Practice Update: Oncology

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Current Concepts
in Stem Cell
Transplantation for
Multiple Myeloma
Interview with Sagar Lonial MD
by Farzanna S Haffizulla MD, FACP, FAMWA
Dr. Lonial is Chair and Professor, Department of
Hematology and Medical Oncology; Chief Medical
Officer, Winship Cancer Institute, Emory
University, Atlanta, Georgia.
Dr. Haffizulla: We know there have been a preponderance of newly
approved myeloma agents that might someday replace first-line
stem cell transplantation. Do you think that that might be the case?
Dr. Lonial: So you know, the idea of replacing transplant with new drugs
or combinations of drugs has been a goal of many over the last few
years, and every time we look at either three drugs or four drug
combinations, the outcomes continue to be better by consolidation
with a transplant, so I’m not sure that it’s going to go away immedi-
ately anytime soon, but what we may identify, particularly from the
recently published IFM/DFCI Trial, is trying to identify which patients
can wait. That may actually happen, but I’m not sure we’re going to
give up transplant anytime soon.
Dr. Haffizulla: Okay, so really no deferring stem cell transplantation
until it aligns?
Dr. Lonial: So we talk about that a little bit. In our center we have 3
criteria that patients have to fulfill to talk about delayed transplant.
One is they have to have achieved a BGPR after 4 cycles of ther-
apy, they have to have tolerated their first 4 cycles well enough that
they could take 4 more, and they have to have standard-risk mye-
loma. If they achieve those 3, then many will say I want to delay, I
want to delay, I want to delay, and we give them that option, but it’s
not something I’m terribly excited about mostly because the data
with transplant consolidation continues to look really good, and as
we talk about curing patients deferring aggressive therapy to give
them the highest chance at cure by delaying transplant may not be
in their best benefits.
Dr. Haffizulla: Well, on that note and given your expertise, I wanted to
highlight that for our viewership. We want to thank you again for the
work that you’re doing, and we’re looking forward to hearing more
from you.
Dr. Lonial: All right. Thank you.
Dr. Haffizulla: Any particular last few studies before we close off that
you wanted to highlight?
Dr. Lonial: You know, I think really the antibody studies at ASCO were
really exciting, the CAR T cells targeting BCMA are really interesting,
and I think that’s really the big highlights from this meeting.
Dr. Haffizulla is the Assistant Dean of Community and
Global Health at Nova Southeastern University’s College
of Allopathic Medicine. She practices general internal
medicine in Davie, Florida, within her own internal
medicine concierge practice.
disease. I think the technology has evolved to an extent that
we are doing now single cell sequencing. Mario Suva from
Boston has published a very, very nice work really showing
the evolution of an oligodendroglioma from single alterations
really showing all the path, all the heterogeneity of that tumor.
I think given that, we will be able to fully get the picture of that
disease. This is first.
Second, also important, the immunotherapy trials that are
being done at this point in time are not only aiming at just pro-
viding efficacy data. Several of them, specifically the smaller
ones, are now trying to provide data on the immuno-moni-
toring, immune function, really understanding and give us an
understanding what they are doing. So whether peptides or
not or whether other approaches will be the future, whether
it will be cells, CAR T cells, whether it will be lysates, I think
it’s not really fully shaped out but I think those immunotherapy
approaches clearly combinations, personalized approaches
for the immunotherapy, combinations with one or the other
checkpoint inhibitors. We may learn that in brain tumors other
checkpoints have a bigger role than the classic checkpoints.
Talking about the last year, we have to talk about some of the
negative data as well. So the EGFRvIII directed immunotherapy
trial ACT IV has been negative. So, no signal off that treatment.
The trial MATRIX 143 has been presented at the World Meeting
of Neuro-Oncology in Zurich and also not shown any additional
effect of nivolumab versus bevacizumab in that disease, so
we get more understanding. I would go for the combination
approaches, both with the drugs and with immunotherapies,
and would really focus on molecular-driven trials and molec-
ular-driven data approach.
Dr. Caudle is a board-certified Family Medicine physician and
Assistant Professor in the Department of Family Medicine at Rowan
University-School of Osteopathic Medicine in Stratford, New Jersey.
Q & A 33
VOL. 1 • NO. 3 • 2017