Thread by @VincentRK

One of the most common questions myeloma patients ask me is: Should I get a stem cell transplant, and if so when should I do it?

The update of the IFM trial at #ASH20 addresses this question. ash.confex.com/ash/2020/webpr… #ASH20VR

Thread 👇

1) Should eligible patients do a transplant: Yes

Two RCTs show an Overall Survival benefit of transplant over chemo alone.

2) Does timing early vs delayed matter?

4 RCTs (including IFM 2009) show similar overall survival regardless of when transplant is done (early vs delayed)

The IFM 2009 results show identical overall survival ~60% at 8 years with early or delayed transplant, even though not everyone who is in the delayed transplant group even gets to a transplant. But there are important caveats.

1) All patients in IFM trial were <65. This strategy won’t work for many older patients whom we consider for transplant.

2) We have other data that for high risk patients survival is better with early transplant

3) There are insurance and storage issues with delayed transplant

4) In many countries transplant is less expensive than drugs used instead of transplant.

5) Longer PFS with early transplant means get time without any big chemo treatments

6) Early transplant allows us to double dip: In selected patients we can consider second transplant.

So my default preference is early transplant followed by maintenance for most patients with myeloma. But if standard risk patients, age<65 are keen on delaying transplant, I would heed the patients wishes & counsel them that their choice is unlikely to compromise overall survival

In summary, auto transplant is like a very effective drug for myeloma & improves survival. We prefer early transplant for various reasons. But IFM data show that in the VRd era delayed transplant produces identical 8yr survival rates. Patient preference must be taken into account