EHA 2015

Transplantation combined with novel agents optimal treatment for multiple myeloma

Prof Vincent Rajkumar - Mayo Clinic, Rochester, USA

With these promising improvements in terms of the efficacy of targeted agents, do you foresee a time when the need for transplant, auto-transplant, is in fact no longer?

Funny you ask me because I just finished a debate with Gordon Cook on whether the transplant is going to stay or go away. I think rather than novel agents replacing transplant they’re just going to complement transplant. For transplant eligible patients transplant is an extremely safe and effective procedure and by combining it with novel agents we are going to see the improvement in overall survival of myeloma patients much more than you would if you just eliminated the transplant. So I think transplant is still going to stay for a while until we have a cure for the disease.

What about the comparison of single versus double transplant?

There are selective patients for whom a double transplant is making a comeback. A meta-analysis by Michele Cavo from ASH of 2013 shows that subsets of patients can really benefit from the second transplant, these include patients with (4;14) and other high risk cytogenetics. These patients had a significant improvement in outcome with tandem transplant compared to a single transplant. So we are selecting our patients, it’s not for everyone, a small number of patients need a double transplant but it is something that is going to be explored in the years to come.

And in terms of any transplant is age an issue anymore?

Age is still an issue because you need to be able to do the procedure safely. We have clearly shown that up to the age of 65 it’s a very safe and effective procedure. There are some randomised data that up to 70 years there is actual benefit in survival. Beyond 70 years the data are scarce, all we know is that you can do transplant safely but in terms of randomised data showing that patients from 70-75 actually benefit, the data are not there yet.

So could you sum up what’s the bottom line take-up, round-up message for cancer doctors coming out of the meeting here at EHA in Vienna? What do you think is the state of the art now for multiple myeloma?

The state of the art is we need to diagnose the disease early because we have extremely good treatments. So we have made changes to the diagnostic criteria that enable early diagnosis. We need to incorporate the best available new agents early in the disease course, when the disease is cytogenetically in its most susceptible state. Then we need to incorporate transplant along with the new drugs rather than just dumping.