When to Consider Second Autologous Transplant for Patients With Relapsed Multiple Myeloma

Andrew J. Cowan, MD, Assistant Professor, The University of Washington, Seattle Cancer Care Alliance, Fred Hutchinson Cancer Research Center, explains when physicians should consider a second autologous stem cell transplant for patients with relapsed multiple myeloma.

Andrew J. Cowan, MD: The question that comes up a lot from referring docs is, "When should I think about a second autologous transplant?" I think it's something we sometimes miss in the era of novel agents and monoclonal antibodies, is thinking about a second transplant.

Many times, we have a patient have a very remarkable duration of remission from a first autologous transplant. I have seen one patient recently who had a 15-year duration of remission after transplant. I think it is very reasonable to think about a second transplant in settings like that.

Notably, that patient was not on any maintenance therapy. I think as a general rule of thumb, what we have used at our center is, if the duration of remission from the first transplant was over 18 to 24 months, in the absence of maintenance, we would consider a second transplant.

Now, that has changed, since most patients these days are all routinely receiving maintenance therapy after autologous stem cell transplantation. The bar, I think, has to be a little bit higher. I think what we've been generally saying is you have to have a remission over three to four years.

Ideally more than five years, because I think, given how hard it can be for patients to go through transplant, the toxicities they can have, and the risk of secondary malignancies, I think it is important to really be thoughtful about which patients you choose for a second transplant.

The other things I think you want to think about, the general frailty of the patient, other comorbidities that may have developed since they were first diagnosed. Also, if they still have stem cells stored at the center where they were originally collected.

Those are the key questions you want to ask. I think another critical point which should not be understated is that in recent times, we've seen more patients get induction with lenalidomide, bortezomib, or dexamethasone go onto lenalidomide maintenance, and actually never do a transplant.

I think it is important to talk about a transplant in that setting, especially in patients if they've never had one. I think the transplant is still a very critical part of our treatment, even our treatment regimen story. Even in the era of these great new novel agents and monoclonal antibodies.