![]() Is ASCT important in today’s treatment paradigm for myeloma? 9-16 In this review, we have examined the data supporting the use ASCT for myeloma, specifically highlighting the pros and cons of an upfront stem cell transplant, and geographical differences in practice patterns and the underlying data that drive these differences. Although many clinical trials have confirmed the survival improvements of ASCT vs not receiving this modality, the data have been equivocal with respect to the timing of ASCT following the initial diagnosis. This has been driven by the significant toxicity associated with ASCT, albeit of very limited duration and reversible, compared with the newer therapies which can lead to similar degrees of response. 7, 8 However, it also remains the most debated therapy for myeloma, especially since the introduction of the newer drugs and their combinations, which are highly effective in controlling the disease. 6 ASCT likely represents the first major improvement in MM therapy since the introduction of melphalan and prednisone and its importance is highlighted by the early and more striking survival improvements observed among the younger patients. 4, 5 A variety of reasons account for this progress including but not limited to better understanding of the disease biology, new more effective classes of drugs, increasing use of autologous stem cell transplantation (ASCT) in patients eligible to undergo the process, and more timely and effective management of disease complications, especially at the time of initial diagnosis. 3 During the past 2 decades, the outcomes of patients with myeloma has significantly improved with median survival going from 2 to 3 years at the turn of the century to 8 to 10 years based on the latest estimates from larger medical centers and phase 3 clinical trials. 1, 2 It is a disorder of the older patient with a median age of 67-69 years in different studies. Multiple myeloma (MM) is the second most common hematological malignancy, and involves the post–germinal center, differentiated plasma cells. It is amply clear from these trials that ASCT will continue to play an important role in management of myeloma and is likely to be used as a platform for enhancing the efficacy of other treatment modalities that are currently in development. Much of these differences are driven by the availability of drugs and drug combinations for initial therapy of myeloma as well as maintenance approaches post-ASCT. Significant geographical variations exist in the use of ASCT, especially between the United States and Europe in terms of its use as part of upfront therapy. Retrospective studies have also demonstrated the feasibility of using ASCT at the time of first relapse rather than as a component of the initial treatment. Recent phase 3 trials have once again confirmed the survival benefit associated with ASCT in myeloma. Despite the introduction of more effective therapies, ASCT continues to play an important role in overall management of younger patients, where it has been integrated with the other therapeutic approaches to provide maximum benefit. Prior to the advent of these new agents, peripheral blood autologous stem cell transplantation (ASCT) was the mainstay of therapy for patients who were eligible to undergo the procedure, with deep and durable responses in the majority of patients. The treatment landscape for multiple myeloma has dramatically changed over the past decade with the introduction of several new classes of drugs, which are very effective at controlling the disease for prolonged periods of time, especially when used in multidrug combinations.
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