Dear BehaviorQueen,
Decisions regarding transplant are complicated. At the present time, high-dose melphalan chemotherapy given as part of an autologous stem cell transplant, either immediately after initial induction therapy or later in the course of the disease, uniformly leads to more durable remissions, as well as improved survival in most studies, compared with continued chemotherapy alone. As such, most of us recommend that patients eligible for this approach should pursue it.
There is only 1 published, randomized study whose purpose was to compare early versus late transplant in multiple myeloma head to head (see reference below). In that (older) study, patients assigned to the delayed transplant arm underwent transplant at the time of first relapse (after receiving a course of chemotherapy first). In this study, there was no difference in overall survival, but the duration of remission after transplant was longer when done as part of initial therapy. As such, I typically recommend that transplant be performed either after a response to initial induction therapy (in first remission) or after a response to therapy at the time of first relapse (second remission). Transplant performed after extensive prior therapy when all else has stopped working often does not go well (less effective and harder to get through).
Currently, there are no data that would indicate that high-risk patients should not undergo transplant. While the duration of benefit may not be as long as it is in patients with average risk disease, that does not mean that continued chemotherapy alone is superior or equivalent to a strategy incorporating transplant.
Many advocate that, outside of a clinical study, higher risk patients should undergo transplant in first remission as opposed to a second remission out of concern that the transplant opportunity may be lost if the patient is very sick at relapse and is no longer healthy enough to go through the process or if the disease cannot be treated back into remission due to the emergence of increasing resistance.
With regards to the former concern, with close monitoring of the myeloma, relapse typically can be caught before the patient is sick.
Concerning the latter issue, we have a lot of tools in the tool box these days to re-establish control of the myeloma, even in situations where the disease has become more resistant.
It is important that the patient, their loved ones and the myeloma specialist carefully review these issues when making this decision. Again, outside of a clinical study, many of us would suggest that the transplant be considered in first remission (and certainly no later than the second).
As mentioned in other threads, there are 2 on-going, randomized studies that will further clarify the role of transplant in the more modern era of multiple myeloma therapy. These studies are evaluating early versus delayed transplant in the context of modern myeloma treatment algorithms. These studies will help us determine:
- If transplant (high-dose melphalan) should be pursued for myeloma patients as a whole; and
- If there are subsets of patients that benefit from a transplant approach and other subsets that do not.
Anyhow, I hope I have not muddied the waters too much.
Good luck with your decision and best wishes to a successful course of treatment, regardless of which pathway is pursued!
Pete V.
Reference:JP Fermand et al, "High-dose therapy and autologous peripheral blood stem cell transplantation in multiple myeloma: up-front or rescue treatment? Results of a multicenter sequential randomized clinical trial,"
Blood, Nov 1998 (
link to full text of article)
