I have my autologous stem cell transplant on November the 8th. My team of doctor's have decided that plan B is a mini allogeneic transplant, either at relapse, or they may offer it to me 3 months after my autologous stem cell transplant and still do it regardless.
I personally have decided to wait after my stem cell transplant in case I have a long remission and deal with it later on relapse. I'm not sure what the advantage is to rush and do a mini allogeneic transplant if you have not relapsed.
Is there an advantage? Can anyone provide information, or personal experiences, about the possibility of doing a mini allogeneic transplants right after an autologous stem cell transplant?
Any advice would be great. Thanks.
Forums
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Dean UK - Name: Dean
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: April 2016
- Age at diagnosis: 41
Re: Mini allogeneic transplant after autologous transplant
Hi DeanUK,
If you want you can search my old posts. I did a couple posts about what patients should consider an upfront allo transplant in this thread:
"Decision time - should I do an allo transplant?" (started Nov 12, 2015)
You wrote:
Allo transplant in first complete response (i.e., the first time a patient has achieved a complete response, which almost always will be after initial treatment) is the therapy with the best chance of curing a myeloma patient currently. Allo transplants are rarely successful in a relapsed setting. I have posted many times in the past showing this.
Asking why you would "rush" to do an allo transplant in first complete response (CR1) tells me you do not understand why you have myeloma or how an allo transplant works. Your immune system is not functioning properly. If it was, you would not have progressed to active myeloma. A myeloma patient is not deficient in Velcade, Revlimid, or melphalan. A healthy functioning donor immune system is the best maintenance therapy in all of blood cancer, in my opinion. It takes about 3 years for the donor immune system to get strong enough to cure the patient. If you do it in a relapsed setting, you will most likely relapse prior to that and the donor immune system will be corrupted by the disease just like your current one is.
What you find when you ask this question in the forum is the few of us who did an allo as part of their upfront therapy are happy with their decision. The patients that never did one and doctors that do not attempt to cure their patients will have negative things to say about the therapy. The thread I posted above shows this very well with respect to the patients.
I am a high-risk patient whose median overall survival is typically 18 months or so. I am currently in a myeloma drug-free remission for about 5 and a half years and enjoy an excellent quality of life. I am very happy with my decision to "rush" and do an allogeneic transplant in first complete response. I did a full allogeneic transplant as opposed to a "mini". I am a very fortunate patient to have had the opportunity to do an allo transplant in first complete response and have the chance at having the best outcome - never relapse, and have no noticeable side effects from the therapy 5 years later. If you view the procedure in a negative way, you should not do it, as your donor has to go through a lot of medical tests, donate cells, etc. Better to not do it if you do not appreciate / understand what your donor is doing for you or why you are doing it.
Good luck moving forward. The fact that your doctors are bringing up potentially doing an allo transplant in CR1 tells me you have some sharp doctors on your team.
Mark
If you want you can search my old posts. I did a couple posts about what patients should consider an upfront allo transplant in this thread:
"Decision time - should I do an allo transplant?" (started Nov 12, 2015)
You wrote:
I'm not sure what the advantage is to rush and do a mini allogeneic transplant if you have not relapsed.
Allo transplant in first complete response (i.e., the first time a patient has achieved a complete response, which almost always will be after initial treatment) is the therapy with the best chance of curing a myeloma patient currently. Allo transplants are rarely successful in a relapsed setting. I have posted many times in the past showing this.
Asking why you would "rush" to do an allo transplant in first complete response (CR1) tells me you do not understand why you have myeloma or how an allo transplant works. Your immune system is not functioning properly. If it was, you would not have progressed to active myeloma. A myeloma patient is not deficient in Velcade, Revlimid, or melphalan. A healthy functioning donor immune system is the best maintenance therapy in all of blood cancer, in my opinion. It takes about 3 years for the donor immune system to get strong enough to cure the patient. If you do it in a relapsed setting, you will most likely relapse prior to that and the donor immune system will be corrupted by the disease just like your current one is.
