In the current climate autologous stem cell transplants should not be carried out except in clinical high risk disease, when a judgement should be made about the risk of progression without transplant, new guidance states.
The advice is included in a suite of myeloma management recommendations issued by the UK Myeloma Forum in response to the inevitable impact the COVID-19 pandemic will have on the ability to deliver healthcare, especially for systemic anti-cancer therapy.
“To try and mitigate the impact of changing capacity, and to minimise the risk that the immunosuppressive effects of myeloma therapy, [the guidance] has been compiled to help support myeloma doctors in their decision-making and treatment planning…it is by no means a comprehensive guide, but lays out principles with some examples. It is expected practice to ratify decisions at the multidisciplinary team (MDT), and to discuss with colleagues any urgent or difficult decisions in between MDTs,” the guidance states.
It advises that newly diagnosed patients fulfilling the CRAB criteria (hypercalcaemia, renal impairment or bone disease) should be offered primary treatment as failure to treat was likely to be fatal in 3 months or less and may adversely affect disease-related morbidity, quality of life and survivorship.
Whereas patients who fulfil only the SLiM part of the SLiM-CRAB criteria or who only have anaemia should be monitored.
In the first-line treatment of transplant eligible patients, bortezomib/dexamethasone should be used with either thalidomide (VTD) or cyclophosphamide (VCD), the guidance states.
For transplant ineligible patients lenalidomide/dexamethasone should be used for 9 cycles then single agent lenalidomide.
Patients with clinically significant relapse should be offered second/third etc line therapy if the benefit outweighs the risk, whereas those with biochemical relapse, deferment of treatment should be considered based on clinical concern or the rate of disease progression.
For patients who would ordinarily be candidates for a second transplant, daratumumab/bortezomib/dexamethasone (weekly) should be initiated unless contra-indicated. Oral regimens should also be used where possible to avoid hospital visits.
The guidance also points out that it is still reasonable to proceed with stem cell harvest at the end of induction with a plan for deferred transplant according to local capacity.
For a full copy of the guidance click here.