ASCT vs. CAR-T for Myeloma?

ASCT vs. CAR-T for myeloma? What’s the difference between these two procedures? Should you choose one over the other? Or have both?

In fact, the two procedures are very different. Yes, both procedures are central to MM care but are completely different.

The short answer to ASCT vs. CAR-T for Myeloma is that it is simply too early in the development of CAR-T cell therapy to say. For example, I had an ASCT in 12/95. There is lots of information that has been generated by MM patients like me since 1995.

But for CAR-T cell therapy? Not so much. There may be MM patients who had CAR-T cell therapy a few years ago. Some MM patients who had CAR-T cell therapy have relapsed and there are some MM patients who have not.

But it is impossible to give accurate or real life 5 and 10 year survival statics for CAR-T cell therapy.

CAR-T Cell Therapy VS Transplant

What are the 10 most serious side effects for an autologous stem cell transplant for multiple myeloma?

1. Infections

High risk due to weakened immune system after high-dose chemotherapy (e.g., neutropenia).
Can lead to sepsis, pneumonia, or viral/fungal infections.

2. Graft Failure (Engraftment Failure)

The new stem cells may not take hold in the bone marrow, leading to persistent low blood counts.

3. Severe Mucositis

Painful sores in the mouth, throat, and digestive tract.
Can cause difficulty eating, drinking, and swallowing.

4. Organ Damage (Heart, Liver, Lungs, Kidneys)

High-dose chemotherapy (especially melphalan) can damage:
- Heart: Risk of heart failure or arrhythmias.
- Liver: Veno-occlusive disease (VOD), causing liver failure.
- Lungs: Pulmonary complications like interstitial lung disease.
- Kidneys: Worsening of myeloma-related kidney damage.

5. Secondary Cancers

Increased risk of myelodysplastic syndrome (MDS) or leukemia due to chemotherapy damage.

6. Prolonged Low Blood Counts (Pancytopenia)

Anemia: Fatigue, shortness of breath.
Neutropenia: Increased infection risk.
Thrombocytopenia: Bleeding, easy bruising.

7. Fatigue & Weakness

Can last months to years post-transplant.

8. Gastrointestinal Problems

Nausea, vomiting, diarrhea, loss of appetite from chemotherapy and transplant process.

9. Neuropathy (Nerve Damage)

Worsening of chemotherapy-induced peripheral neuropathy (tingling, numbness, pain).

10. Cognitive Issues (“Chemo Brain”)

Memory, concentration, and mental fog that may persist long-term.

What are the 10 most common side effects for CAR-T cell therapy for multiple myeloma?

Cytokine Release Syndrome (CRS) – Fever, low blood pressure, chills, rapid heart rate, and difficulty breathing due to an immune system overreaction.
Neurotoxicity (ICANS – Immune Effector Cell-Associated Neurotoxicity Syndrome) – Confusion, memory loss, speech difficulty, headaches, or seizures.
Fatigue – A common side effect due to immune activation and treatment stress.
Neutropenia (Low Neutrophils) – Increased risk of infections due to reduced white blood cell count.
Anemia (Low Red Blood Cells) – Leading to fatigue, dizziness, and shortness of breath.
Thrombocytopenia (Low Platelets) – Causing easy bruising, bleeding, or prolonged clotting time.
Infections – Due to weakened immune function, patients are at higher risk for bacterial, viral, and fungal infections.
Hypogammaglobulinemia – Low levels of antibodies, leading to recurrent infections.
Fever and Chills – Often linked to CRS but can also occur independently.
Gastrointestinal Issues – Nausea, diarrhea, constipation, or decreased appetite.

At this point, what is known about the two MM procedures is:

ASCT is FDA approved and a component of the FDA standard-of-care for all newly diagnosed MM patients-
While two types of CAR-T cell therapy have been approved by the FDA, many have not but may be in the future-

ASCT is covered by most health insurance plans- even Medicare-
CAR-T cell therapy is not covered as the procedure is currently “experimental.”

Both procedures include a long list of potentially serious side effects. My MM survival, while long, has been negatively affected by devastating long-term side effects. Please be sure to learn about possible side effects before you undergo either procedure.

Email me at David.PeopleBeatingCancer@gmail.com with questions about either/or/both MM procedures.

Thank you,

David Emerson

MM Survivor
MM Cancer Coach
Director PeopleBeatingCancer

In Multiple Myeloma, Will ASCT Survive Collision With CAR T-Cell Therapy?

“Ever since high-dose melphalan with autologous stem cell transplantation (ASCT) became standard-of-care for multiple myeloma (MM), many have sought a replacement.

Part of the reason is the historical toxicity of ASCT; however, advances in supportive measures have significantly improved transplant-related morbidity and mortality, thereby allowing it to expand to wider populations and to be performed in the ambulatory setting.^1-3

Perhaps, in part, the desire to find an alternative to ASCT stems from the perceived lack of refinement of the continued use of myeloablative chemotherapy for a disease in which clinicians have many highly effective novel agents and cellular/immunotherapies…

The hurdles that CAR T-cell therapy must overcome to replace ASCT are substantial, not only because of the proven efficacy of ASCT compared with other therapies but also because of ASCT’s toxicity profile, the known effectiveness of subsequent therapies, and the favorable financial burden in comparison with CAR T-cell therapy…

Although ASCT with maintenance has long been the standard, substantial evidence exists demonstrating the efficacy of subsequent therapies after relapse.⁶

Frontline CAR T studies must also demonstrate that early use of CAR T-cell therapy does not impair therapies deployed after relapse, including stem cell collection and ASCT; therefore, PFS2 (time to second objective disease progression) and OS are imperative secondary end points…

Although ASCT with maintenance has long been the standard, substantial evidence exists demonstrating the efficacy of subsequent therapies after relapse.⁶ Frontline CAR T studies must also demonstrate that early use of CAR T-cell therapy does not impair therapies deployed after relapse, including stem cell collection and ASCT; therefore, PFS2 (time to second objective disease progression) and OS are imperative secondary end points.

High-dose melphalan with ASCT does have a transient negative impact on quality of life (QOL) metrics.¹⁸ Pivotal BCMA CAR T-cell therapy studies reported improvements in QOL, although many patients had advanced, symptomatic disease and the studies lacked control groups.¹⁹Whether CAR T-cell therapy can meaningfully improve QOL among patients with controlled disease relative to standard of care remains to be seen.

Beyond PFS, all of the abovementioned end points (toxicity, QOL, OS, PFS2) are needed to gauge the relative efficacy and cost-effectiveness of these 2 modalities.²⁰

With an established median PFS exceeding 5 years, a survival benefit among those with high-risk cytogenetics, manageable and predictable toxicity, and total treatment cost representing a fraction of that of CAR T-cell therapy, ASCT with maintenance is unlikely to be overtaken as frontline consolidation.

Unless CAR T can effectively cure a substantial proportion of patients with MM, it would best serve patients as a complement to ASCT after relapse or potentially for those with suboptimal response to ASCT.”

ASCT vs. CAR-T for myeloma? ASCT vs. CAR-T for myeloma? ASCT vs. CAR-T for myeloma?

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