What you find when you ask this question in the forum is the few of us who did an allo as part of their upfront therapy are happy with their decision. The patients that never did one and doctors that do not attempt to cure their patients will have negative things to say about the therapy. The thread I posted above shows this very well with respect to the patients.
I am a high-risk patient whose median overall survival is typically 18 months or so. I am currently in a myeloma drug-free remission for about 5 and a half years and enjoy an excellent quality of life. I am very happy with my decision to "rush" and do an allogeneic transplant in first complete response. I did a full allogeneic transplant as opposed to a "mini". I am a very fortunate patient to have had the opportunity to do an allo transplant in first complete response and have the chance at having the best outcome - never relapse, and have no noticeable side effects from the therapy 5 years later. If you view the procedure in a negative way, you should not do it, as your donor has to go through a lot of medical tests, donate cells, etc. Better to not do it if you do not appreciate / understand what your donor is doing for you or why you are doing it.
Good luck moving forward. The fact that your doctors are bringing up potentially doing an allo transplant in CR1 tells me you have some sharp doctors on your team.
Mark
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Mark11
Re: Mini allogeneic transplant after autologous transplant
I had a mini allo 8 weeks after my auto transplant. I am 18 months post, taking no maintenance meds and fortunate also to require no immunosuppression. I second Mark in saying if you want to be cured, this is your best shot. Allo transplants done at relapse do not provide any benefit greater than other much easier options.
Cindy
Cindy
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CindyBrown - Name: Cindy Brown
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: 4/26/14
- Age at diagnosis: 48
Re: Mini allogeneic transplant after autologous transplant
Thank you Mark and Cindy,
Info has been great. Now after reading your posts, I really want to crack on and go for both now as soon as. I'm seeing the team of doctors this week to see what they have decided. Two of the doctors in the team are saying allogeneic later, the other 4 want go for next year after your stem cell transplant when I'm in remission
I was told they will make there final decision on a recent study been done as only a small few have been done in the UK. Fingers crossed will know next week. Now I understand the advantage of doing allogeneic early. I'm very worried about the risks, but either way I've decided I want to do it.
Thanks again for taking the time to reply
Info has been great. Now after reading your posts, I really want to crack on and go for both now as soon as. I'm seeing the team of doctors this week to see what they have decided. Two of the doctors in the team are saying allogeneic later, the other 4 want go for next year after your stem cell transplant when I'm in remission
I was told they will make there final decision on a recent study been done as only a small few have been done in the UK. Fingers crossed will know next week. Now I understand the advantage of doing allogeneic early. I'm very worried about the risks, but either way I've decided I want to do it.
Thanks again for taking the time to reply
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Dean UK - Name: Dean
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: April 2016
- Age at diagnosis: 41
Re: Mini allogeneic transplant after autologous transplant
Hello Dean:
I do not have direct experience with allogeneic transplants, as do Cindy and Mark. No one, I am sure, will go into an allo transplant – i.e., a transplant using stem cells from another person, a donor – lightly. I am not sure where you are on the research curve, however, so I thought I might relay to you some basic information (and maybe you know all this already).
Allo transplants were carried out more frequently for multiple myeloma in the 1990s, but have been used less frequently since then, particularly in the U.S., with the emergence of newer treatment approaches. Because they are not carried out very frequently in multiple myeloma, the allo-related data in multiple myeloma is not "deep". Numbers are somewhat less "hard". There are not hundreds or thousands of data points, as there are with other multiple myeloma treatments (unless you go back many years). Allos are more frequently used for leukemia or lymphoma, and perhaps some other conditions, as those are very aggressive conditions with less treatment options. So even though there is not a lot of data on allo transplantation in multiple myeloma, there is still other data on the overall procedure.
Being young (for multiple myeloma) and presumably in good health, it is not surprising that your doctors would present the option to you, as the chance for a long-term remission. In my research, the terminology used by doctors is "potentially curative".
The bottom line numbers, I believe, for allo transplants is that the rate of long term remission / cure is in the range of 20%. The rate of treatment-related mortality (death in one year) is about 20%, and the remaining 60% do relapse. It is hard to pin those numbers down, as I mentioned, based on the paucity of data points. As a reference, the treatment-related mortality for autologous stem cell transplants, which use your own stem cells, is in the range of 1% to 1.5% range, and there is a good deal of data on that. The best case for allo transplants is the very rare case of identical twins. In that case, there is no graft versus host disease, and the procedure is usually successful.
