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COMy 2022 | The importance of autologous transplantation in the era of immunotherapy

In this video, Arnon Nagler, MD, Chaim Sheba Medical Center, Tel Aviv, Israel, addresses the importance of continuing to use autologous stem cell transplantation (autoSCT) in patients with multiple myeloma. Prof. Nagler first highlights the improved response and progression-free survival (PFS) observed in patients following autoSCT, and then discusses novel immunotherapies in the field. Following this, Prof. Nagler discusses whether autoSCT will remain a treatment option in multiple myeloma, and concludes by explaining reasons why autoSCT is an important option for patients. This interview took place at the 8th World Congress on Controversies in Multiple Myeloma (COMy) 2022, held in Paris, France.

Transcript (edited for clarity)

For many years, autologous transplant was a mainstay in multiple myeloma. Many studies showed when you compare autologous transplant to conventional therapy, at that time, it was pre-novel therapy, then novel therapy. But of course it was without the quadruplet induction, the patient that underwent autologous transplant had a better response and a better progression-free survival in six out of seven studies and in three studies better overall survival...

For many years, autologous transplant was a mainstay in multiple myeloma. Many studies showed when you compare autologous transplant to conventional therapy, at that time, it was pre-novel therapy, then novel therapy. But of course it was without the quadruplet induction, the patient that underwent autologous transplant had a better response and a better progression-free survival in six out of seven studies and in three studies better overall survival.

Now, of course, autologous transplant is old, it’s chemotherapy, and we all want to get a very fancy kind of therapy. Everything is a immunotherapy. Revlimid is immunotherapy, immunomodulatory drugs and we have now the monoclonal antibodies, anti-CD38 antibodies, and now the drug conjugated antibodies, the bispecific antibodies and we have the CAR-T cells. So the question, if still we need the autologous transplant, and I would say definitely yes, because transplant is the more efficient way to get to a measurable residual disease negativity 10 to the minus five and 10 to the minus six, and also most importantly, sustained MRD negativity. And I will show all the new studies with quadruplet induction, CASSIOPEIA study with the dara-VTd, GRIFFIN study with the dara-VRd, KRd with dara like Costa’s study, the MASTER study. All of them show that MRD negativity post-transplant was in higher percentages, more sustained, mainly more sustained for instance, in the FORTE study then after induction therapy. So, transplant is here to stay and also with the most fancy therapies today, the CAR-T cells. So, we can do the CAR-T cells post-transplant, but vice versa, doing transplant after CAR-T cells is not logical, there are still many patients that relapse after CAR-T cells.

We don’t have MRD sustained data after CAR-T cells, and of course at the end of the day, we will combine CAR-T cells and autologous transplant. The last is partly a practical issue that when ide-cel and cilta-cel are approved, only minority of the patients can get these drugs because it’s so complicated. So, few slots, production is much less than the demand. So from the practical issue, we can offer transplant to actually all myeloma patients that are eligible for transplant, while CAR-T cells are still for minority of patients and the end of the day, we combine them.

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