BETA - If I relapse from a stem cell transplant, should I try another transplant or do another type of therapy?

If I relapse from a stem cell transplant, should I try another transplant or do another type of therapy? For those relapsing early after transplant, do most have high risk genetic features? What treatments do those patients get? Generally the data shows that if patients have had less than a two year remission after their first transplant, it won't really be of benefit to do a second stem cell transplant for those patients because each time we do it, it's going to have a shorter remission. Really doing that for less than two years of remission is probably more like one year of remission is not really worth the toxicity with the mucositis and the GI toxicity, et cetera, of the bone marrow transplant. still usually collecting enough stem cells for two transplants just in case we want to use that up as a later line of therapy. If someone relapses after transplant, we'll typically go to non-transplant options first because they're a lot less toxic and especially if the patient has never had an anti-CD38 antibody, for example, those combinations are very effective and can get patients in remission for years. And then often we'll even want to keep those stem cells in the freezer in case they have any bone marrow toxicity from CAR T cells, for example, it can occasionally cause really low blood counts and require a stem cell boost in rare patients. So those stem cells may come in handy even if they don't do a second transplant. So if you had a transplant and the first transplant lasted for a prolonged period of time, yes, I will recommend another one because you can buy a few more years of freedom, right? So you reset the clock, you refreeze the myeloma and your myeloma will remain in remission for a few more years. If the first transplant didn't last long, you want to go with alternative, new targets, you want to 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, 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. 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 based on the age, how long they lasted, how well they did it. I always collect for more than one transplant, two to three because I like to have my backup. How common is it to do a second ASCT in the era of CAR T cell therapy? In the era of CAR T, I would say doing a second stem cell transplant is not very common these days, less than 10% and maybe even much less, especially now that we can do CAR T and bispecifics in late line therapy, the role of second stem cell transplant is decreasing further and further, although certainly still can be an option to bridge those patients. Let's say they can't get to a clinical trial or a certain therapy and need something to get in remission to keep them going for a while, it's something that we can consider. Should a patient consider CAR T therapy instead of a second transplant? That is a very good question. Now that we see the CAR T cell moving earlier, we probably are going to have better responses. We'll need to see. I think that it's becoming easier to treat patients on the CAR T cell. We know how to manage the toxicity. Some physician will tell you that the CAR T cell may be even easier. The transplant is debatable, depends on 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 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. We just have to wait and see. 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. He has to be on a transplant in a credited facility. So it's not like out of the shelves, like many of the other drugs.