I recall another poster, (I believe it was TerryH) indicating that the risk/reward also relates to how good the donor match is. A full match will increase the success rate, and lower the side effect / mortality rate, whereas less than a full match pushes the numbers negatively.
I have read that allo transplants for multiple myeloma are done most frequently in Germany and Northern Europe.
I wish you the best in evaluating all your options and making your decision. I would suggest, however, that if you decide to go for the allo, find a facility that has a lot of experience with the procedure and does them regularly. Such a facility will have a better critical mass of specialists to deal with the potential of rare and troublesome side effects that might arise.
Good luck to you.
I do not have direct experience with allogeneic transplants, as do Cindy and Mark. No one, I am sure, will go into an allo transplant – i.e., a transplant using stem cells from another person, a donor – lightly. I am not sure where you are on the research curve, however, so I thought I might relay to you some basic information (and maybe you know all this already).
Allo transplants were carried out more frequently for multiple myeloma in the 1990s, but have been used less frequently since then, particularly in the U.S., with the emergence of newer treatment approaches. Because they are not carried out very frequently in multiple myeloma, the allo-related data in multiple myeloma is not "deep". Numbers are somewhat less "hard". There are not hundreds or thousands of data points, as there are with other multiple myeloma treatments (unless you go back many years). Allos are more frequently used for leukemia or lymphoma, and perhaps some other conditions, as those are very aggressive conditions with less treatment options. So even though there is not a lot of data on allo transplantation in multiple myeloma, there is still other data on the overall procedure.
Being young (for multiple myeloma) and presumably in good health, it is not surprising that your doctors would present the option to you, as the chance for a long-term remission. In my research, the terminology used by doctors is "potentially curative".
The bottom line numbers, I believe, for allo transplants is that the rate of long term remission / cure is in the range of 20%. The rate of treatment-related mortality (death in one year) is about 20%, and the remaining 60% do relapse. It is hard to pin those numbers down, as I mentioned, based on the paucity of data points. As a reference, the treatment-related mortality for autologous stem cell transplants, which use your own stem cells, is in the range of 1% to 1.5% range, and there is a good deal of data on that. The best case for allo transplants is the very rare case of identical twins. In that case, there is no graft versus host disease, and the procedure is usually successful.
I recall another poster, (I believe it was TerryH) indicating that the risk/reward also relates to how good the donor match is. A full match will increase the success rate, and lower the side effect / mortality rate, whereas less than a full match pushes the numbers negatively.
I have read that allo transplants for multiple myeloma are done most frequently in Germany and Northern Europe.
I wish you the best in evaluating all your options and making your decision. I would suggest, however, that if you decide to go for the allo, find a facility that has a lot of experience with the procedure and does them regularly. Such a facility will have a better critical mass of specialists to deal with the potential of rare and troublesome side effects that might arise.
Good luck to you.
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JPC - Name: JPC
Re: Mini allogeneic transplant after autologous transplant
JPC wrote:
Wrong. Those statistics apply to transplants done for patients who are relapsed or not in remission. Please show a link to a recent study that shows those statistics for allos in an upfront setting.
The bottom line numbers, I believe, for allo transplants is that the rate of long term remission / cure is in the range of 20%. The rate of treatment-related mortality (death in one year) is about 20%, and the remaining 60% do relapse.
Wrong. Those statistics apply to transplants done for patients who are relapsed or not in remission. Please show a link to a recent study that shows those statistics for allos in an upfront setting.
