HSCT Treatment is a Viable Option for Older Myeloma Patients
While myeloma occurs most commonly in people over 60 (the average age at diagnosis is 70), many clinicians do not consider HSCT an option for older patients due to concerns about toxicity and frailty, says Dr. Pashna N. Munshi, associate clinical director of the stem cell transplant and cellular immunotherapy program at MedStar Georgetown University Hospital in Washington, D.C. Interested in the reasoning behind this, Dr. Munshi and her team set out to study HSCT in older myeloma patients and presented the study’s abstract at the recent TCT Meetings Digital Experiences.
Dr. Munshi and her colleagues studied 360 patients (63% men; 84% white) aged 75 and older, who underwent their first autologous HSCT within 12 months of their multiple myeloma diagnosis between the years of 2013 and 2017.
At two years post-transplant, 66% of patients remained progression-free (the cancer hadn’t gotten worse) and 83% were alive. High-risk cytogenetics was the only factor associated with increased risk for relapse.
“Hopefully this motivates referring providers and payers to not negate the benefits of standard therapies based on age alone,” Dr. Munshi told the clinical information website Healio.
“Patients with newly diagnosed multiple myeloma should be referred for consideration of consolidative therapy with [autologous HSCT] regardless of their age, as specialists can then determine true eligibility based on their comorbidities and also their physical function.”
Older Patients and Stem Cell Transplants
There are two types of stem cell transplants: autologous (using the patient’s own cells) and allogeneic (using cells from a donor), explained Dr. Amrita Krishnan in a recent Patient Power interview. Dr. Krishnan is the director of the Judy and Bernard Briskin Center for Multiple Myeloma Research at City of Hope, a cancer center with more than 30 locations in Southern California.
In an HSCT, stem cells are taken from either the bone marrow or the bloodstream, frozen and stored, while the patient undergoes high doses of chemotherapy or other intense treatments. The stem cells are then transplanted back into the patient’s body, where they generate new, healthy cells, Dr. Krishnan said.
Because a stem cell transplant involves taking the patient’s immune system down to zero and slowly bringing it back to a normal range, cancer patients have to wait until they are healthy enough to have the procedure. This can take days, weeks or even a month.
“Older patients tend to have a couple more days in the hospital, but the infection rate, everything else is really basically the same,” Dr. Krishnan told Patient Power. “There's been data even from MD Anderson (a cancer center in Houston), looking at transplants and patients up to the age of 80. So, clearly, that age limit really is going, is gone, away.”
Number of Older Patients Undergoing HSCT Increasing
The number of older patients with multiple myeloma undergoing HSCT is increasing.
In another study, Dr. Munshi and her colleagues analyzed data from 16,000 patients with myeloma in the Center for International Blood and Marrow Transplant Research (CIBMTR) database; 2,092 patients were 70 years of age and older.
Compared with 2013, when 15% of patients aged 70 or older received a transplant, by 2017, the number had almost doubled to 28%. Using patients aged 60 to 69 years as a reference, patients 70 and older had similar benefits from the treatment.
That being said, minorities remain less likely to undergo the procedure than white people, even though Black people are twice as likely to be diagnosed with multiple myeloma than whites.
In a study of nearly 112,000 patients diagnosed with multiple myeloma between 2004 and 2013, 15,021 (13.4%) received HSCT as part of initial therapy. Of those, 77.5% of patients were white, 15.1% were Black and 5.2% were Hispanic.
Dr. Munshi and her colleagues also reported higher transplant utilization rates during their study period for white men aged 75 years or older than Black men of the same age. A similar disparity was found between white women and Black women. Even when taking income into account, Black people were still less likely to undergo a transplant.
The reasons for the disparity are unclear. But Dr. Munshi speculated to Healio that there are “likely referral biases, access issues or even patient biases on receiving more ‘aggressive’ therapies.’”
“The racial and gender disparity is now actively studied in many malignancies, yet knowledge gaps remain,” she said. “Educators, outreach and support groups can be key players in helping the transplant community highlight these deficiencies.”