Additional Study Finds Auto-Allo Transplants Can Provide Long-Term Control Of Myeloma
Findings from a small, retrospective French study show that an autologous stem cell transplant followed by a reduced-intensity donor stem cell transplant may lead to long-term control of multiple myeloma.
With a median follow-up time of seven years, the five-year progression-free and overall survival rates were 26 percent and 52 percent, respectively.
The results of the current study also show that myeloma patients who receive a donor transplant as part of their first-line of treatment appear to benefit more from the procedure than patients who receive the transplant after relapsing. These findings demonstrate the benefits of early donor transplantation compared to waiting until relapse.
The researchers point out that prolonged follow-up times after donor transplantation seem to be necessary to see the survival benefit of the procedure. They state that the positive impact of donor transplantation in their study did not emerge until two to three years after the procedure.
These findings are in line with another recent European study that showed during long-term follow-up that an autologous stem cell transplant followed by a reduced-intensity donor transplant provided a survival benefit compared to a single or two back-to-back autologous transplants (see related Beacon news).
However, an important caveat to these as well as the European results is that many of the patients in both of the analyses did not receive novel agents, such as thalidomide (Thalomid), Velcade (bortezomib), or Revlimid (lenalidomide), as part of their treatment.
These novel agents have significantly improved the life expectancies of multiple myeloma patients and, in turn, have raised questions about the appropriate role of stem cell transplantation in the treatment of myeloma.
In addition, donor transplants in both studies frequently involved serious complications. In the current study, for example, 17 percent of the patients died within a year of their donor transplant due to transplant-related complications.
The French researchers therefore recommend that the autologous-donor transplantation approach be investigated further in combination with novel agents, and that such investigation be primarily in high-risk myeloma patients, since high-risk patients are particularly in need of better treatments.
Background
Multiple myeloma continues to be incurable for the majority of patients, despite recent advances in the treatment of the disease.
Donor (allogeneic) stem cell transplantation, however, has the potential to be a curative therapy for myeloma.
As part of the transplantation procedure, a patient is first treated with a “conditioning” regimen, consisting of radiation and/or chemotherapy, which kills off many of the patient’s myeloma cells. The conditioning regimen, however, also kills off many of the patient’s healthy stem cells and blood cells.
Thus, after the conditioning regimen, the patient receives an infusion of stem cells to replenish the cells destroyed during the pre-transplant conditioning regimen. The stem cells can be ones collected from the patient prior to conditioning therapy, which is known as an autologous transplant, or the cells can be collected from a healthy donor, which is known as an allogeneic transplant.
There are two different kinds of conditioning regimens that can be used as part of the donor transplantation process: The first includes high-intensity regimens, which are designed to destroy as many myeloma cells as possible. While very effective, these treatments are quite toxic. The second option includes so-called “reduced-intensity” regimens, which are both less intense and less toxic than the high-intensity treatments. Due to their lower toxicity, the reduced-intensity regimens are particularly useful for older patients and patients with other diseases.
Study Design
In the current study, researchers from the Institut Paoli-Calmette in Marseille, France, sought to assess the long-term outcomes of multiple myeloma patients who received an autologous stem cell transplant followed by a reduced-intensity donor transplant.
They retrospectively analyzed the records of 53 multiple myeloma patients who underwent an autologous stem cell transplant followed by a reduced-intensity donor stem cell transplant at their institution between 1999 and 2007.
The median patient age was 50 years. At the time of diagnosis, 87 percent of patients had stage 3 multiple myeloma.
All patients had received initial treatment with a combination of vincristine (Oncovin), doxorubicin (Adriamycin), and dexamethasone (Decadron) (VAD) or another similar regimen.
Overall, 42 percent of patients were classified as having high-risk disease at the time of diagnosis. These patients received the reduced-intensity donor transplant as part of their first line of treatment, immediately following the autologous stem cell transplant, which is also known as tandem transplantation.
