Do MRD-Negative Patients Still Benefit From Transplant?

During the 27th Annual Acute Leukemia Forum (April 4-5th, 2024, San Diego), Dr. Frederick R. Appelbaum, MD, from the Fred Hutchinson Cancer Center in Seattle, Washington, shared his insights on the role of transplantation for MRD-negative patients. He presented groundbreaking information that helps understand how useful or harmful transplants can be to patients who achieved complete remission and have a low probability of cancer coming back. 

With new and more efficacious treatments available for AML, if a patient responds exceptionally well to non-invasive treatments, might not need to undergo a bone marrow transplant. Considering that allogeneic transplantation, although powerful against cancer, has significant risks and might impact negatively on a patient’s quality of life and overall health. 

Dr Appelbaum summarized the results of numerous studies and concluded that there is not enough data to identify which patients should or shouldn’t skip transplantation after the first complete remission. However, the risk of side effects, especially graft-versus-host disease, which can be life-threatening in some cases, should always be carefully considered. 

How Do I Know that Allogeneic Stem Cell Transplantation is Right for Me? 

When considering a treatment, the most important goal is to achieve remission, meaning that the cancer won’t come back after this procedure. Current recommendations encourage avoiding transplantation after chemotherapy if relapsing is less than 50% likely.  

Although many studies have been conducted to determine if transplantation could benefit patients after complete remission, no large randomized trials have reached a solid conclusion. So, to make a decision based on each patient’s unique situation, it is recommended that the oncologist takes into consideration the following factors: 

• Risk of relapse with or without transplant
• Health issues or death risk with or without transplant
• Probability of applying transplant in patients intolerant to other treatments 

A 2024 study in patients 60 years or younger with intermediate-risk AML showed that allogeneic stem cell transplant during the first complete remission did not have a better survival rate when compared to only using chemotherapy.

These varying results show that it is difficult to agree on an overall recommendation, especially because many of these studies are limited by small groups of patients. 

Numerous individual characteristics make it challenging to study patients requiring therapy with stem cell transplants. Still, more research can be done, especially if a large database is used to choose individualized therapy.

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Sources: 

• Postinduction molecular MRD identifies patients with NPM1 AML who benefit from allogeneic transplant in first remission
• Allogeneic Hematopoietic Cell Transplantation vs Standard Consolidation Chemotherapy in Patients With Intermediate-Risk Acute Myeloid Leukemia: A Randomized Clinical Trial