Here is that study again.
"Very effective combination chemotherapy using novel agents has become available in multiple myeloma. Its impact on the use of high-dose chemotherapy and autologous hematopoietic stem cell transplantation (AHCT) as part of initial therapy is unknown. Using the National Cancer Data Base, we studied the rate of upfront AHCT use among 137,409 newly diagnosed multiple myeloma patients from 1998 to 2010 in the United States and determined whether disparity exists among various sociodemographic as well as geographic subgroups.
Overall, 12,378 (9.0%) patients received AHCT as part of initial treatment. The use of upfront AHCT increased steadily from 5.2% in 1998 to 12.1% in 2010 (trend test, P < 0.001), with no sign of plateau. This was seen across all socio-geo-demographic subgroups except among patients treated in the Northeast, where the rate fell from 8.7% in 1998 to 6.6% in 2010.
In multivariable analysis, patients with the following characteristics were the least likely to receive AHCT (odds ratio):
- Year of diagnosis from 1998 to 2003 before the era of novel agents (0.67)
- Older age (0.35)
- Black race (0.58)
- Hispanic ethnicity (0.78)
- Low level of education or annual household income (0.55)
- Residence in a metro area (0.66)
- No or unknown medical insurance (0.30)
- Treatment at a community cancer center (0.16), and
- Treatment facility located in the Northeast region (0.54).
Even after the introduction of novel agents, the rate of upfront AHCT in multiple myeloma continues to increase annually. Significant disparities exist dependent on demographic, social, and geographic factors."
Reference: M Al-Hamadani et al., "Use of autologous hematopoietic cell transplantation as initial therapy in multiple myeloma and the impact of socio-geo-demographic factors in the era of novel agents," American Journal of Hematology, Aug 2014 (full text of article)
I did a quick search of the 2015 ASH abstracts to see if I could find something that would give us an idea of how many transplant-eligible patients would choose an auto for initial therapy if they had access to novel agents. I found one that may give us an idea. I am not saying this is the definitive study to show us, but it was the only one I have ever seen that does this or could give us an idea. It is a U.S.-based study.
If I am reading this correctly, the patients started off with 4 cycles of Revlimid and dex and collected stem cells after Cycle 4. They had the option of staying on Revlimid and dex or doing an auto transplant. Some patients were using Revlimid and low dose dex, and some used Revlimid with high dose dex.
The key thing is that the percentage that chose the auto was 21%.
Here is the abstract and link to that study.
Upon completion of four cycles of therapy, patients enrolled in E4A03 had the option of proceeding to ASCT or continuing on their assigned Ld or LD. A prior post-hoc retrospective landmark analysis (Siegel DS, Abstract, Blood 2010) comparing outcomes of early ASCT vs. no early ASCT showed that in patients <65, 65-70, and >70, the survival with early ASCT at 3 years appeared higher, supporting the role of early consolidative ASCT in newly diagnosed patients. This analysis is the long-term follow-up of the aforementioned study."
Results: 21% of patients opted for early ASCT (n=90). At baseline (four cycles prior), early ASCT patients were younger (median 57.5y vs 66y), more fit (ECOG PS 0 45% vs 56%) and with less aggressive disease (ISS Stage 3 12% vs 28%). Median treatment duration was 7.6m for no early ASCT patients. The 1, 2, 3, 4, and 5-year survival probability estimates were higher for early ASCT vs. no early ASCT at 99%, 93%, 91%, 85%, and 80% vs. 94%, 84%, 75%, 65%, and 57%. The median OS in the early ASCT vs. no early ASCT was not reached vs. 5.8 years, respectively (Table 1). The survival hazard ratio (HR) for early ASCT was 0.55 [95%CI (0.38-0.80)]. In a further subgroup analysis of patients </= 65, 5-yr survival probability of those who had early ASCT vs. no early ASCT was 79% [95%CI (67-87)] vs. 62% [95%CI (54-69)], respectively. In patients </= 65, median OS in the early ASCT vs. no early ASCT was not reached vs. 7.4 years and the survival HR was 0.74 [95%CI (0.48-1.15)]. For patients >65, 5-yr survival probability of those who had early ASCT vs. no early ASCT was 83% [95%CI (56-94)] vs. 52% [95%CI (45-59)], respectively. In patients >65, median OS in the early ASCT vs. no early ASCT was not reached versus 5.2 years and the survival HR was 0.38 [95%CI (0.17-0.87)]. In all age groups, overall response rate was similar prior to the decision of proceeding with ASCT vs. no early ASCT. In a multivariable model adjusting for baseline prognostic factors, early ASCT retained marginal significance.
Conclusions: The landmark analysis demonstrated that patients opting for ASCT after induction Ld/LD had a higher 1, 2, 3, 4, and 5- year survival probability and improvement in median OS regardless of DEX dose density. Results were stronger within the older age cohort and upheld in adjusted models. Limitations include lack of randomization and data on salvage therapy. At a time when lenalidomide and dexamethasone as induction is gaining worldwide acceptance in all age groups, early ASCT is safe and efficacious and should remain a standard of care for newly diagnosed multiple myeloma even in the era of novel therapies.
Reference: N Biran et al, "Outcome with Lenalidomide Plus Dexamethasone Followed By Early Autologous Stem Cell Transplantation in the ECOG-ACRIN E4A03 Randomized Clinical Trial: Long-Term Follow-up," ASH 2015 annual meeting abstract #3174.
