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?

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. And so, you know, 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 and etc., of the bone marrow transplant. However, we are still usually collecting enough stem cells for two transplants just in case. We want to use that as a later line of therapy. And if someone relapses after transplant will typically go to non-transplant options first because there are 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, and 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 to transplant, the first transplant lasted for a pretty long period of time. Yes, I will recommend another one because you can buy a few more years of freedom. 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. So you want to do something different because that the myeloma will not respond to the chemotherapy well again. or you can use the cycle as a salvage. But I think if your first transplant last five, six, seven years, you buy few more years. So freedom. Why not? And the transplant, a lot of people are concerned about transplant because the chemotherapy but melphalan is not really end organ damage chemotherapy, you can do a multiple times and these an outpatient procedure in some institutions, so it’s not like as bad you take three months to recover that's for sure. But then at the end 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. 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 are resolved with another transplant in some time with the transplant, the second last more than the first. So because now I have different maintenance. So I think every patient is individual and I choose the therapy based on the age, are long they lasted how well they did it, but they always collect for more than one transplant. two to three because I like to have my back up. 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 Bispecific 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 patients consider CAR-T therapy instead of a second transplant? CAR-T cell therapy is now available for the treatment of adult patients with relapsed or refractory multiple myeloma, who have received at least one prior line of therapy, including a proteasome inhibitor and an immunomodulatory agent, and are refractory to lenalidomide. 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 is becoming easier to treat patient on the CAR-T cell. We are known to manage the toxicity. Some physician will tell you that the CAR-T cell, it maybe 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 as not be incurable intent, curative intent. But we'll see when it moves earlier in the field, it may impact on the disease so much more. There is a trial that is launched by Cidian and 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. And that would be very interesting to determine. And if we can do immunotherapy after in 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 patients, I will not be able in the community is not something that can be done in a community in a rural places. Yes, to be on the transplant in accredited the facility and so is not like out of the shelves like many of the other drugs.