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Mark11
Re: Mini allogeneic transplant after autologous transplant
Hi Mark,
You wrote:
Well, how about:
Lokhorst, HM, et al., "Reduced Relapse Rate In Upfront Tandem Autologous/Reduced-Intensity Allogeneic Transplantation In Multiple Myeloma Only Results In Borderline Non-Significant Prolongation Of Progression-Free But Not Overall Survival", Haematologica, December, 2015 (full text of article)
which concluded:
"With the longest follow-up (median 113 months after Auto-SCT therapy) in published studies as yet, we found no benefit for Allo-SCT as part of first-line therapy on PFS and OS. The positive graft-versus-myeloma effect as demonstrated by the significantly reduced incidence of relapse in the donor arm did not compensate for the higher TRM"
Or how about the results of this study, which was instrumental in decreasing how often allo transplants are done for myeloma patients in the U.S.
Krishnan, A, et al., "Autologous haemopoietic stem-cell transplantation followed by allogeneic or autologous haemopoietic stem-cell transplantation in patients with multiple myeloma (BMT CTN 0102): a phase 3 biological assignment trial," The Lancet Oncology, December 2011 (abstract, full text of article at Pubmed Central)
which found:
"In this trial of autoHCT followed by alloHCT using a non-myeloablative conditioning regimen in patients with [standard risk disease], we demonstrate no benefit of this approach in three-year PFS or OS compared to auto-auto. There was indirect evidence of a graft-vs.-myeloma effect with a 60% reduction in the risk of relapse in patients diagnosed with chronic GVHD. TRM was significantly higher in the auto-allo group (11% vs. 4%), despite use of a non-myeloablative conditioning regimen."
Note that, among the high-risk patients in the above study, 3-year overall survival was lower in the auto-allo patients (59%) than in the auto-auto patients (67%).
None of this means Dean should not pursue the auto-allo option. I strongly believe he should learn more about the option. He should ask his doctors what to expect in terms of treatment-related mortality, progression-free survival, overall survival, his chances for a true cure, etc. And Dean, if you do that, please let us know what you're told.
I also agree that younger myeloma patients with very high-risk disease should seriously consider the allo transplant option.
But, having said all that, I think it's also true that a lot of the published "pro allo transplant" studies are based on single-center datasets, or are retrospective in nature, or both. I have in mind the John Theurer (Hackensack) study that was published a couple of years ago, recent data from Wisconsin that have been published, and the like.
I believe the results of large, controlled trials – the kind of studies physicians put a lot of weight on – have generally not been very favorable to allo transplantation.
You wrote:
Please show a link to a recent study that shows those statistics for allos in an upfront setting.
Well, how about:
Lokhorst, HM, et al., "Reduced Relapse Rate In Upfront Tandem Autologous/Reduced-Intensity Allogeneic Transplantation In Multiple Myeloma Only Results In Borderline Non-Significant Prolongation Of Progression-Free But Not Overall Survival", Haematologica, December, 2015 (full text of article)
which concluded:
"With the longest follow-up (median 113 months after Auto-SCT therapy) in published studies as yet, we found no benefit for Allo-SCT as part of first-line therapy on PFS and OS. The positive graft-versus-myeloma effect as demonstrated by the significantly reduced incidence of relapse in the donor arm did not compensate for the higher TRM"
Or how about the results of this study, which was instrumental in decreasing how often allo transplants are done for myeloma patients in the U.S.
Krishnan, A, et al., "Autologous haemopoietic stem-cell transplantation followed by allogeneic or autologous haemopoietic stem-cell transplantation in patients with multiple myeloma (BMT CTN 0102): a phase 3 biological assignment trial," The Lancet Oncology, December 2011 (abstract, full text of article at Pubmed Central)
which found:
"In this trial of autoHCT followed by alloHCT using a non-myeloablative conditioning regimen in patients with [standard risk disease], we demonstrate no benefit of this approach in three-year PFS or OS compared to auto-auto. There was indirect evidence of a graft-vs.-myeloma effect with a 60% reduction in the risk of relapse in patients diagnosed with chronic GVHD. TRM was significantly higher in the auto-allo group (11% vs. 4%), despite use of a non-myeloablative conditioning regimen."
Note that, among the high-risk patients in the above study, 3-year overall survival was lower in the auto-allo patients (59%) than in the auto-auto patients (67%).
None of this means Dean should not pursue the auto-allo option. I strongly believe he should learn more about the option. He should ask his doctors what to expect in terms of treatment-related mortality, progression-free survival, overall survival, his chances for a true cure, etc. And Dean, if you do that, please let us know what you're told.
