Should Stem Cell Transplantation be Suggested for Older Patients With Multiple Myeloma?

At the 2024 Great Debates & Updates (GDU) in Hematologic Malignancies meeting in Los Angeles, California, Ajai Chari, MD, University of California, San Francisco, California, participated in a debate in which he argued against the use of stem cell transplantation for patients with multiple myeloma (MM) over the age of 65.

“My conclusion was that in 2024, we have a lot of exciting new options, and transplant has its role for younger patients, but in the older patients I think we don't necessarily need to do transplant,” explained Dr Chari.

Transcript:

Hi, my name is Ajai Chari. I am a professor of clinical medicine and the director of the myeloma program at the University of California, San Francisco. I'm here at the [Great Debates and Updates in Hematology meeting] in Los Angeles.

One of my debates today was about the role of transplant: Should we be transplanting newly diagnosed patients over the age of 65? I was assigned the task of no, and I do believe that. I think stem cell transplants have a long history in myeloma of safety and efficacy and cost effectiveness. I think many studies have shown that they're feasible and efficacious in younger patients.

But the question is what do we do with older patients? We know that the principle of transplant is just that high dose of melphalan that gives you not only myeloma killing, but it extends [progression-free survival] PFS. But it also comes with toxicity. And so, with the older patients, it's a little bit less clear.

In my debate, I show first that currently only 12% to 30% [of] patients max are getting transplanted and that's of all comers, let alone the older patients. Next, we know that the benefit of transplant is related to the dose and yet many studies are showing for older patients you need to reduce the dose of the drugs, the melphalan. I think the other important thing to keep in mind is we have amazing new therapies, CD38-based triplets and quadruplets, such as in [the] MAIA study, [daratumumab, lenalidomide, and dexamethasone] DRd, or the BENEFIT study with [bortezomib with isatuximab, lenalidomide, and dexamethasone] Isa-VRd and [the] IMROZ [study] with Isa-VRd, we're now seeing PFS over 5 years.

And so, in these older patients—in these studies, at a median age of 73—if you're getting a PFS of over 5 years, it's hard for me to believe that every 1 of those patients needs a transplant, or even that the vast majority do, because we know that older patients generally tend to have better cytogenetics and their bigger issue with prediction of outcomes is really their performance status. If somebody's performance status makes them have a worse outcome, [it] probably will also make their transplant more challenging.

My conclusion was that in 2024, we have a lot of exciting new options and transplant has its role for younger patients, but in the older patients I think we don't necessarily need to do transplant. It preserves quality of life without doing transplant so for all of those reasons it's good to have an option not to do transplant.

Source:

Chari A. Debate - Stem Cell Transplant Should Be Offered to Patients over 65 – NO. Presented at the Great Debates and Updates in Hematology meeting. July 27-28, Los Angeles, California.