Determining Stem Cell Transplant Eligibility, Quality of Life in Myeloma

It’s important for patients with multiple myeloma to understand what determines eligibility for stem cell transplants. This is notable because it is currently the standard of care for patients who are transplant-eligible, an expert during the CURE® Educated Patient® Multiple Myeloma Summit.

At the summit, Dr. Omar Castaneda Puglianini, a medical oncologist at Moffitt Cancer Center, spoke about stem cell transplant eligibility, quality of life and toxicities, and potential secondary malignancies.

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Determining Stem Cell Transplant Eligibility

To be eligible for transplants in the U.S., Puglianini explained that patients’ overall health status and organ function are considered. The selection process in the U.S., he said, is different than other countries, which depend on the chronological age of patients.

Of note, some patients aged 75 or older may be eligible for transplant, although it is important for them to discuss other health complications with their care teams.

“However, for these patients who are older, of course, we're going to pay more attention to all other variables like other comorbidities. We're going to have a little bit more careful selection for eligibility,” Puglianini said.

Patients who may be eligible for transplants also must have a good performance status, Puglianini noted. Patients who are able to complete daily tasks independently, take care of themselves and are “up and around more than 50% of the time” are likely eligible, he said.

Puglianini also said that patients who experience renal impairment (kidney failure) may still be eligible for transplant.

“Most patients with myeloma will present some degree of renal insufficiency that may or may not recover after induction therapy,” he said. Of note, induction therapy is the first line of treatment and has the goal of decreasing the number of myeloma cells in the bone marrow. “So, transplantation is not an issue for those patients and can be safely performed without concerns for further decline on the kidney function.”

Patients who are ineligible for transplants typically have a performance status of 3 or 4, meaning patients “spend more than 50% of the time resting,” he explained.

“When [these] patients are sitting, they don’t have any symptoms. But as soon as they do any minimal activity, they either develop shortness of breath, extreme fatigue or chest pain,” Puglianini said.

Quality of Life and Toxicities With Stem Cell Transplants

It’s important for transplant-eligible patients to know that they may experience a temporary reduction in their quality of life after receiving the transplant, Puglianini said. This period lasts for approximately one to three months.

“So, you’re not going to be home, you're going to be coming [to the clinic] every day, you are going to be fatigued,” he said. “[It] is impactful in terms of your regular quality of life. But after that period of time, your quality of life will continue to recover [and] go back to your pretransplant quality of life.”

Puglianini also noted that stem cell transplants in his institution are done in an outpatient setting, which means patients are not treated in a hospital. Because of this, patients are monitored daily while receiving transplants and are only hospitalized if they experience a decline in performance status from side effects. Common side effects include infection, mucositis (inflammation and soreness in the mouth or gut) and atrial fibrillations (irregular heart rate). Approximately 45% of patients receiving transplants require hospitalization from side effects, according to the presentation.

“This doesn't necessarily mean that the transplant is not working. This doesn’t mean that the transplant needs to be longer. The usual amount of time of the process will be about the same,” he said.

A major risk factor in stem cell transplants for patients with multiple myeloma, Puglianini said, is opportunistic infection. This type of infection is considered more severe in people with weakened immune systems and occurs more often. It is typically caused by germs such as viruses, fungi, bacteria and parasites, according to the National Institutes of Health. Because of this risk, Puglianini emphasized the importance for patients to have a caregiver with them, especially during the transplant process.

“Transplants cannot be performed without adequate caregiver support,” he explained. “You need someone to help you [with] your daily activities. If you are in an outpatient setting, you are going to need someone to drive you back and forth to your appointments, someone to supervise your medications, someone that makes sure you’re drinking and eating and to call the [cancer] center if someone doesn’t look right.”

Secondary Malignancies in Transplant-Eligible Patients With Myeloma

The risk of a secondary primary blood cancer is approximately 5.8% higher at five years in patients who had a stem cell transplant, according to a study published in Cureus. Puglianini also noted that the risk for certain patients may be “genetically unfavorable” with poor outcomes after receiving a transplant. These patients may also need an allogeneic transplant — or a blood transplant from a donor — for therapy-related myeloid neoplasms, such as leukemia or myelodysplastic syndromes (MDS).

Currently, the secondary malignancy rate after transplant for patients with multiple myeloma is 3% to 4%, Pugliani noted in the summit.

“Around 4% of patients were reported to have died from a secondary malignancy,” Puglianini said.

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