Published on October 23, 2020
What You Should Know About Stem Cell Transplant Recovery
What is the recovery process like after a stem cell transplant? What side effects can you expect? How long does it take for your immune system to heal? Will you be eligible for other treatments or vaccines?
During our recent Answers Now program, multiple myeloma patients and stem cell transplant survivors Jack Aiello and Steve Albano met with Dr. Amrita Krishnan from City of Hope to discuss all of these questions and more, including whether or not recovered individuals would be eligible for a future COVID vaccine.
This is Part 3 of a 3-part series. Watch all segments in the series below:
Transcript | Stem Cell Transplant Expert Talks Recovery & COVID Vaccine
How Does Stem Cell Transplant Recovery Impact Immune Response?
So certainly, we give people flu vaccines anywhere within four to six months after the transplant, the COVID vaccine is obviously going to be a dead vaccine. More the question is also, even if you get a vaccine, how much of an immune response are you going to make? Are you going to be as immune, as someone who didn't, and that's an unknown.
It's not so much the absolute number. It's more the big picture. There clearly is data emerging more and more that getting a deeper response before their transplant leads to better outcomes, but you also have to look in that big picture of how long does it take to get to that better response? Some people may not get to that better response. So those are all those things that you kind of, again, individualize. So, if someone's had the strongest drugs that we have, even four drugs, as part of the induction and haven't gotten to zero, and maybe that's at that point, you're really not going to keep going and waiting for them to get to zero before going to a transplant. The numbers in terms of your blood counts, it's 11 to 12 days after the transplant. Most people go home at day 13. So, it's actually about two weeks for the whole process.
Yeah. And then there's the issue of being tired, and we have patients in our support group who will say, "I went back to my desk job a month after having it," and others who will say, "I never quite got my energy back for a year." It really does vary, doesn't it?
Absolutely. There is interesting data from Sloan Kettering, that Dr. Giralt's published. Some of it may correlate also with your stem cell dose and cytokines that are activated during the transplant, probably all have a role in this, and explains some of the variability in terms of people's recovery.
Some of it is just yeah, cytokines, which are just sort of proteins released in your own body in response to inflammation basically, or a stimulus that's what you hear during COVID, for example, cytokines, and they cause inflammation in the body. So, the same thing happens after chemotherapy, for example. After the engraftment of stem cells, your body makes cytokines. So, a lot of that plays a role as well, this whole idea of this inflammatory picture in your body, that's ongoing and people have different responses and there's no way of predicting who falls into what group, certainly.
What Are Common Side Effects During Stem Cell Transplant Recovery?
Just a comment in terms of recovery from the stem cell transplant. For me, my biggest issue was lack of appetite and loss of weight. And it took me probably a month before I was eating normally and had regained weight. But other than that, I was back to work about a month, month and a half later, and pretty much back to normal within about three months. So, I think mine was sort of middle of the road in terms of what we hear from other patients in our support group about their experiences with transplant. It's not an easy process to go through for sure, but for me it was well worth it. The reward was well worth putting up with the difficulty of the process.
It can take really up to three months to really see the full benefit of transplant. But obviously, most of us don't want to wait three months. And also, because we want to start maintenance therapy or this concept of consolidation therapy. So, we usually repeat the myeloma tests around eight weeks after. Don't forget the IgG protein, for example, has a half-life of 30 days. So, you can't test too soon after your transplant because you're still just seeing the residual myeloma protein in a lot of patients.
Patients with high risk chromosome abnormalities, specifically really even more the 17P deletion is the one that is the most challenging. The lengths of remission are shorter than people with what we call standard risk myeloma. I mean, they're still better than they are with regular chemotherapy, but they're not to the same level that you see with someone without, for example, that 17P. Patients with t(4;14), with the advent of Velcade (bortezomib), carfilzomib (Kyprolis), and proteasome inhibitors, do seem to help that group of patients particularly. But again, you're right, patients who have higher risk, what we call advanced ISS stage, have a shorter [inaudible] standard risk.
The one thing I should say, there was a trial in Italy called the FORTE Trial, which specifically looked at people with high risk disease. So advanced stage, a stage 3 or high risk cytogenetics, comparing getting carfilzomib, lenalidomide (Revlimid), dexamethasone (Decadron) plus transplant, plus carfilzomib lenalidomide and dexamethasone again as consolidation compared to a non-transplant approach just with that carfilzomib, lenalidomide, dexamethasone and showed that transplant helped keep people in remission longer, especially in that high risk group.
How Do Transplants Compare With Other Multiple Myeloma Treatment Options?
It's interesting to me that despite all the drug developments and all the great progress that transplant remains an important and viable option for patients. And I kind of look at it as having various treatments available. And I kind of look at all these new drugs as I kind of am keeping those in reserve for future treatment. So, if I can get into remission and even if I had a second transplant, as we discussed, that I could keep additional treatments kind of in reserve for future use. I don't know if that's a scientifically valid way of thinking about it, but that's kind of how I think about it.
I think what's important to recognize, as she said herself, Dr. Krishnan, is definitely a transplant doctor. We always encourage patients to get second opinions and third opinions from myeloma experts. And there are myeloma experts out there, doctors who will not necessarily recommend the transplant, and you'll hear different responses to some of the questions that we asked. So there's nothing better than trying to get as full a picture as possible for patients before treatment is done. And like we said, it's always possible to harvest stem cells in advance. I think what Dr. Krishnan said though, that transplants were certainly a viable and an effective treatment as a first line treatment goes.
Based on some of the clinical studies, it's led to longer progression free survival. How long does it take before the disease comes back, then not having it done initially. It can be done effectively, both as an outpatient and an inpatient. And she called it the day clinic, which was the same as the outpatient. And it can also be an effective treatment for down the road. Like in your case, Steve, if, you relapse a second transplant is something that you will consider at least having as part of your treatment arsenal available to you.
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