[Nan]

Stem cell transplant at 81?

by Nan on Tue Feb 11, 2014 3:25 am

My family member is 81 and is choosing to be treated for primary plasma cell leukemia (an aggressive myeloma) at a hospital that does not have a myeloma program or resident myeloma specialist. His oncologist initially said he was not a candidate for a stem cell transplant but now is saying that the hope is that he will be able to get a stem cell transplant. Patient was recently diagnosed with the PCL, and before the symptoms was very healthy and fit, but he waited so long that by the time he entered the hospital, he had experienced renal failure and congestive heart failure. His nephrologist says his kidneys are getting better and he may eventually not need dialysis. He's been in the hospital for over two weeks and had two chemo treatments so far.

In doing research, I called Arkansas and the patient coordinator told me that they don't do stem cell transplants over 75, even where the person is healthy. She said that Medicare does not cover it over 75 and they wouldn't consider it even if it were paid outside of Medicare. She said that we would not be able to find a place in the US where this would be done at his age.

We are still trying to understand what the oncologist is planning, but has anyone heard of a place in the US that does stem cell transplants over the age of 80?

If no one does, should the induction treatment at this time be different?

Thanks for your help and experience.

Nan

[Dr. Ken Shain]

Re: Stem cell transplant at 81?

by Dr. Ken Shain on Thu Feb 13, 2014 8:00 pm

Primary PCL at 81 or at any age is a difficult disease. Generally, no one transplants patients with multiple myeloma over the age of 80 and as you learned in discussion with Arkansas above 75 is rare even in the healthiest 75-80 year old. For PCL I think that risk benefit would be even less I am sorry to say.

PCL therapy typically involves relatively aggressive therapies in the young- VRD-PACE, HyperCVAD. But there are instances in which triple agent therapy (VRD, VCD) or even doublet therapy is reasonable. At ASH 2012, an Italian study of Len/dex was presented as an oral abstract for the treatment of PCL with overall response rates approaching 73%. The small fraction that did not go to transplant relapsed from 3-22 months after starting maintenance therapy. This was a younger patients population and not how I would treat that population, but for an 81 years it suggests that tolerable therapies will be effective for at least a time, before you need alternate therapies.

I have had a couple of elderly frail patients on sequential therapy for PCL and have done very well. So, although we think transplant may be ideal, it is not always. There are multiple agents not Len, Borteozmib Pom, and Carfilzomib- not including more traditional cytotoxics.

As such, I would recommend a lower intensity regimen for anyone with PCL at 81 and expect reasonable outcomes.

Musto et al. Blood (ASH Annual Meeting Abstracts) 2012 120: Abstract 729
http://abstracts.hematologylibrary.org/cgi/content/abstract/120/21/729?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=Lenalidomide+Plasma+cell+leukemia&searchid=1&FIRSTINDEX=0&volume=120&issue=21&resourcetype=HWCIT