The remaining 58 percent of patients were classified as having low- and intermediate-risk disease at diagnosis. These patients received the reduced-intensity donor transplant after they had relapsed following at least one autologous transplant.
No patients in the study had initial treatment that included a novel agent, but 38 percent were treated with novel agents after their first relapse and prior to donor transplantation.
The conditioning regimen used prior to autologous transplant was high-dose melphalan (Alkeran).
For the donor transplants, there were two different conditioning regimens used
The median time between diagnosis and the reduced-intensity donor transplant was 34 months, and the median time between the autologous and donor transplants were 10 months.
Following donor transplantation, 21 percent of patients received a median of two donor lymphocyte infusions, a process in which white blood cells from the stem cell donor are infused into the myeloma patient.
The median follow-up time was seven years.
Study Results
The progression-free survival rate for all patients included in the analysis was 26 percent at five years and 24 percent at 10 years. The researchers found that progression-free survival plateaued after six years.
The patients who received the donor transplant as part of their first-line therapy, however, had a significantly higher five-year progression-free survival rate compared to patients who received the donor transplant after relapsing (41 percent versus 16 percent).
The researchers made a similar observation with regard to the overall survival rate. Among all of the patients included in the study, the overall survival rate was 52 percent at five years and 32 percent at 10 years. However, the five-year overall survival rate was 67 percent for those who received the donor transplant as part of their first-line therapy versus 42 percent for those who received it after relapsing.
These results are particularly notable given that the patients who received a donor transplant as part of their front-line therapy were patients who had been classified as having high-risk disease. The remaining patients, who received a donor transplant at relapse – and who had poorer overall survival outcomes – had been classified as having low- or medium-risk disease.
Graft-versus-host disease (GVHD) was a common side effect among the patients in this study. GVHD is a serious donor transplant-related complication, in which the donor cells recognize the patient cells as foreign and attack them.
Overall, 38 percent of patients experienced acute GVHD, which occurs within 100 days of the transplant. In addition, 59 percent of patients experienced chronic GVHD, which occurs 100 or more days after the transplant.
The researchers found that the development of chronic GHVD had a positive effect on progression-free survival.
Within the first year of donor transplantation, 17 percent of patients died due to transplant-related complications. Patients who developed acute GVHD were at higher risk of dying from transplant-related complications.
Despite the risk of such complications, the authors of the current study believe that the autologous-donor transplantation approach deserves further investigation -- particularly in high-risk myeloma patients, for whom current treatment approaches still are often not very effective, and in combination with novel anti-myeloma therapies.
For more information, please refer to the study in the American Journal of Hematology (abstract).
Related Articles:
- Number And Type Of Stem Cell Transplants Carried Out Each Year For Multiple Myeloma Vary Markedly Across U.S. Cancer Centers
- Stem Cell Transplantation May Be Underutilized In Multiple Myeloma Patients In Their 80s
- Revlimid, Velcade, and Dexamethasone, Followed By Stem Cell Transplantation, Yields Deep Responses And Considerable Overall Survival In Newly Diagnosed Multiple Myeloma
- Selective Digestive Decontamination May Reduce Risk of Infection In Myeloma Patients Undergoing Autologous Stem Cell Transplants
- ECT-001 Granted Regenerative Medicine Advanced Therapy (RMAT) Designation By U.S. FDA
That is an interesting study, although the 17% mortality due to transplant related issues seems really a lot. I wonder how what the criteria were to ascertain that the patients were 'high , moderate or low risk'.? Was it to do with chromosomal deletions, or some other factors?
It seems that with novel agents now being used, the legnths of PFS and OS are increasing too.
Hi Nancy,
Thanks for your comments and question. According to the study authors, high-risk disease was based on "elevated b2-microglobulin and chromosome 13 deletion."
Thanks again for more great news with respect to long term followup on allo transplants. I am sure the stats on allos will be much better when novel agents are incorporated into the process. It is interesting to me how Europe seems so far ahead of the US with respect to curing myeloma patients. I do not see any US based studies showing:
"The researchers found that progression-free survival plateaued after six years."
