Trends in Autologous Stem Cell Transplantation for Newly Diagnosed Multiple Myeloma: Lessons for Resource-Challenged Regions

Swan et al report the trends in autologous hematopoietic stem cell transplantation (ASCT) for newly diagnosed multiple myeloma over the past three decades in the European Society for Blood and Marrow Transplantation (EBMT) centers.[1] The stem cell utilization rates (STUR) of ASCT for myeloma have shown a rising trend for most resource-rich regions (13 to 24% in Northern America and 15 to 22% in Europe).[2] However, we would like to focus on the trends in treatment-related mortality (TRM) that has important lessons for resource-challenged regions. The TRM rates from ASCT reported in the EBMT centers show a downward trend over the past three decades from approximately 5 to 1%.[1] The same in the US centers is down from approximately 3 to less than 1%.[3] [4] Trends in increasing STUR parallel decreasing TRM for ASCT in multiple myeloma. ASCT is the standard of care in the treatment paradigm of eligible myeloma patients.[5] [6] Undoubtedly, there is a progression-free survival (PFS) benefit to multiple myeloma patients with ASCT as reported in meta-analysis; however, no overall survival benefit was observed.[7] [8] The data on PFS benefits are drawn from landmark randomized controlled studies in resource-rich countries. With the current standard dose therapy (SDT) comparator (VRD-bortezomib-lenalidomide-dexamethasone), this median PFS benefit has narrowed to just 14 months (50 vs. 36 months).[9] There is no reason to believe the benefits would be different in other parts of the world. However, what level of TRM justifies this narrow PFS benefit needs to be addressed.