Is there still a role for allogeneic stem cell transplant with newer therapies?

Is there still a role for allogeneic stem cell transplant with newer therapies?

So the question of allogeneic stem cell transplantation keeps on coming in every meeting. It's a very difficult question because now with the advent of many novel agents combinations, which are highly effective and relatively safe, it is more and more difficult to position or to find the right spot on when to use allogeneic stem cell transplantation, because the complexity of allogeneic stem cell transplantation relies on the toxicity and the mortality. Even with the most recent advances, this is still around 20%, which is quite significant. One patient out of five. It also carries the risk of graft versus host disease, which can really impact the quality of life. So this is why the use of allogeneic stem cell transplantation has significantly decreased when we have seen the approval and the wider availability of novel agents.

Well, of course, if you are in an environment where there are no drugs available, I would say why not? But definitely we need to really stick into clinical protocols, clinical trials. But today, with all the available options, I think that allogeneic stem cell transplantation is not the most appropriate answer to myeloma.

Is there a reason why people who have had allogeneic transplants are excluded from trials?

Well, this is a very good question, which is about inclusion and exclusion criteria. Well, a protocol by definition is not really the real life, because it has to take into account different characteristics, different features. And of course, you end up having some, I would say, bizarre or exclusion criteria. So when it comes to allogeneic stem cell transplantation in general, most of the protocols in myeloma and in all other diseases would exclude these patients because the allogeneic stem cell transplantation has a different immune system. These are usually fragile patients that are highly vulnerable to more toxicities, to more morbidities. So you are not in an ideal setting if you are testing a new drug or an experimental approach, because in order to succeed in your trial, you really need to avoid maximum all the confounding factors.

So this is why, in general, although it may work and there should be no harm outside the protocol, this is why people would rather go away from the complexity of the transplantation.