Potentially curing high risk patients. That are not even close to doing that in the non-allo setting.
The major caveat here is that this was a very small retrospective study of 53 patients over close to a decade. The mortality rate within a year is quite high. Mark, you make (usually the case!)good points. However, practically speaking, I still don't know how a US patient gets around the insurance issue for an early allo since the system still seems to be rigidly geared for an an upfront autologous SCT.
Hi Terry L.,
I think you are missing the real significance of this study and the other one the Beacon recently reported on. Full allo transplants are currently the only form of immunotherapy that has shown success (cure) for myeloma patients. Showing a plateau with non-myeloablative allos IMO is very important because it shows that curative strategies not involving full allos can be explored. If non-myeloablative allos do not work it stands to reason that other immunotherapy strategies that do not include intensive preparative regimines will fail also. The other attempts you see using T Cell or NK cell therapies are an attempt to get the benefits of allo transplant without actually doing the transplant. You need the most comprehensive form of immunotherapy (allo transplant)to work well before you can expect less comprehensive strategies to succeed.
I know from personal experience about the great benefits successful immunotherapy can bring to a cancer patient. I really hope more patients will be able to benefit from it in the future. IMO this is a great step forward. I am sure the high risk patients and their families are very grateful that there is a good chance they have been cured of myeloma. Any percentage of patients being cured that is greater than zero like most therapies show is a big deal IMO.
Mark
I hope that if the reduced intensity allow can be shown to work better with the 'novel' agents , in terms of mortality due to transplant issues, that would be progress. Thanks for the explanation Mark about immunotherapy. it's all food for thought and we are learning a lot about immunology from reading up on these studies too.
This is a great article - thanks for posting it.
There are a couple of things I would like clarification on if someone could help.
Quite a few people do not want an allo because of the unacceptably high mortality rates with the myeloablative conditioning. Mortality in the first year after transplant is 17% - what exactly are the transplant related complications? Does that include infections & acute GVHD or is it solely related to the high dose of melphalan and its toxic effects on the body? When I was in hospital as an outpatient after my allo there were other allo patients (different haematological malignancies)that weren't taking their immunosuppressive drugs (Celcept & cyclosporin) because it made them feel sick!!! I think (hope) most patients would be taking the appropriate medication but if they dont & they died it changes the meaning of the 17% mortality. There could be other instances where the patients choice of behaviour could skew the first year stats.
What are the causes of mortality after the first year and is it a steady ~10% mortality/year out to 6 years and then it plateaus? What is the "normal" mortality rate for the age group studied? What % would be attributable to a relapse in the myeloma? What % could be attributable to the wear & tear of the myeloblative conditioning on the body? And of course what % is caused by chronic GVHD? How much of the patients medical/genetic background is included? If I had a heart attack tomorrow (I dont plan on it) would that be included as a treatment related mortality (the melphalan affected my heart) or would they consider my genetic background (lots of heart attacks at 48/49 in my fathers family) the cause?
The longest surviving time of a patient after an allo (not myeloma) at the clinic where I was treated is 20 years (he is still alive). I like the sound of that.
Finally, how do you know if you are cured if you do not know what genetic mutations caused the myeloma in the first place? I don't know if I was high risk but my myeloma was certainly chemorefractory. I believe I am cured of the myeloma by having had a reduced intensity mini allo but can't prove it. If I am cured it means that you do not need myeloablative conditioning and there is the potential that other immunotherapies will also be curative.
Hi Libby,
I will try and answer some of your questions. The thinking that a 17% non relapse mortality is "too high" is just an opinion. Considering that the patients in the study above were high risk newly diagnosed patients or relapsed patients IMO 17% is not high at all. Median OS for a newly diagnosed high risk patient was likely only in the 3 year range during this study. Do not forget that in all treatment groups, non-transplant or transplant, there is non-relapse mortality rate. It is not 17% compared to 0%. I saw a study with Revlimid and high dose DEX on newly diagnosed patients that showed an Overall Survival of 87% after the first year. One tiny difference - allos can be curative and REV/high dose DEX is not.
