Working with risk

Over the last few years, I’ve been helping to evaluate new patients in our bone marrow transplantation clinic. As a fellow, this practice has been useful on two fronts: I’ve been learning about how different practitioners from different parts of the state have chosen to treat complicated hematologic diseases, and I’ve been preparing for my eventual chosen field of practice (stem cell transplantation).

A few patients have come through in the last few weeks with multiple myeloma, and the controversial topics of second autologous transplantation (outside of a planned tandem transplant) and allogeneic transplantation (for younger patients) have arisen. In neither of these cases did we elect to pursue the less common and more controversial approach, but the discussions that ensued were interesting.

For example, what is the role for allogeneic transplantation in myeloma? Proponents of this approach in selected patients will point to a plateau in the survival curves and suggest that this is the only true opportunity for cure. Detractors note the relatively modest toxicities of newer myeloma treatments, the substantial proportion of autologous transplant patients (as many as 30%) who can live for 10 years following that type of approach, and the significant risk of morbidity and mortality with allogeneic transplant. If I were the patient and I were given the choice, what would I choose? A lower toxicity approach with a smaller chance of longer-term survival, or a much more morbid approach with a chance for cure?

In the July 16th issue of Blood, authors of two separate trials analyze the influence of cytogenetic risk on the response to lenalidomide (Revlimid, Celgene)/dexamethasone in myeloma patients. Though these were not transplant trials, I suspect that cytogenetic and molecular prognostic markers may help to tell us which patient subsets may most benefit from riskier procedures as well.