I also agree that younger myeloma patients with very high-risk disease should seriously consider the allo transplant option.
But, having said all that, I think it's also true that a lot of the published "pro allo transplant" studies are based on single-center datasets, or are retrospective in nature, or both. I have in mind the John Theurer (Hackensack) study that was published a couple of years ago, recent data from Wisconsin that have been published, and the like.
I believe the results of large, controlled trials – the kind of studies physicians put a lot of weight on – have generally not been very favorable to allo transplantation.
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JimNY
Re: Mini allogeneic transplant after autologous transplant
Well thanks again JPC, Mark, and Jim.
All information is always a great help with every one's individual views
At present I have decided to go early with the mini allogeneic transplant as I feel I want to do this on my terms, not the myeloma's, as I'm already in a stringent complete response (sCR) after induction and hopefully should stay that way after the autologous stem cell transplant. The last 3 months I've not been on treatment and the disease seems to be stable. I do not have any FISH test results as my local hospital, where I was first diagnosed, forgot to run the test. After induction, a FISH test was done, but it came back clear of myeloma, so I still had no FISH test result. So I could be high risk; I just don't know. Hence another reason to go early with my allo as you don't get maintenance in the UK.
I managed to track down two patients down in the UK who have had an autologous transplant followed by a mini allogeneic transplant (not many have been done). One patient sailed through and is doing well. The second patient one year later is only just starting to feel better but is lucky to be alive. Everyone is different.
Still not sure if I'm doing my allo early as the team of doctors still hasn't decided. I suppose it's a good thing they are not rushing their decision. So it's a waiting game for me to find out, but it should be any day now.
I'm have my transplant done at King's Collage in London . This is where my new team is. It's one of the leading teams for transplants, so I definitely feel in safe hands.
When I was at Kings, I got talking to 2 patients with myeloma. One had an allogeneic transplant 8 years ago and has just relapsed, I did ask him if he was in complete response before the allogeneic transplant went ahead, and he did say "No," as his myeloma was getting out of control and he had no choice. Maybe that's why he relapsed as he was not in complete response (CR)? The second patient is 10 years since his first stem cell transplant only and no signs. I thought get your head around that then Dean. The world of myeloma is unbelievable. You just have to go with what you think is right for that time and it's horrible that we have to make life-changing decisions. Myeloma is such a unique disease. This is one thing I have learnt since my diagnosis.
My wife wants me to wait due to the risks and want us as a family to be normal for 2017, but I look at my young daughters and I feel I have to do it otherwise I will say "What if?". Either way, I will keep you all updated, as over the months since being diagnosed, you all at the Beacon have been a great help and support to me. (Sorry if I have gone on too long.)
Dean
All information is always a great help with every one's individual views
At present I have decided to go early with the mini allogeneic transplant as I feel I want to do this on my terms, not the myeloma's, as I'm already in a stringent complete response (sCR) after induction and hopefully should stay that way after the autologous stem cell transplant. The last 3 months I've not been on treatment and the disease seems to be stable. I do not have any FISH test results as my local hospital, where I was first diagnosed, forgot to run the test. After induction, a FISH test was done, but it came back clear of myeloma, so I still had no FISH test result. So I could be high risk; I just don't know. Hence another reason to go early with my allo as you don't get maintenance in the UK.
I managed to track down two patients down in the UK who have had an autologous transplant followed by a mini allogeneic transplant (not many have been done). One patient sailed through and is doing well. The second patient one year later is only just starting to feel better but is lucky to be alive. Everyone is different.
Still not sure if I'm doing my allo early as the team of doctors still hasn't decided. I suppose it's a good thing they are not rushing their decision. So it's a waiting game for me to find out, but it should be any day now.
I'm have my transplant done at King's Collage in London . This is where my new team is. It's one of the leading teams for transplants, so I definitely feel in safe hands.