"The 1-year overall survival was 96% (95% CI 94–99) in the low-dose group compared with 87% (82–92) in the high-dose group; 2-year overall survival was 87% (81–93) and 75% (68–93), respectively."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3042271/
Deaths in most myeloma patients including those that do allos are from infection. I have put up this Swiss study from 2011 ASH that
show Overall Survival and Progression Free Survival curves for patients that do allos as part of upfront therapy compared to in a relapsed setting a few times. Take note the OS curve is flat (meaning no patient died)after 2 years for the upfront group. The relapses slow down considerably in year 2 and seem to plateau at around 5 years for that group. Basically the risk of dying is higher for the first 2 years for allo patients than non-allo patients but is lower after 2 years. An allo is used by Doctors that view myeloma as a marathon since the benefits of the allo show up in "full force" after 5 years.
https://ash.confex.com/ash/2011/webprogram/Paper37067.html
There is no definitive test that declares a myeloma patient cured. Across all blood cancers the risk of relapse is low after 5 years of remission for allo patients. There does appear to be a slightly higher risk for late relapse (after 6 years) for patients that do non-myeloablative allos than full allos. That is why this is such great news that there is a plateau in the two recent studies on allos that used Reduced Intensity Conditioning (RIC). No other myeloma therapy shows a plateau as early as 5-6 years.
If you want to read a very well written discussion about plateau in blood cancers, you check out the March 1st post on Nicks Myeloma Blog. Unfortunately UAMS "Total Therapy" does not show a plateau in the 8 year range for low risk patients. Allos, both myeloablative and now RIC, appear to be the only curative therapy for myeloma patients. Like you, I think doing the allo was the best decision I could have made. I am coming up on 2 years of DRUG FREE remission and I feel great!
I hope that helped answer some of your questions and do not forget I am the farthest thing from a Doctor. Just a patient that did a lot of reading after diagnosis!
Mark
Great discussion on this paper so far, and I'm really glad you commented, Mark, given all the research you've done about allo transplants.
A few quick comments ... First, the survival plateau seen in this study is not something specific to allo transplantation. If you view the overall survival curves in this Beacon article about the three large Revlimid maintenance trials, http://tinyurl.com/7uax7fy, one of the striking things is that they, too, show plateaus -- particularly the data from the IFM trial.
In fact, I think that growing awareness of these sorts of plateaus is the reason why you are hearing more and more myeloma specialists wondering if there might be a subset of myeloma patients who are being essentially (or actually?) cured using therapies that include the novel myeloma agents ... but don't include allo transplantation.
Which brings me to my second point. I'm the first person to say that greater research into allo transplantation is an excellent idea, and I don't understand why the approach isn't used more often. But I also think that high levels of treatment-related mortality are still a fact when it comes to allo transplantation, and that mortality, combined with the relative randomness with which it occurs, is a key reason why doctors in the U.S. and many other countries are hesitant to use allo transplantation as first-line therapy.
Hi Terry H,
It really depends on how you read data but I do not think I have seen any long term data that shows a plateau in the non-allo setting before 12 years or so. You are in the large majority as far as your opinion on using allos goes. I am just presenting the minority opinion.
You are a well read/informed patient. Do you agree with Nicks analysis of the 8 year followup on "Total Therapy" data?
"There's no plateau at all. What looked like a plateau from about years 3-5 was a false plateau. Remission losses resume again shortly thereafter. In fact, six years after complete response shows only 76% of people are still in remission and it's ticking down at a steady rate. You can see where it looks like it's going to flatten off...only to resume again."
"Which leads to the potentially REMARKABLE counter-intuitive conclusion that the new drugs in which everybody holds such promise -- Velcade and Revlimid -- might not be curing anybody whatsoever, and the cure could simply be coming from PACE and Melphalan, same as 10 years ago, and all the novel drugs do it keep remission longer."
