Continued post-transplant response predicts improved prognosis in multiple myeloma

Image: PD RANKL protein structure

1. Continued monoclonal protein response to autologous stem cell transplantation (ASCT) is associated with improved progression-free survival, time to next therapy and overall survival.

2. This marker should be considered in post-transplant care of multiple myeloma (MM) patients.

Evidence rating: 2 (Good)

Study Rundown: The treatment options for multiple myeloma, a cancer of plasma cells, include both standard and newer chemotherapy drugs, corticosteroids, and stem cell transplantation. In the latter option, MM patients have their tumor burden reassessed approximately 100 days following treatment. In some, continued decline in monoclonal protein is seen after this initial follow-up, even in the absence of additional therapy. The purpose of this study was to investigate the clinical significance of this response. In order to do so, the authors reviewed MM patients who underwent ASCT without complete remission at 100 days, and compared the long-term outcomes of those with and without continued response to treatment. The authors found that patients with continued response experienced longer progression-free survival, time to next therapy, and overall survival. Therefore, they suggest that continued response following ASCT has prognostic value, and may be used to guide post-ASCT therapy for MM patients. Furthermore, their findings may influence the design of future ASCT studies.

However, though these results benefit from a large patient population, the retrospective nature of this study also presents a limitation to these interpretations. Furthermore, as the selection criteria excluded patients in complete remission at 100 days or who had received follow-up therapy, there was potential selection bias. Finally, the history of previous plasma cell disorders in these patients was not completely known.

Click to read the study in Blood

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In-Depth [retrospective cohort study]: The study authors performed a retrospective review of the outcomes of 430 MM patients who underwent their first ASCT at the Mayo Clinic between 1999 and 2012. They excluded patients who had achieved complete remission at day 100 or who had undergone a second ASCT or other follow-up therapy, and included those who had follow-up approximately 100 days following treatment. Follow-up included skeletal survey, bone marrow biopsy, protein electrophoresis of serum, 24-hour urine collection with immunofixation when no M-protein was measurable. These measures were repeated at subsequent visits except for biopsy.

On analysis, 167 (39%) of patients had a continued response at a median of 9.4 months following ASCT, and 263 (61%) did not. The response group had longer progression-free survival (35 months vs 13 months, p < 0.001), time to next therapy (43 months vs 16 months, p < 0.001) and overall survival (96 months vs 57 months, p < 0.001). Factors that predicted a continued response included having an IgG isotype (p = 0.0007), history of an antecedent plasma cell disorder (p = 0.0485), and a bone marrow plasma cell percentage of <3 (p = 0.0014) at 100 day follow-up.

By Monica Parks and Andrew Bishara

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