Transplant Eligibility Considerations in Patients With Newly Diagnosed Multiple Myeloma

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Leading myeloma experts from Emory University and Mount Sinai discuss the evolving landscape of transplant eligibility criteria for patients with newly diagnosed multiple myeloma (NDMM). Dr Rossi emphasizes moving beyond the traditional “transplant-eligible vs -ineligible” framework, advocating for a continuum approach that considers patient frailty rather than strict eligibility criteria. The discussion highlights how modern quadruplet induction regimens are achieving minimal residual disease (MRD) negativity rates comparable to historical transplant outcomes, with only about 20% of patients who collect stem cells proceeding to delayed transplant. This shift reflects the improved efficacy of contemporary induction therapies and changing patient preferences regarding upfront vs delayed transplantation strategies.

The ADVANCE trial represents a novel approach to transplant decision-making in NDMM, using MRD status after initial therapy to guide treatment decisions. Unlike previous trials that used transplant as consolidation, ADVANCE randomly assigned patients based on MRD negativity after 8 cycles of induction therapy. The trial design included 4 treatment arms, with MRD-negative patients randomly assigned to receive transplant or continue therapy without transplant. Early results showed patients receiving daratumumab-based quadruplet therapy (D-VRd) achieved 60% MRD negativity compared with 35% with VRd alone, demonstrating the superiority of quadruplet regimens. However, experts caution that the trial may be too early in determining transplant necessity, as other study data consistently show improved depth of response with transplant consolidation.

The integration of MRD-guided treatment decisions represents a significant advancement in personalized myeloma care, though experts acknowledge the complexity of translating trial data into clinical practice. The discussion emphasizes that although quadruplet induction regimens are becoming standard of care, the role of transplant remains important for achieving optimal long-term outcomes. Clinicians must balance the benefits of treatment intensification against individual patient factors including age, comorbidities, and patient preferences. The consensus suggests that stem cell collection should remain standard practice to preserve future treatment options, even as the timing of transplant becomes increasingly individualized based on response depth and MRD status.