Thread by @ManniMD1

My approach to transplant for myeloma (some nuance lost):
Young stnrd-risk who prioritizes PFS: Upfront auto
Young stnrd-risk who doesn't prioritize PFS: Defer
Young high-risk: Upfront auto
Older high-risk: Transplant only if mel200 can be given
Older standard risk: No auto
#mmsm

3 trials and supporting evidence in brief thread:

1)DETERMINATION: PFS benefit, but no OS at 7-8 years of follow-up, despite low cross-over in control arm
nejm.org/doi/full/10.10…

2)IFM-2009: PFS benefit, but no OS benefit at 7-8 years, although high-cross over to transplant in control arm

nejm.org/doi/full/10.10…

3) DSM XIII

Mel 140 could not beat continuous len/dex in an older patient population.

ash.confex.com/ash/2022/webpr…

And although high-risk is under-represented in all these trials, a key meta-analysis done by my friend @rajshekharucms shows improved outcomes with transplant for high-risk, hence increased emphasis placed on transplant for high-risk.

pubmed.ncbi.nlm.nih.gov/35377484/

KEY POINT:

Patients should be referred to a transplant center for discussion of all of this- and collection of stem cells to allow for a deferred approach

(especially those who are young and for whom a decision is made to defer rather than completely forego transplant).

Lastly, renal failure not contraindication to auto-transplant, but Mel should be dose reduced in such situations.

Also, how to handle and de-escalate quads (if you choose to give them) is unknown if you choose a non-transplant approach!

END

I must also say- this is for US audience

In lower resource settings, transplant remains one of the most cost effective ways to have a longer remission.

Also, many patients prefer transplant to many more additional months of weekly infusions- a very nuanced discussion necessary.