Professional Statements and Societal Positions Guidelines
American Society for Blood and Marrow Transplantation – 2015
The ASBMT (2015) published evidence-based guidelines on the use of HCT in individuals with multiple myeloma (MM). The ASBMT recognized that much of the evidence from RCTs summarized in the 2015 guidelines came from trials that predated the novel triple-therapy induction regimens.Furthermore, advances in supportive care and earlier disease detection have increasingly influenced decision making and allow individual tailoring of therapy. ASBMT guidelines did not address POEMS or other plasma cell dyscrasias besides MM.
TheASBMTand3 other groups (2015) published joint guidelines based on an expert consensus conference.These guidelines contained the following recommendations for HCT as salvage therapy:
"...autologous HCT: (1) In transplantation-eligible individuals relapsing after primary therapy that did NOT include an autologous HCT, high-dose therapy with HCT as part of salvage therapy should be considered standard; (2) High-dose therapy and autologous HCT should be considered appropriate therapy for any individuals relapsing after primary therapy that includes an autologous HCT with initial remission duration of more than 18 months; (3) High-dose therapy and autologous HCT can be used as bridging strategy to allogeneic HCT; (4) The role of post salvage HCT maintenance needs to be explored in the context of well-designed prospective trials that should include new agents,such as monoclonal antibodies,-modulating agents, and oral proteasome inhibitors; (5)Autologous HCT consolidation should be explored as a strategy to develop novel conditioning regimens or post-HCT strategies in individuals with short remission (less than 18 months remissions) after primary therapy (and (6) Prospective randomized trials need to be performed to define the role of salvage autologous HCT in individuals with MM [multiple myeloma] relapsing after primary therapy comparing to ‘best non-HCT’ therapy.
Regarding allogeneic HCT... (1) Allogeneic HCT should be considered appropriate therapy for any eligible individual with early relapse (less than 24 months) after primary therapy that included an autologous HCT and/or with high-risk features (ie, cytogenetics, extramedullary disease, plasma cell leukemia, or high lactate dehydrogenase); (2) Allogeneic HCT should be performed in the context of a clinical trial if possible; (3) The role of post allogeneic HCT maintenance therapy needs to be explored in the context of well-designed prospective trials; and (4) Prospective randomized trials need to be performed to define the role of salvage allogeneic HCT in individuals with MM relapsing after primary therapy."
National Comprehensive Cancer Network - 2020
The NCCN guidelines (v.2.2021) consider autologous HCT a category 2A recommendation as a follow-up to induction therapy for newly diagnosed MM and as a category 1 recommendation for relapsed or progressive disease if the individual is considered a transplant candidate.For relapsed or progressive disease, the guideline also says, “allogeneic stem cell transplant in multiple myeloma should only be used in the setting of a clinical trial. Current data do not support mini-allografting alone.”
The NCCNrecommends collecting enough stem cells for 2 transplants in all eligible individuals.
The NCCNrecommends the following for allo-HCT: “Allogeneic stem cell transplant may include nonmyeloablative (mini) following autologous stem cell transplant or fully myeloablative, preferably on a clinical trial. Current data do not supportmini-allograftingalone” (category 2A).
NCCN guidelines recommend autologous stem cell transplant in individuals who are eligible as sole therapy or as consolidation after induction therapy.