Lay Summary: Single or tandem autologous transplant is standard of care for multiple myeloma. Other types of transplants are discussed under separate rubrics.
Single or tandem autologous transplant is standard of care for multiple myeloma. Autologous stem cell transplantation has emerged as standard therapy for patients with multiple myeloma, primarily as a result of randomized trials performed in France over the past decade. Recent guidelines agree on several recommendations. An autologous stem cell transplant is recommended for patients with stage II or III multiple myeloma who have a good performance status. They state that evidence of benefit is strongest for patients who are younger than 55 years of age and have a serum creatinine level less than 1.7 mg/dL. They recommend using clinical judgement for patients who do not fit these criteria. Importantly, they advise early and integrated treatment with collection of stem cells before exposure to alkylating agents. They also support the use of peripheral blood stem cells over bone marrow. They suggest that early transplant produces the best results. They recommend a single transplant with high-dose Alkeran®, with or without total-body irradiation unless patients are on a clinical trial. In terms of treatment regimen, at the present time, there is no convincing evidence that total body irradiation adds anything to Alkeran® alone regimens. More recent studies suggest that tandem transplants are as or more effective than single transplants. A second transplant, after inadequate response to the first cycle of high dose therapy, is also recommended by the more recent guidelines.A single or tandem autologous transplant is a reasonable option and it is supported by guideines, such as NCCN. Since this consensus, new and more effective drugs had been introduced for myeloma. It is possible that future studies will result in modification of these recommendations in favor of drug therapy alone, without transplant. However, at this time, the guidelines continue to stand as the guide to clinical decision making.
There were two studies supporting maintenance presented at ASCO 2010, and one, the CALGB, was actually stopped after benefit was demonstrated. Maintenance afer transplant appears to be beneficial. two studies presented at 2010 ASCO, showed that maintenance is beneficial and the CALGB study was stopped based on positive results. NCCN aready incorporated Revlimid maintenance, as well as interferon, steroids and thalidomide with or without prednisone into its guideline on p. 17.
Some forward-looking institutions have begun performing transplants on the outpatient basis. They arrange a place for these patients to stay, daily visiting nurse service and close oversight. Under such conditions, it has been found that autologous stem transplants van be safely performed.
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