Stem Cell Transplant and the Future Treatment Landscape in Multiple Myeloma

Jatin Shah, MD: As we look to the future, now with the incorporation of targeted therapies and immunotherapies into myeloma in combination therapies, it’s important to look at where we may go over the next 3 to 5 years. One of the questions that comes up is the role of transplant, for example, and that has become a recurring question now in the myeloma field over the last decade. There’s significant debate about the role of transplant; however, I think it’s very clear when you look at the data itself in multiple randomized phase III studies that there’s still a role for transplant.

If we think about that as an important therapeutic option for patients, I think it’s still an important backbone that we can look at, and we’ve looked at, even in the era of novel therapies that we saw from the IFM group, where they looked at RVD as an optional induction regimen historically with earlier delayed transplant; even those patients with an early transplant had improvements in their progression-free survival, and too early to talk about overall survival yet. But, I think that what that trial showed is that the transplant is still an important therapeutic option. And though we may be curing a small subset of patients, really we’re not curing the vast majority of patients.

So, in this space when essentially it’s an incurable disease with the vast majority of patients, you want to keep all your therapeutic options open. And that, I think is important, that when we ask that question of, “Does stem cell transplant still have a role right now,” I think multiple phase III trials have shown that. But I think more globally in a setting where we don’t have a cure for the disease yet, keep all of your options on the table.

In the next 5 years with these targeted therapies leading to maybe significant improvements in long-term disease control, then maybe we’ll have to re-evaluate what the treatment paradigm will be—is transplant still necessary? But, again, that’s a question and not an answer. So, first of all, we need to have some more long-term follow-up with these trials beyond just 2 or 3 years’ follow up, but we need longer term follow-up for these patients. And once we have that, then we can come back and answer that question with good randomized phase III studies. And importantly, there’s going to be other options down that road, as well as, BiTE therapy, as well as checkpoint inhibitors and PD-1 inhibitors, again, which are going to continue to change the treatment paradigm as we move forward.