Here’s an excerpt from an interesting and comprehensive article from the July edition of Clinical Oncology News, How I Manage: Evolving Role of Autologous Transplantation in Multiple Myeloma. It features the views of myeloma specialist, Sagar Lonial, with the Winship Cancer Institute at Emory University in Atlanta:
There is some discussion that, perhaps, patients with high-risk MM do not benefit as much from auto-HCT; however, there are data from European groups suggesting that high-risk patients actually may gain additional benefit from tandem auto-HCT.1 These conflicting data sets confuse the management of patients on a moment-to-moment basis. Our group recently published on a series of high-risk patients who were induced with RVD, followed by auto-HCT, and then placed on RVD maintenance for 3 years.2,3 These patients were all high-risk, with more than one-fourth having del 17p. In our analysis, the median progression-free survival and OS were far superior to what is reported in many other large clinical trials, suggesting that for the high-risk cohort, aggressive maintenance is needed to maintain remission. The Spanish Myeloma Group has shown that high-risk patients may achieve conventional complete remission (CR) at a rate similar to standard-risk patients, yet they fail to achieve minimal residual disease (MRD) negativity.4 This lack of MRD negativity may contribute to early and rapid relapse, especially when no maintenance therapy is planned.
Currently, which group of MM patients derives the most benefit from front-line auto-HCT?
This question also is awaiting data from randomized trials. However, careful review of older data sets may help to answer this question. For instance, data from European groups suggest that many centers have a 10% to 15% tail on the OS curve, suggesting that some patients may be cured simply with the use of alkylating agents. An update from the PETHEMA group suggests the presence of a tail on the OS curve,6 as does a series of patients from the Arkansas group, where there are more than 15% of patients from total therapy 1 (induction with vincristine, doxorubicin, dexamethasone , tandem auto-HCT with melphalan 200 mg/m2 and interferon maintenance) who are in continuous CR more than 10 years after completion of therapy.7 Based on these long-term follow-up reports and others from large cooperative groups, it appears there is a group of standard-risk patients who could be potentially cured with front-line auto-HCT. Although this may not be a large cohort of patients, the recent and soon-to-be-available new agents may serve to increase the number of patients in this cure group, and it is possible that the use of early auto-HCT may render these patients MRD-negative, thereby increasing their chances of achieving a cure…
The article delves into detail in areas not normally covered in media interviews. It’s definitely worth a look. And I’d be interested in our thoughts; some of his conclusions are a bit controversial.
Here’s the link:
Feel good and keep smiling! Pat