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Published on November 5, 2020
What Do I Need to Know About Consolidation Therapy and Stem Cell Transplants?
After induction therapy for AML, there is a second phase of therapy called “consolidation,” which is intended to rid the body of any remaining cancer cells. There are many different consolidation therapy treatment options, from chemotherapy to stem cell transplant. Hear a doctor explain stem cell transplant consolidation therapy, including what it entails and reasons why an individual may be eligible or ineligible for this treatment.
Dr. Elizabeth Bowhay-Carnes, director of the Adult Non-Malignant Hematology Program and co-director of the Adolescent/Young Adult Oncology Program at UT Health San Antonio MD Anderson Cancer Center, has the answers to frequently asked questions from patients.
This program is sponsored by AbbVie Inc. and Genentech Inc. These organizations have no editorial control. It is produced by Patient Power, and Patient Power is solely responsible for program content.
Transcript | Consolidation Therapy and Stem Cell Transplants for AML
What is Consolidation Therapy?
Dr. Bowhay-Carnes: So after induction, then this second phase, if you will, medically we call it consolidation. The idea of consolidation is that we have killed off as many cancer cells as possible in the beginning, and then we want to kill off any cancer cells that could be hiding still somewhere in someone's body, to give a patient the best chance of a true cure or prevention of the cancer from coming back.
So, when we talked about consolidation, one path is further chemotherapy, using one of the chemotherapy drugs that was given in induction. Another consolidation path is using the azacitidine (Vidaza), venetoclax (Venclexta) after a different combination of induction. Or another path is an allogeneic bone marrow transplant. And we have a few patients who have joined us, who are recovering from the bone marrow transplant.
How Does a Bone Marrow Transplant Work?
I like to call a bone marrow transplant an immune system cell transplant. So, it's a process where, as these cancer cells they're being made in the bone marrow, so we treat people with strong chemotherapy that will kill off the cells in the bone marrow. And then we give them someone else's bone marrow stem cells, and then those will grow back and create a new immune system in their body. So, this bone marrow transplant is used for patients as a method to try to cure the acute myeloid leukemia. The choice of whether someone should pursue a bone marrow transplant also depends on a lot of factors.
One of those is where are we going to get the cells that will be transplanted into someone's body. We always look for the best match. And so, as this process is going along with your treatment team, frequently they will start the process if the transplant is considered before making the final decision to go ahead with the transplant, to see if someone has a good match or not. The better the match, the less side effects and the better the chance of a good outcome from the transplant is.
Are You Eligible for a Transplant if You are Not MRD Negative After Induction?
Not everyone is a good candidate and should undergo a transplant. Everyone — we look at their case individually and determine if we should consider a transplant. And there's a few different things that we have to look at. Again, we have to look at the patient themself, do they have any other medical problems, age, and do they have a good match or not? Secondly, we have to look at the status of the cancer. In order for a bone marrow transplant to be successful, there has to be a minimal amount of cancer left. If there is still a very large amount of leukemia in someone's body, then transplants have not been shown to be effective.
If You’re an Older Patient, Can You Still Receive a Transplant?
Age is one of the factors that is looked at... So, it does matter, but it's not the only factor. And I do stress that there is not a strict cutoff of age. So, in the medical literature, when we do research studies, we usually divide patients at the age of 60. So, 60 and older versus younger, but that age is not a strict cutoff for being able to consider a bone marrow transplant. That is more of a, when we look at the data on how patients do from a research setting.
How Hard is it to Find a Stem Cell Transplant Match?
Well, the fact that we have increased diversity helps make it easier to find a match. When we're looking through the bone marrow donor databases, it's actually an international process. So, you can look for matches across the world, but historically it is true that people from European ethnicity descent had an increased chance of finding a match through an unrelated donor search than people from other ethnic backgrounds. That should not discourage somebody, regardless if they're deemed eligible for a transplant. The transplant team will do their best to find a match, but the take home point to everybody on this meeting is we would encourage you to get the word out for your friends and family, loved ones, church community, people within your civic community, to consider being bone marrow donors to increase the chances that someone will find a good match.
What are the Differences Between Stem Cell Transplants and Cord Blood Transplants?
So that comes down to finding the best match. So, a cord blood transplant is another form of being able to get stem cells. And so, in the hierarchy of the cells we like to get, so one option is if you have a perfectly matched sibling, brother or a sister, that tends to be the best. The next option is to be looking at a perfectly matched unrelated donor. But many people do not have those matches, a matched related donor, unrelated donor. So, then we search for other sources of the stem cells that can be used for our transplant. And one of those is cord blood. And so, it's not necessarily that hematopoietic stem cells from bone marrow versus cord blood is better than the other. It depends what's the best match for that patient. So that's why cord blood is considered in that way.
Does a Transplant Eliminate the Genetic Mutations Present in Your AML?
If the genetic mutations were in the hematopoietic stem cells, then the hope is it will kill those hematopoietic stem cells and you get new cells put in. So, it would get rid of the genetic mutations in those cells.
What Happens After a Stem Cell Transplant?
Patients are continued to be closely monitored by their leukemia team and the transplant team after a transplant. We do celebrate if a repeat bone marrow comes back as no cancer, but we do need to continue monitoring. There are some other steps such as patients need to receive all their vaccinations again, that they would have received as a child. And when we're giving someone a whole new immune system, we have to think of it as their immune system is like a newborn baby again and have to give them all their child vaccinations back over the next few years. And so, there's an ongoing treatment process, but it's focused more on trying to have that new immune system be as healthy and functioning as possible while someone recovers from the process.
Are We Moving Away from Utilizing Transplants?
In some patients that we have targeted mutations and a medicine that is effective against those mutations, then yes, we would be getting away from transplant, but there are still a lot of patients, actually, the majority of patients with AML, that we don't yet have a medicine that can target their mutations. So, transplant still plays a very important role in those pieces.