Single vs. Tandem transplants in newly diagnosed myeloma patients (NDMM)? ASCT remains a component of the FDA approved standard-of-care therapy plan for NDMM.
Having said that, the study and video below make it clear that the application of ASCT, single or tandem, is getting narrower and narrower.
I can’t stress this last point enough. Tandem transplantation, especially in the era of novel therapies for myeloma patients, has become a high-risk procedure- in my opinion anyway.
So who benefits from tandem autologous stem cell transplantation? According to the study below, only those NDMM patients who do not reach complete remission from induction therapy. And even in that group, NDMM patients who present with advanced MM (stage 3) and/or those with kidney involvement may not benefit from tandem stem cell transplantation.
Identifying patients who may benefit from autologous stem cell transplantation (ASCT) in newly diagnosed multiple myeloma is crucial, especially in the era of effective induction and consolidation strategies.
We analyzed data from 12763 patients enrolled in the German Registry for Hematopoietic Stem Cell Transplantation and Cell Therapy (DRST), distinguishing those who underwent single (n = 8736) or tandem ASCT (n = 4027) from 1998 to 2021.
Our findings show that the median age at first ASCT increased over time, while the use of tandem ASCT declined. The shift in treatment practices coincided with higher rates of complete response (CR) post-induction therapy.
Significantly improved overall survival and event-free survival over time were observed across all age groups, especially in older patients, but not in patients under 40.
Tandem ASCT showed benefits for patients who did not achieve CR after initial ASCT. However, patients with ISS III and renal impairment had poorer outcomes with tandem ASCT.
In conclusion, while ASCT remains an important anti-myeloma tool, careful patient selection for tandem ASCT is essential, particularly avoiding its use in patients with ISS III and renal impairment, older age, and those already achieving CR after initial ASCT…
Despite its frequent application in NDMM patients, there are several areas of uncertainty connected to ASCT. Identifying patients who benefit the most from this invasive treatment modality remains challenging.
The evolution of modern induction therapies led to unprecedented rates of deep, long-lasting remissions that can be achieved even without the application of HDT and ASCT.
Therefore, it is important to analyze the impact of ASCT in patients based on their response to induction therapy over time…
Since there is an ongoing discussion about the value of tandem ASCT in certain high-risk populations, we investigated its impact based on ISS and renal impairment.
In total,
- 33.1% of patients with ISS I underwent tandem ASCT,
- 32.7% with ISS II and
- 28.9% with ISS III.
As for renal impairment, 35.9% and 30.9% received tandem ASCT with Salmon Durie stage A and B, respectively. ISS stage and renal impairment were strongly associated to each other (p < 0.001) with only 3.3% of patients with ISS stage I compared to 42.1% of those with ISS stage III having a renal impairment.
When comparing the benefits of tandem ASCT on OS, Fig. 4 shows a significant benefit of tandem transplantation for those patients with ISS 1 and no renal impairment (p = 0.026). In contrast, results show significantly better OS outcomes for patients with ISS III and renal impairment who underwent single ASCT (p = 0.011)…
In summary, outcomes for transplanted patients across all age groups have improved significantly over the last decades, especially in older patients.
In our retrospective analysis, we showed that while most patients did benefit from tandem transplantation, those at older age or who achieved CR after initial ASCT did not have an advantage from a second ASCT, and those with ISS III and renal impairment even have significantly decreased survival rates and should not be considered for tandem ASCT.
Single vs. Tandem transplant
