- Age is the first factor to consider
- Transplant is routinely considered for patients under age 65 years. Between 65-75 years the decision is on a patient by patient basis. Above age 75 years transplant is not routinely performed.
- Practical steps for patients under 65 years.
- Since stem cell transplant is a rather onerous procedure the first requirement is to be generally medically fit to undergo such a procedure. There must be no major underlying medical issues related to heart, lung, kidney, or liver disease. Also, such issues as active infection or poorly controlled sugar diabetes or high blood pressure for example can be a serious concern.
If the patient is generally healthy, then practical steps are as follows:
- Confirm the diagnosis of active myeloma that requires anti-myeloma treatment.
- If there is any doubt about the diagnosis or approach to treatment, it is an important time to seek a second opinion before going ahead with frontline strategy.
- Proceed with initial or frontline therapy to bring the myeloma under control and achieve an initial response.
- Make sure to avoid melphalan or other therapy that may reduce the success of normal blood stem cell harvesting. Radiation therapy to the pelvis, for example, can reduce stem cell reserves and should be avoided if possible.
- Assess the response to treatment with each cycle of therapy (usually every 3 to 4 weeks).
- After 3 to 4 cycles of treatment, more complete re-evaluation is recommended, including bone marrow testing plus x-ray/scans as needed to determine the level of response.
- Review with the physician the pros and cons of stem cell transplant (and/or stem harvesting without immediate transplant).
- If >50% response, (PR>50% reduction in myeloma protein level in blood and/or urine) is achieved, stem cell harvesting can be planned if it is agreed to proceed. If there is no plan for harvest and/or transplant, a plan for ongoing maintenance or follow-up treatment is required.
- If there is <50% response, then other therapy may be required before proceeding to transplant.
The main addendum to these steps is to be aware that with the advent of the novel agents, thalidomide, Velcade, and Revlimid, many new combinations can be used to achieve initial response prior to proceeding with stem cell transplant. The added value of transplant for a patient who has already achieved an excellent response is the focus of many ongoing trials. It is extremely important for each patient to discuss their exact personal situation with their treating physician.
Besides age, the other factors which influence the choice for transplant or not include:
- The amount or stage of the myeloma at diagnosis.
- The aggressiveness of the myeloma. Factors that can indicate “aggressiveness” include:
- Clinical features such as the speed of new changes, severity of pain and disability or other disease manifestations.
- Blood test results such as: blood calcium level, LDH, CRP as well as sβ2M, s albumin plus serum creatinine – all linked to disease stage.
- Bone marrow genetic findings. Right now features considered to be poorer risk:
- Abnormal chromosomes (cytogenetics) versus normal
- Loss of total number of chromosomes (hypodiploidy) versus normal or increased (hyperdiploidy)
- Specific abnormalities on fluorescent testing of chromosomes (FISH testing)
- (4;14) translocation
- 17p- deletion
- Changes involving chromosome 1
Obviously, the final decision is personal. There is no mandate for transplant – it is a choice. For patients who are eligible or potentially able to proceed, it is, however, extremely important to keep that option open if the decision is not to proceed immediately with transplant. Stem cells can be harvested and saved for future use.
“Questions and Answers” about stem cell transplant.
“Questions to Ask the Doctor” about the potential procedure.