When I was at Kings, I got talking to 2 patients with myeloma. One had an allogeneic transplant 8 years ago and has just relapsed, I did ask him if he was in complete response before the allogeneic transplant went ahead, and he did say "No," as his myeloma was getting out of control and he had no choice. Maybe that's why he relapsed as he was not in complete response (CR)? The second patient is 10 years since his first stem cell transplant only and no signs. I thought get your head around that then Dean. The world of myeloma is unbelievable. You just have to go with what you think is right for that time and it's horrible that we have to make life-changing decisions. Myeloma is such a unique disease. This is one thing I have learnt since my diagnosis.
My wife wants me to wait due to the risks and want us as a family to be normal for 2017, but I look at my young daughters and I feel I have to do it otherwise I will say "What if?". Either way, I will keep you all updated, as over the months since being diagnosed, you all at the Beacon have been a great help and support to me. (Sorry if I have gone on too long.)
Dean
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Dean UK - Name: Dean
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: April 2016
- Age at diagnosis: 41
Re: Mini allogeneic transplant after autologous transplant
Dean,
You may already have spotted it before, but this link will take you to a list of all allo-related discussions here in the forum.
The link is to the results of a forum "advanced search" that returns any forum discussion having either "allo", "allogeneic", or "donor" in the topic title. (You can find the link in the "Forum Discussions - View By Specific Subject" area on the right side of the forum, and also in the "Useful links to previous forum discussions" posting at the top of the Treatments & Side Effects section of the forum.)
Mark is the forum's resident expert on allo transplants, and you'll find feedback from him in just about every allo-related thread.
Over time, I've found it useful to familiarise myself with how to use the forum's basic and advanced search. You can dig up LOTS of useful information. Just bear in mind when you're doing searches that you want to use keywords, like "allo" or "melphalan" or "maintenance", and not type in entire questions, like "What is an allo transplant".
Glad to hear that you've had such a tremendous response to induction therapy. Hope both of your transplants are smashing successes and you achieve a permanent remission.
Cheers!
You may already have spotted it before, but this link will take you to a list of all allo-related discussions here in the forum.
The link is to the results of a forum "advanced search" that returns any forum discussion having either "allo", "allogeneic", or "donor" in the topic title. (You can find the link in the "Forum Discussions - View By Specific Subject" area on the right side of the forum, and also in the "Useful links to previous forum discussions" posting at the top of the Treatments & Side Effects section of the forum.)
Mark is the forum's resident expert on allo transplants, and you'll find feedback from him in just about every allo-related thread.
Over time, I've found it useful to familiarise myself with how to use the forum's basic and advanced search. You can dig up LOTS of useful information. Just bear in mind when you're doing searches that you want to use keywords, like "allo" or "melphalan" or "maintenance", and not type in entire questions, like "What is an allo transplant".
Glad to hear that you've had such a tremendous response to induction therapy. Hope both of your transplants are smashing successes and you achieve a permanent remission.
Cheers!
Re: Mini allogeneic transplant after autologous transplant
Hi JimNY,
The first study used VAD – vincristine, doxorubicin, and dexamethasone – as induction. That hardly qualifies as a modern trial with patients doing an allo in first remission. The second study also did not include novel agents in induction and only had short term followup (3 years) when I posted, As stated in my post, it takes a minimum of 3 years for the donor immune system to show an advantage for patients that are in remission at the time of transplant.
Please post a link to a modern study that shows a 20% treatment-related mortality and a 20% cure rate with patients that did the transplant in first remission like I did mine.
You all just do not understand that the key to having a successful allo transplant is doing it in first complete response, and that is why studies with VAD induction are irrelevant to a patient considering an allo transplant today. Note the comments of Paul Richardson, hardly a pro allo transplant doctor, on this topic:
"In aggregate, both studies also provide important information to challenge a strongly held view in the field of myeloma that there is little or no role for allo-HCT. Each suggest a rationale for further prospective studies, and in particular, they lend support to the further integration of novel therapies into allo-HCT. Specifically, and as mentioned above, other trials have shown that lenalidomide given at a fixed dose earlier in the allogeneic setting is associated with unacceptable toxicity, in particular aGVHD. The study by Alsina et al. demonstrates that a 3-week on and 1-week off schedule deployed later after transplantation, and similar to that used in the postautologous setting, creates a major advantage. Moreover, maintenance strategies incorporating proteasome inhibition have been associated with improved outcomes, and bortezomib currently provides an exciting opportunity for more selective antimyeloma effect with less aGVHD, so providing a strong rationale for using proteasome inhibition as a maintenance strategy either alone or in combination. Prospective studies of this particular approach and using oral proteasome inhibitors are, therefore, planned by a unified team of investigators across various groups in the United States, including the Alliance and the Clinical Trials Network.
