Clifton C. Mo, MD, of Dana-Farber Cancer Institute, Boston, Massachusetts, also noted that this retrospective study adds value to the field by demonstrating that transplant can play a significant role on a case-by-case basis in patients of relatively advanced age. However, Dr Mo questioned whether many of these patients need to be transplanted given the significant advances in novel therapies made in the last 15 years.
In fact, in the current treatment era, sending patients to transplant in their first remission is increasingly becoming an area of controversy among myeloma specialists, he said.
“Historically, an ‘upfront’ transplant in first remission has been the standard of care, but, in my opinion, it is no longer a one-size-fits-all scenario where everyone fit enough to get a transplant should get one,” Dr Mo said. “There are now patients who may be able to do quite well in the long run without the need for immediate transplant.”
These advances are mainly due to the advent of multiple highly efficacious novel agents that are much better than their cytotoxic chemotherapy predecessors in terms of getting patients into deep and durable remissions.
“In what I would call the ‘RVD [lenalidomide, bortezomib, and dexamethasone] era,’ the available evidence does not suggest an across-the-board survival benefit to upfront transplant in patients of any age,” Dr Mo said. “In the pre-RVD era, you could look a patient in the eye and confidently quote them a survival advantage by going to transplant in first remission, but I just don’t think the data allow us to do that anymore. It is a much grayer area now in terms of proven benefit.”
For example, the IFM 2009 Study showed that RVD therapy plus transplantation significantly prolonged progression-free survival compared with RVD alone (adjusted HR, 0.65; P <.001), but overall survival at 4 years was not significantly different between the 2 groups.4
For a fit patient aged 70 to 75 years, Dr Mo said he still presents ASCT as an option – especially for patients with high-risk cytogenetics and those with poor responses to initial novel agent therapy — but encourages patients to approach the decision to transplant cautiously, educating them about the real risks and significant toxicity.
“I am cautious in terms of making sure that I am taking the right septuagenarian to transplant for the right reasons, rather than not considering age as a factor at all,” he said.
Dr Munshi said that these data were not intended to answer the question of whether to transplant these older patients. That answer does not currently exist, she said.
“The question was to look at outcomes in elderly patients compared with younger patients,” Dr Munshi said. “These data should make the community physician feel more comfortable to refer patients with myeloma to transplant to allow transplant specialists to make a thorough assessment as to whether transplant is the right option.”
Finally, Dr Munshi pointed to a racial disparity in the data indicating that Blacks are underrepresented among patients undergoing transplant. Of the almost 16,000 patients undergoing transplant included in the study, 78% had a self-reported race of White and 85% of patients 70 years or older self-reported as White.
“This shows that we need to see more representation of other populations and not just Caucasians,” Dr Munshi said. “Myeloma is much more prevalent in African-American populations, so these data may reflect a bit of a referral bias.”
However, Dr Mo said that it is important to note that overall outcomes for Black patients with myeloma in the United States are currently not inferior to those of Whites, suggesting novel therapies may in turn be further improving survival more broadly, given the observations described above.2
- Kaufmann GP, Gertz MA, Dispenzieri A, et al. Impact of cytogenetic classification on outcomes following early high-dose therapy in multiple myeloma. Leukemia. 2016;30(3):633–639.
- National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Cancer stat facts: Myeloma. Accessed January 27, 2020.
- Munshi PN, Hari P, Vesole DH, et al. Breaking the glass ceiling of age in transplant in multiple myeloma. Presented at: 61st American Society of Hematology (ASH) Annual Meeting and Exposition; December 7-10, 2019; Orlando, FL. Abstract 782.
- Attal M, Lauwers-Cances V, Hulin C, et al. Lenalidomide, bortezomib, and dexamethasone with transplantation for myeloma. N Engl J Med. 2017;376:1311-1320.