What is the process of ASCT? What is it like?

[Music] why consider a Natalia stem-cell transplant in the age of novel therapies myeloma experts have differing opinions on the use of stem cell transplant in the age of newer therapies in this video you will hear varying opinions from world renowned myeloma experts it is essential that you discuss all your treatment options including stem cell transplant with your doctor I get challenged with this question by a lot of my patients and I obviously love to sit down and go over my reasoning of course we are all thrilled and we are all excited about all the new treatments that have come out especially in the last 15 years or 15 to 20 years now which was unleashed by the LED amide and of course followed by other immunomodulatory drugs and then proteasome inhibitors and followed by antibodies and now various immunotherapy reagent so that is great but why is stem cell transplants still a important part of treatment first two very basic things it is safe number two it is effective it is effective on its own where before any other treatment before any maintenance or consolidation when you do a stem cell transplant more than 90 percent would respond and their average progression-free survival or the duration of remission would be about eighteen months to two years so those were excellent results so since then a number of trials have been done some were done before the availability of these new newer agents and several have been done now with the availability of novel drugs basically all the studies show that when you combine stem cell transplant with conventional treatment whether novel or the older ones number one we get deeper responses which in this day and age includes minimal residual disease negative status number two we get more durable responses so almost all the trials have shown that there is a longer progression free survival when you combine stem cell transplant with novel agents and in some of the studies there is an improvement in overall survival since there is no single curative therapy available for myeloma and the goal and the intent is to achieve the deepest and the most durable remission and to achieve that goal I think stem cell transplant is one of the time-honored safe effective and in this day of cost consciousness which actually should have been there always is a reasonably cost effective treatment also so I think with all the evidence we still feel that it is an integral part of myeloma treatment so I think some of the biggest questions nowadays we get asked in clinic or whether someone should or should not do a stem cell transplant especially in at the time of first diagnosis it is a very controversial topic because historically it has been one that has in standard of care for patients I can tolerate high-dose therapy in the stem cell transplant mainly because historically it improves survival at that time we do not have a lot of our novel therapies so the decision was a bit more straightforward for patients I can tolerate a stem cell transplant now it's a bit more complicated because we have so many different medications plus we have more tools such as cytogenetics as looking at response to therapy and even increasingly so MRD testing than sometimes helped us make decisions about whether an individual should undergo a stem cell transplant or not so i tell transplant eligible patients commonly let's look at the pros and cons of whether high-dose therapy would benefit an individual at that initial diagnosis certainly deferred transplantation approach has been validated without compromising survival and our most recent studies but I think again kind of honing in on that theme of individualized therapy you know don't feel that a particular mode of therapy is an absolute necessity for an individual it's it's a discussion you should have with your doctors about pros and cons of therapy there's plenty of patients we recommend a stem cell transplant for but there's plenty that we do feel that can potentially keep it in reserve at a later time so this is an important question that will hopefully continue to get more clarity as we get more tools about how to individualize therapy and choose a particular mode of therapy for a page so the way we look at transplant is in the age of new therapies those new therapies can just make transplant more effective so we've already made transplant extremely safe in fact the risk score is the same mysteric chemotherapy now what we do is then build upon that both in the induction or the treatment before the transplant as well as the treatment after where that's consolidation or maintenance therapy we don't have definitive evidence yet we still know that transplant provides a strong benefit in terms of progression-free survival there's no overall survival benefit yeah but they have readouts early the only three are read out for some patients they just don't want to have a transplant right now there are issues etc but I do recommend for all patients they should have their stem cells collected if they are a transplant eligible patient if they're not going to go on to a transplant early on because those patients they do delay and they get a lot of therapy may have damaged marrow so I think that it's better off giving your stem cells click early regardless I still recommend it right now in the current age because we don't have better data suggesting that chemotherapy alone or chemotherapy a new drug approach this period clearly in the old days autologous stem cell transplant was a mainstay of treatment it was a bridge to the next bridge and I think what's important to recognize is it was a very valuable and important tool it evolved the question is how does it apply now and I think what's been very rewarding is to see that we could combine novel therapies with transplant and improve outcome but what then has happened is that these treatments have become so good the question is how much does transplant add and what we saw at this meeting was that antibodies added to three drug platforms are revolutionising the outcomes at the same time we have to be very honest with our patients that mal Fallon at high dose is toxic there are side effects of the transplant itself both in the short and the long term and so with that and with the impact that that has on quality of life we have to really weigh its risks and benefits what we saw at this meeting was a fantastic percent presentation from dr. Francesca gay in the Italian group where they showed that in fact which is a trip that we use in the upfront setting who gave it for 12 cycles it was just as good as kod times 8 with a transplant but what was interesting in her analysis was that in a subgroup of patients with higher risk actually the transplant may be helpful now the important point to remember is in all of this data it's very early so it may be with longer follow-up that we see more of a benefit from transplant we don't know but the flip is also true that in those patients in whom were high risk disease was defined we don't know at this point how they were maintained and so I think the conclusion she drew which is one size doesn't fit all is absolutely correct I think assuming just if you have high risk disease that you must get a transplant is not necessarily true either yet because we don't know what they were maintained with and as one of my colleagues pointed out to me the playing fields completely change yet again anyway because of the antibodies and so you may say well ok we've got nothing to lose why not just do it anyway ah there's a sting because what we're realizing as our patients thankfully live longer that the long-term consequences of Mallen exposure are real and they revolve around myelodysplasia and secondary leukemia fortunately uncommon arguably rare but for those patients affected absolutely devastating so for that reason we need to better understand who benefits from it and who doesn't protect those who don't need it and at the same time optimize it for those patients who might derive significant benefit from it the data generated from back in the 80s and 90s showing that when you compare high-dose melphalan to conventional chemotherapy you have better survival outcomes but each time you know one of those studies would come out you know that the discussion would be well you know the standard of care for myeloma is changing so what does does high-dose melphalan really help us in the context of novel agents that we are giving to patients as part of induction treatment as part of maintenance treatment is it really the Melfi land that's creating the value for the patient in terms of survival outcomes here or not to date you know what we know with novel agent induction and maintenance treatments that at the very least the depth of response and PFS is better when you give high-dose melphalan to myeloma patients in the frontline setting will high-dose melphalan be replaced by other cellular therapy modalities in the future sure I think that that can certainly happen you know the goal of treatment is to get better depth of response you know get patients to MRD negativity with that depth of response being the goal it doesn't matter how you get there you want to get there with efficacious regimens and without causing a lot of toxicities so even though you know I'm saying that high-dose melphalan should be part of that front-line approach for patients if we get better drugs that are safer and do the same job why the heck not you know we go ahead and change our treatment paradigm as you can see there is still controversy even among the top myeloma specialists in the world as to if and when autologous stem cell transplant should be used this is an individualized and personal decision goals of treatment should be getting the greatest depth of response and longest duration of response discuss with your doctor the pros and cons of transplant and your unique situation only then can you decide what is right for you you you [Music]