask, “With so many other treatment options, can I actually reach what's known as MRD-negative status with or without a transplant?" Can you share more insights into what patients should consider when making these decisions?
So I think you touched on it, Jack, in terms of the depth of response is getting more and more important. So we do have a trial, the IFM Dana-Farber trial, which randomized patients to after RVD chemotherapy, four cycles, everyone had stem cells collected, half the people had a transplant, the other half had four more cycles of RVD. So the important thing is then they looked at MRD. So you had about a 20% better chance of becoming MRD negative with the transplant. So the problem is you don't know after four cycles, are you going to be in that group who will become MRD after eight or not. So some of this, it's not going to help you make that decision when you go see your doctor at four cycles, is the challenge, which is why I said, it's a little easier to make a decision in people who haven't gotten the complete remission because you already know that they're not going to be and they don't have the same depth of response.
So, I think the issues are, we do know that transplant still gives you a better chance of a deepest remission. The other thing is we have data, so did a great retrospective trial of a thousand patients treated with RVD and looked at those who got to transplant, they had a median progression-free survival, in terms of lengths of remissions, that was about 60 months and up to 76 months. So right now we don't have too many other frontline treatments outside of transplant that can give you five to six years of response and remission.
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