Let’s talk about transplant for a minute. Now, Jack, you had three in the end, including an allo. Dr. Lonial and Dr. Orlowski, I want to ask you both because I do this every time I do a myeloma program. Where are we now with transplants? Dr. Lonial, your view in Atlanta.
I hear the statement from other patients or community oncologists all the time, quote, I don’t believe in transplant, unquote, and I think that what that does is reduce what we as physicians do to a belief system. And I’m not sure that that’s necessarily the way that I approach medicine and I’m fairly certain that’s not the way Dr. Orlowski approaches medicine. I think what we try and do is use available evidence to say is there evidence that certain treatments or approaches can offer benefit to patients. And I think if you look at the weight of evidence there is a significant amount of data that says that transplant is a tool that can offer significant benefit to lots of patients with myeloma.
Now, does it benefit every patient with myeloma? No. But I think that the way I visualize the use of transplant is that it is not the single one treatment that we say yes or no to. It is one of the tools that we use to treat myeloma and keep myeloma under control over the life of the course of a given disease. So to say to somebody be who is young and fit, I don’t believe in transplant so I’m not going to bring it up with you is like saying I’m going to build a house and I’m not--I’m going to do it without a hammer. You need different tools to build that house, and you need different options to control the disease over time, and I think transplant is one of them.
Dr. Orlowski, similar view from you?
Yeah, I would agree. I think a lot of people now say that because we have all of these new drugs maybe we can get away without doing the transplant, but there was one presentation from a study done by the Eastern Cooperative Oncology Group that had treated patients with lenalidomide and dexamethasone and then looked later on what happened to them if they got a transplant or they didn’t, and it wasn’t a randomized study so it wasn’t necessarily a fair comparison, but the patients who got transplant seemed to do better than the ones who didn’t, and I think that still argues that even with novel drugs we still need to keep transplant in the mix.
The one negative thing I would say about transplant is that there was a presentation from one large randomized study that looked at tandem autologous transplant versus an autologous followed by what’s called a mini or nonmyeloablative allo transplant where the second transplant is given from stem cells from a donor like a brother or a sister. And in that study the tandem autologous transplant did as well as the other arm with less side effect, which I think really says that we should still consider allogeneic transplant or stem cells from another donor as still being experimental. And I think some people, and I’d be interested to hear what Dr. Lonial thinks, some people may say even that that approach shouldn’t be considered even in a clinical trial.
Yeah, I think that Dr. Orlowski brings up a great point and that is that was very in my mind definitive data regarding at least in that trial--which was a large trial, regarding the lack of benefit for allogeneic transplant as performed in that study for patients with myeloma. And I think in my mind philosophically it breaks down into a couple of different camps.
You’ve heard about all the great stuff that’s happening, all the new drugs that are being developed, how the survival of patients with myeloma has increased markedly over the last five to 10 years, and so I think that if you break down patients into three categories, standard risk, high risk and then somewhere am the middle, where we’re not exactly sure where they fit, if you take the standard or good risk patients I think that their median survival is over eight years. If you look at the high-risk patients where we’ve not done as well with the new drugs as we would like to do, in both of those patient subsets in the trial that Dr. Orlowski referred to there was no benefit for an allo transplant.
And so I would argue that for the standard or good risk patients the risk is much, much higher in those patients without significant benefit. And in the high-risk patients, while the benefit--potential benefit may be high the time for that maneuver to really work was simply not there because the disease grows too fast. And so for both of those I would say I don’t think allografting offers much of an advantage for them. It’s the people in the middle that I think we’re debating about oftentimes and again I think you really--the burden is on the trials to show the benefit rather than saying we should keep doing it.