I pretty much agree with Nick on those points. It is hard not to when looking at those graphs. Unless you think the other drugs used in "Total Therapy" are making the novel agents less effective, I do not think we currently have the drugs necessary to cure a good percentage of patients. I would not be surprised if the 10-20% figure given in the Black Swan announcement is in the right "ballpark", but IMO it is not nearly enough to call myeloma a curable disease outside of allo transplant.
Again, it just depends on how you read the data and your overall view of what a myeloma patients real problem is. I do not think a myeloma patient has a melphalan, Revlimid, Velcade or carfilzomib deficiency. They do have an immune system that fails to recognize the myeloma and kill it. Only allo transplant can possibly correct that problem currently. Long term use of those drugs seems to make patients immune systems work less effectively since myeloma patients are so prone to infection.
Just my minority opinion. I am sure glad I did not get treated like the "big name" myeloma Docs recommend. I would not have nearly as good of a quality of life as I have (Zometa is the only pharmaceutical drug I currently take) and I know I would have much less of a chance of being cured. I did a full allo in CR1 and I did not participate in a clinical trial. You can see how much I value the majority opinion on therapy!
Mark
Mark: Despite the lack of a plateau with the latest UAMS data, Nick still believes that there is a substantial cure rate of about 60 percent. While I am not sure of the basis for this belief - it may be based on long term projections of the slowly declining survival curve - it true, it would not be inconsistent with novel drugs playing a key role in a cure - at least for some patients. But which patients? This disease is so individualized, it is hard to know.
Hi Mark,
Thanks for the links to the papers. I agree with you that 17% is not too high, particularly when a bullet is the other option. There will be treatment related mortality regardless of which treatment is used (eg first paper) and the natural attrition rate for the ages studied is not going to be zero (~1% for 54-64 and 2% 64-75). "17% mortality" has a much more ominous ring to it than "OS for the first year was 83%". The OS at 2 years for the REV/high dex group is probably not significantly different than the OS of those having had an allo.
So why aren't more allos being done? If you dont need myeloblative conditioning the risk of treatment related mortality decreases. The risk of infection is still present but vigilance (both doctor and patient)and prophylaxis can decrease this. (The patient does need to have a good understanding of how quickly an infection can take hold & what they need to do if this is the case.) There is no cure for natural attrition so that number will stay the same. I guess the unpredictability of GVHD scares too many. If that is the case do you/does anyone know if there are any studies aimed at understanding the mechanisms involved/predicting the target organs of GVHD? Can it be manipulated? On another track if myeloablative conditioning is required is it possible to test the melphalan on a patients myeloma cells in vitro prior to being exposed? (I do not want any one else to have to go through what I did after having melphalan) If say 90% of the cells die then treatment could go ahead if on the other hand only 15% are killed why bother. For that matter why cant all the drugs be tested and treatment could then be individualised! High risk patients can have treatment that best targets the myeloma cells followed by an allo (that might be a bit of wishful thinking).
Like you the allo was the best thing I ever did in this crazy MM journey. It will be 2 years on the 29th April and although I am not drug free (have to keep my GVHD under control) each day I can do more. The reason I believe I am cured is due to the depth and severity of my acute liver GVHD (stage III/IV) and chronic muscle GVHD (undiagnosed for a couple of months). At the time of the liver GVHD my paraprotein (in the space of 3 weeks)decreased from 18 down to 4 (never saw such a great response with any of the chemicals). It then trickled down to trace. The paraprotein then went back up to 1 at the same time I was being weaned off cyclosporin. Liver function was slightly off so my cyclosporin was increased BUT this was not a therapeutic dose (found that out later) so although my liver was stable I developed the chronic muscle GVHD and the paraprotein was undetectable and has been since then. No chemical would have achieved this for me.
Hi,
I read many studies about allogeneic transplants with great interest since I went through an allo in September last year. The problem in my opinion is that the statistics vary A LOT in different studies. Sometimes the TRM is 17%, sometimes its 6%.
