If I relapse from a stem cell transplant, should I try another transplant or do another type of therapy? So, that is very difficult because we only have one study, only one. Do something different because you know that the myeloma will not respond to the chemotherapy well again. Or you can use the second as a salvage. I think if your first transplant lasts five, six, seven years, you buy a few more years of freedom. Why not? And the transplant, you know, a lot of people are concerned about transplant because the chemotherapy. But the melphalan is not really an end organ damaged chemotherapy. You can do it multiple times. And it's an outpatient procedure in some institutions. So it's not as bad. You take three months to recover. That's for sure. But then at the end, you know that you can go back to your life, maintenance, traveling, quality of life, versus if I choose something that you have to receive weekly, you have to come to my office every week, right? Until that therapy stops to work and then you have to change again. So sometimes a salvage transplant is really, really good because it will bring you back to your baseline, your situation and buy you a few more years. So retrospectively, there are some studies showing again, the transplant prolongs, give you more time. But prospectively, only one run of my study and the companion was not really good. So it is also based on our experience. I do have a lot of patients that I salvage with another transplant. And sometimes the transplant, the second, lasts more than the first because now I have different maintenance. So I think every patient is an individual and I choose the therapy base, the age, how long they lasted, how well they did it. But I always collect for more than one transplant, two to three, because I like to have my backup. For those relapsing early after transplant, do they usually have a high-risk genetic feature? What treatments do those patients get? We studied that recently and only 25% of the patients had translocation 414, 1416 and deletion 17P. That's something else going on. They are refractory to melphalan, that's clear. So they don't benefit as other myeloma patients do from high-dose melphalan. We haven't a clear picture of that yet. Would a patient consider doing CAR T-cell therapy during the second time around or do a transplant? That is a very good question. You know, the registration that the CAR T-cell that was commercially now available is after four lines of therapy. So you know, that study was very important for us, but because it was treating patients with failed multiple lines of therapy, the responses were not so durable, a little bit shy of a year. So now that we see the CAR T-cell moving earlier, we probably are going to have better responses. And so we'll need to see. I think that it's becoming easier to treat patients on the CAR T-cell. We are now to manage the toxicity. Some physician will tell you that the CAR T-cell, it may be even easier. The transplant is debatable, depends how much experience you have with both the procedure. We don't know yet. We don't know if CAR T-cell so far has not been curable, curative intent, but we'll see it when it moves earlier in the field, it may impact on the disease much more. There is a trial that is launched by the CTN, the transplant network, where if you go through transplant and you don't achieve a good response, you can go directly to CAR T-cell. That will be very interesting to determine if we can do immunotherapy after an autologous transplant and improve your immune system. That is all about that. And so we just have to wait and see. And it's not for every patient. I will not be able, in the community, it's not something that can be done in the community, in the rural places. It has to be on the transplant, in a credited facility. And so it's not like out of the shelves, like many of the other drugs.
HealthTree • November 12, 2021