Further, the integration of 3 drug initial treatment strategies has generated unprecedented and very high levels of overall response (regardless of adverse cytogenetics), providing a vital next step in considering the overall treatment approach in the allogeneic setting. These combinations, together with less toxic conditioning regimens, as well as improved post-transplantation strategies, suggest that selected patients (both with HLA-identical sibling and unrelated donors) might reasonably be candidates for participation in prospective, multicenter studies."
Reference:
Richardson, Paul, "Allogeneic Transplantation in Multiple Myeloma: A Potential Renaissance in the Era of Novel Therapies?," Biology of Blood & Marrow Transplantation, August 2014 (full text of article)
While you are waiting to see the obvious, that incorporating the novel agents will improve outcomes for younger myeloma patients that do upfront allos, I will continue enjoying my 5 and a half year (and counting) drug free remission and the excellent quality of life that comes along with it.
Mark
The first study used VAD – vincristine, doxorubicin, and dexamethasone – as induction. That hardly qualifies as a modern trial with patients doing an allo in first remission. The second study also did not include novel agents in induction and only had short term followup (3 years) when I posted, As stated in my post, it takes a minimum of 3 years for the donor immune system to show an advantage for patients that are in remission at the time of transplant.
Please post a link to a modern study that shows a 20% treatment-related mortality and a 20% cure rate with patients that did the transplant in first remission like I did mine.
You all just do not understand that the key to having a successful allo transplant is doing it in first complete response, and that is why studies with VAD induction are irrelevant to a patient considering an allo transplant today. Note the comments of Paul Richardson, hardly a pro allo transplant doctor, on this topic:
"In aggregate, both studies also provide important information to challenge a strongly held view in the field of myeloma that there is little or no role for allo-HCT. Each suggest a rationale for further prospective studies, and in particular, they lend support to the further integration of novel therapies into allo-HCT. Specifically, and as mentioned above, other trials have shown that lenalidomide given at a fixed dose earlier in the allogeneic setting is associated with unacceptable toxicity, in particular aGVHD. The study by Alsina et al. demonstrates that a 3-week on and 1-week off schedule deployed later after transplantation, and similar to that used in the postautologous setting, creates a major advantage. Moreover, maintenance strategies incorporating proteasome inhibition have been associated with improved outcomes, and bortezomib currently provides an exciting opportunity for more selective antimyeloma effect with less aGVHD, so providing a strong rationale for using proteasome inhibition as a maintenance strategy either alone or in combination. Prospective studies of this particular approach and using oral proteasome inhibitors are, therefore, planned by a unified team of investigators across various groups in the United States, including the Alliance and the Clinical Trials Network.
Further, the integration of 3 drug initial treatment strategies has generated unprecedented and very high levels of overall response (regardless of adverse cytogenetics), providing a vital next step in considering the overall treatment approach in the allogeneic setting. These combinations, together with less toxic conditioning regimens, as well as improved post-transplantation strategies, suggest that selected patients (both with HLA-identical sibling and unrelated donors) might reasonably be candidates for participation in prospective, multicenter studies."
Reference:
Richardson, Paul, "Allogeneic Transplantation in Multiple Myeloma: A Potential Renaissance in the Era of Novel Therapies?," Biology of Blood & Marrow Transplantation, August 2014 (full text of article)
While you are waiting to see the obvious, that incorporating the novel agents will improve outcomes for younger myeloma patients that do upfront allos, I will continue enjoying my 5 and a half year (and counting) drug free remission and the excellent quality of life that comes along with it.
Mark
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Mark11
20 posts
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