If you’re interested you can watch the numbers from Helsinki in Finland that are impressive (ASH 2012); NRM (non relapse mortality) at 1 year of 2% for MA (myeloablative allo) and 9% for RIC.
I personally think an allo is worth considering if you have high risk MM.
https://ash.confex.com/ash/2012/webprogram/Paper52750.html
Hi Libby,
Congrats on coming up on 2 years post allo. I believe around 80% plus of the patients that have not relapsed at 2 years become long term survivors. Looks like you are going to be around for while!!! I am 2 years in May.
This is a good video featuring well known allo transplant specialist Dr. Sergio Girlat discussing GVHD. He is Robin Roberts allo Doctor. As everyone can see on Good Morning America she is doing great roughly 6 months after her allo. Hopefully she will be cured of MDS.
http://www.mskcc.org/cancer-care/blood-marrow-stem-cell-transplantation/multimedia/graft-versus-host-disease
Here is a paper on GVHD that Dr. Giralt recently wrote. It gives an update on where the allo Docs are with GVHD currently.
http://hwmaint.jco.ascopubs.org/cgi/content/full/30/26/3160
Allos are commonly used as upfront therapy for diseases like Acute Myeloid Leukemia. Robin Roberts decided to do hers shortly after diagnosis. It seems like myeloma Doctors and patients have much more negative view of the procedure than patients/Docs of other blood cancers. I cannot understand why a patient would talk badly about a procedure that cures thousands of patients with different blood disorders/cancer every year. I agree with Dr. Giralts opinion on which myeloma patients should consider allo transplant and when they should consider it.
"Oncologists frequently see multiple myeloma patients in their practice who have achieved a stringent complete response (CR) after receiving several cycles of combination therapy, such as bortezomib plus thalidomide plus dexamethasone, followed by an autologous SCT. “These patients ask, ‘Can I be cured? What is my life expectancy? Will my disease come back?’” Dr. Giralt said in his presentation at the meeting. “There is a chance these patients will be cured, but more likely the disease will come back and will be more difficult to control due to clonal evolution, and will be more difficult to control with chemotherapy.”
The question for these patients is “would replacement of their bone marrow with the bone marrow and immune system of someone else be able to achieve long-term disease control? That is, can I do SCT and exploit the graft-versus-myeloma [GvM] effect that will prevent the disease from coming back. Is the risk of the procedure worth the benefit?”"
"Dr. Giralt summarized his view as follows, that current results with both autologous and allogeneic SCT justify the following patterns of care:
* IN STANDARD PRACTICE ALLOGENEIC SCT CAN BE OFFERED TO PATIENTS WITH HIGH-RISK DISEASE, OR YOUNGER PATIENTS WITH STANDARD-RISK DISEASE WHO ARE HIGHLY MOTIVATED AND WELL-INFORMED.
* Allogeneic SCT as consolidation of a first remission should preferentially be performed under the auspices of a clinical trial.
* Autologous SCT remains the most reasonable consolidative therapy for myeloma patients today.
http://journals.lww.com/oncology-times/Fulltext/2011/12100/Sergio_Giralt__Allogeneic_Transplant_Remains.4.aspx
Take note, the negativity about allos are from patients that have never done the procedure. The 3 of us in this discussion that have done one have a positive view of the procedure.
Mark
Hi Asa,
Glad to read that you are doing so well. I noticed your comment in Dr. Goodman's column about the USA having the most therapy options. We may have more drugs here but as I have written before IMO the Docs over in Europe are ahead of us with respect to curing their myeloma patients. That non-relapse mortality is great. Those Docs deserve a lot of credit.
Did you see this small Italian study from 2012 ASH as well? MR stands for molecular response.
"Auto-allo approach in newly diagnosed MM induces high rates of prolonged FullMR and StandardMR (up to 50%), similar to those reported after myeloablative allografting. MR significantly associated with better TTP and OS and increased during the first year post-allografting, clearly documenting the existence of an effective and persistent graft-vs-myeloma effect, potentially curative in a subset of patients."
https://ash.confex.com/ash/2012/webprogram/Paper47472.html
I always love seeing the "C" word when discussing myeloma therapy. All good vibes being sent your way from here in the USA.
