Dr. Philip McCarthy, MD Roswell Park Cancer Institute Interview Date: August 3, 2016

 Stem cell transplant continues to be a strong treatment in multiple myeloma. Based on clinical trials, early stem cell transplant vs. later transplant showed longer progression free survival (an eight month benefit). There was no difference in overall survival (based on the current time frames) and Dr. McCarthy says that overall survival rates will take longer to assess now that newer treatments are being added and patients are living longer. Tools like minimal residual disease testing to see how patients respond to induction therapy will also help determine how transplant timing relates to overall survival. He suggests that triple combos are more powerful as induction therapy for stem cell transplant instead of doublets. Dr. McCarthy reviews results from several clinical trials with over 1200 patients to see whether lenalidomide maintenance is beneficial. According to those studies, there is a 26% reduction in the risk of death and a roughly 2.5 year increase in life if lenalidomide maintenance is used. With all the new treatment options, they are now considering doing a doublet for maintenance therapy (len plus daratumumab, elotuzumab or a HDAC inhibitor), watching for impact and quality of life. For how long should maintenance be used? According to Dr. McCarthy, there is not enough data to give a definitive answer. Some experts are saying "until progression" while others are looking to assess specific time frames (2-5 years?) but until more studies are performed, the right answer is unknown. When they looked at specific myeloma genetic features in a subgroup analysis, it looked as though high-risk genetic features were not completely overcome by lenalidomide maintenance while bortezomib maintenance worked well for del 17 patients but did not have impact for 4;14 patients. Dr. McCarthy discusses additional stem cell transplant strategies (natural killer cells, vaccines and checkpoint inhibitors) that are being evaluated in myeloma.