[Pat Killingsworth]

Question about stem cell transplant timing

by Pat Killingsworth on Tue May 18, 2010 12:27 pm

At a meeting with my oncologist yesterday, we disagreed about when it is best to initiate a stem cell transplant (SCT).

After achieving a complete response (CR) in 8 months using Rev/dex, I dropped the dex and have maintained CR for over two years--until now. My M-spike is back to .3 and holding relatively steady.

My doc, a myeloma specialist and transplant coordinator, thinks I should transplant now. (My stem cells were harvested two years ago) I would like to wait until my multiple myeloma creeps back up--then hit it again hard with high dose Rev/dex and hopefully knock-it-down again. Once that stops working, I would try Velcade or some other new clinical study.

My doc argues that would be a mistake--that a patient is more likely to achieve positive (SCT) results if they transplant while in CR, or immediately after multiple myeloma starts to return.

I have read SCT results are not affected by when it is done. I understand being able to achieve CR is a good indicator of SCT success. But I have never seen any data showing it would make any difference if I SCT right away, or continue to wait and use my SCT as my last, best therapy option.

Do the Ohio State guest docs have an opinion on this? Can you refer me to any literature supporting either my docs, or my opinion about SCT timing?

Thanks- Pat

[Dr. Craig Hofmeister]

Re: Question about stem cell transplant timing

by Dr. Craig Hofmeister on Tue May 18, 2010 10:22 pm

I think we've talked about this question before on this site.

There is very little information about the timing of autologous transplant. While your oncologist describes accurately the theoretical benefit -- i.e. the idea that alkylator-based chemotherapy (melphalan) would be as effective early or late doesn't make much biologic sense - this has not been proven. And if it hasn't been proven, it's just an opinion.

The only trial really to assess this was reported by the French group in 1998 by Jean-Paul Fermand -- they looked at 202 patients enrolled 1990-1995 who were up to 56 years old and divided them into two groups -- those that got standard chemo followed by transplant versus standard chemo for a longer period and then transplant. In this late transplant group, transplant was performed as a rescue treatment. Survival was the same in each group, but the early transplant group had longer time without symptoms, treatment, or treatment side effects.

And finally the attainment of CR is important in all blood cancers -- myeloma really no different than any other slow growing lymphoma. It is least important for aggressive cancers (and for that matter aggressive myeloma), where duration of complete continuous remission is a better measure of therapeutic success than the depressingly brief attainment of CR.

[Pat Killingsworth]

Re: Question about stem cell transplant timing

by Pat Killingsworth on Thu May 20, 2010 3:24 pm

Thank you, doctor! But I must ask: From a myeloma patient's perspective, could there possibly be a more important question--if or when to SCT? I can't imagine one! I understand Dr. Kumar at the Mayo Clinic in Rochester, Minnesota, is involved with an ongoing study comparing the use of novel therapies and delayed transplantation at relapse versus moving to SCT three or four months after initial inductioin therapy. But even he admits, in the latest edition of the IMF's Myeloma Today, his retrospective study is not enough. So why not more studies? Cost? Lack of patient centered thinking? You would think Millennium or Celgene would be motivated to prove using their drugs early and often, even after induction, is a viable therapy option--just as using maintenance therapy after SCT. Hey, at least we most of us have options! But that doesn't mean we shouldn't push harder for research studies which may help improve our quality of life. These are tough choices--made tougher when no one knows the answers!

[Dr. Craig Hofmeister]

Re: Question about stem cell transplant timing

by Dr. Craig Hofmeister on Fri May 21, 2010 10:28 pm

I couldn't agree more.

But let's face it -- clinical trials in myeloma are funded essentially by pharmaceutical companies that are responsible to their shareholders - not to you, not to me. While the U.S. government takes a hand in funding a few of the larger trials, that is in cooperation with drug companies. So let me ask you, as the CEO of a dramatically successful drug company -- would you spend another $10 million dollars for a trial that might not improve your revenue?