Mark
Hi Mark and thanks for good vibes!
Yes I’ve seen the study. I particularly like that results are improving for at least a year after the transplant.
This is interesting; I ´m in Europe thinking you’re better off in the US. You are in the US thinking we’re better off in Europe.
Good luck to all of us wherever we are!
I was diagnosed with MM june 2011. Had chemo (velcade & decadron) 4 sessions of 4. Had an autologous t/plant Dec 2011. I was told I was in remission and the word "cancer free" was used Oct 2012. I am watched every 3 mths & in Jan 2013 was told my Dec 2012 tests were suspicious. I was told y/day that the cancer has returned. That was the shortest remission I have ever heard.
My oncologist in Jan 2011 just 1 mth after the auto t/transplant advised I was high risk & should consider "allo" t/plant. I have read alot on it & have not found any positive reasons to do it. Death rate is high. GVDH is guaranteed. I consulted w/ another hospital that does allo t/plants in Montreal, Canada and was not impressed with their experience & attitudes. I was basically told doing allo was a trade-off between death & GVDH.
Now I'm scheduled again to do auto t/plant again with Velcad & Revlimid after the transplant. From my almost 2 yrs with this, I see europe is much further ahead. I have been following Dr. Arnold's columns on his allo t/plant and he has had a very hard time.
Libby, Mark are you physicians? I have seen some of your comments before & they are very technical most I which I have no idea what you are talking about and what they mean. Is this info supplied to you by your physicians. I am assuming at this time you are either physician or both MM patients. I can tell at this time I am really confused about my own treatment and willing to go thru the auto & chemo again. It seems the 2nd round with MM is alot more painful this time. I am told it everywhere except my hand & foot bones. So at least I can still shake someone's hand & walk (just joking) have to keep spirit & sense of humor up as this disease is certainly no fun & games.
Thanks for all the info you provide.
Hi Mark,
Sorry for the delayed reply.
I appreciate your comments and I've always learned a lot from the information you provide.
I've not read what Nick has written about the Arkansas data because, among other things, I think the Arkansas approach is very unique and I therefore am not sure it's useful to generalize about myeloma treatment outcomes in general based on the Arkansas results.
You are mistaken if you feel my views on allo transplantation are the same as everyone else's. As I mentioned in my earlier post, I think allo transplantation deserves a lot more attention and research than it gets. However, I don't think it's fair to mock concerns about allo transplantation as treatment-related mortality is real and it's far from trivial.
You seem very enamored of European data on allo transplantation, so let's look at what may be the most recent European data available on the issue. Here's an Italian study looking at allo transplantation:
http://www.bbmt.org/article/S1083-8791(13)00138-9/abstract
And here's the key part of the abstract: "To evaluate trends in allografting from unrelated donors, we conducted a study on 196 consecutive myeloma patients transplanted between 2000 and 2009 in Italy. Twenty-eight percent, 37%, and 35%, respectively, received myeloablative, reduced-intensity, and nonmyeloablative conditioning. In these 3 cohorts, 1-year and 5-year transplantation-related mortalities were 28.8% and 37.0%, 20.3% and 31.3%, and 25.0% and 30.3%, respectively ..."
Again, one-fifth of the patients who received reduced-intensity allos died due to transplant-related complications within a year of their transplant, and almost a third died of such complications within five years of their transplants.
Those are not trivial numbers, and they are the kind of numbers that should legitimately give a myeloma patient (and a myeloma specialist) pause.
Finally, I feel you should be very careful about arguing that allos should be considered more frequently for myeloma because they are used so regularly for MDS and AML.
The main reason allos are used more commonly for MDS and AML is because there are so few other effective treatment alternatives for those diseases. Physicians pursue the allo option in these diseases, despite the risk of the procedure, because the other treatment options have a median survival of a year or two, at best.