Published on September 30, 2021
What Should Myeloma Patients Know About Allotransplantation?
Watch as host and patient advocate Cindy Chmielewski sits down with Edward N. Libby, MD, and Sarah S. Lee, MD, two physicians at Seattle Cancer Care Alliance (SCCA), to discuss allotransplantation for multiple myeloma. This is an excerpt from our recent “Evening with the Docs” program with SCCA.
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Transcript | Experts Discuss Allotransplantation for Multiple Myeloma
Good evening, Washington, and welcome to “Evening with the Docs” for myeloma patients and their families. I'm so excited to be here with you tonight. My name is Cindy, and I'm going to be a myeloma patient who's hosting the show, and I have been living with multiple myeloma now for, I guess, since 2008. So you could do the math. It's getting late. I'm here on the East Coast and you guys are on the West Coast. I'm joined tonight by two myeloma experts, Dr. Sarah Lee and Dr. Edward Libby. Dr. Lee, would you take a few minutes to introduce yourself?
Like Cindy said, my name is Dr. Sara Lee. I recently joined the program at SCCA about a year ago. I see primarily patients with multiple myeloma and plasma cell disorders. And I actually got my start in clinical trials back when Revlimid (lenalidomide) and Velcade (bortezomib) were the only drugs that were out. And so I feel like it's a really exciting time to be treating patients with multiple myeloma. And it's really an honor to be here with you guys tonight.
Well, thank you for taking the time out of your schedule and Dr. Libby, can you share a few things about yourself?
Yes. Hi, my name is Ed Libby and I'm the director of the multiple myeloma program here at the Seattle Cancer Care Alliance. Been here for a little bit more than 10 years. I am very fortunate to have fallen into a tiny aspect of clinical oncology, and that is multiple myeloma and related diseases.
This question, I think is kind of important. A person wants to know if they had an allotransplant, will it disqualify them for CAR T-cell therapy?
How Can Allotransplantation Impact a Patient’s Treatment Journey?
It's a really good question. It's a very important question. And the answer is it could. It won't necessarily. So, the new approved CAR T-cell therapy, probably you will still be able to get it if you've had an allotransplant. It depends on a lot of things. Your insurance plan might say no. And the reason they might say no, is that the studies that were done to get this thing, Abecma (idecabtagene vicleucel) approved, the new approved CAR T-cell, there were no patients with allotransplants in that study. So an insurance company might say, "Well, there's no proof that it works. It's not to toxic, so we're not going to pay." It just depends on the insurance company. They might, they might not.
We personally, our practice because we're doing the approved CAR T-cells, as well as research CAR T-cells. Our practice will be that we're going to say, if you relapsed and you had an allotransplant that we think you should get Abecma, but we'll recommend it to the insurance company, but the insurance company, it's up to them. It's not up to us. They have to approve it. Our research, CAR T-cell studies and ours and many more around the country, are now allowing patients who've had allotransplants to get CAR T-cell to be in CAR T-cell research trials. So that's another round, but not all studies up until now have allowed allotransplant patients to get CAR T-cells.
And what's the role of allotransplants now in myeloma, who should be thinking or considering them?
What Is the Role of Allotransplantation in Multiple Myeloma Management?
It is not something that's done at many in the community. And I'd say even in a lot of transplant centers. I think if you're going to even start talking about it, go to a place that does them and does a lot of them like at Seattle Cancer Care Alliance. I think with all the treatments that we have now available for patients with multiple myeloma, we have just more options for patients who are relapsed or who have aggressive disease. Patients who are considered, who go for allogenic transplant is a very specific patient. I think there's a very strict criteria. Generally, young, really high-risk disease maybe, and a lot of other factors that go into it. So, it's not something that's generally offered as standard of care or even something that we talk about to most patients, I would say.
That's still really experimental and in some ways, so it's rarely done in myeloma. It is done, but rarely now.
So we were talking about allotransplants and CAR T-cell therapy. Does having any of the other BCMA-directed therapies, like the Blenrep (belantamab mafodotin), would that disqualify you from CAR T-cell trials coming up? And I know there's all these new bites coming up too. There are all directed at BCMA. So how careful does that patient need to be when they're choosing a BCMA-directed therapy? It's so confusing.
I think that first of all, myeloma patients who have had many different therapies that maybe used most of the good therapies need to be looking at research trials and these research trials have very good drugs that potentially will be released in the next few years. So it's a real chance to extend your life by being on a research study in myeloma. But some of these drugs, for instance, anti-BCMA drugs, whether it's a BiTE or that's in a research study or Blenrep. Blenrep could, which is an anti-BCMA approved therapy for multiple myeloma, could make you ineligible for a bi-specific antibody. Those are abbreviated as BiTEs. Those are very exciting research agents in myeloma. It could possibly make you ineligible for a CAR T-cell treatment. I don't think it would exclude you from getting the approved CAR T-cell, Abecma, that's approved by the FDA a few months ago.
I don't think Blenrep would prevent you from getting it. Blenrep could limit your response. So, that's a worry. If you get an anti-BCMA therapy of any kind, say other than a CAR T-cell, and then you get a CAR T-cell, will the CAR T-cell work as well? We don't know. So, it's something we're all concerned about. Should we use these drugs before you get a CAR T-cell? So in general, if I had a choice for a patient of mine, okay, you can have a CAR T-cell, I mean, you can have a BiTE or you can have Blenrep. I'm going to say let's get the CAR T-cell first, because I don't want anything that might interfere. We just don't know.