Autologous Stem Cell Transplantation For Multiple Myeloma In Patients Over Age 70: Decision Making, Eligibility, and Preliminary Outcomes

Although it has been well described that autologous stem cell transplantation (ASCT) can be performed successfully in patients with multiple myeloma (MM) over the age of 70, with the plethora of new therapies and concerns about potential toxicities of ASCT there is little data on what happens to such patients after they are referred for a transplant opinion. We now describe our experiences with all MM patients referred to our program within 6 months of their 70^th birthday to determine who actually proceeds to transplant, why patients do not proceed and the success and toxicities of ASCT.

Over the past 18 months 38 patients with MM over the age of 70 were referred for a transplant evaluation at our center. To date 15 have undergone transplantation, and 5 are in active workup for their transplant. Eighteen patients (47%) did not proceed to transplant. Seven patients (18%) were determined by the transplant physician to not be medically suitable to undergo transplantation (3 cardiac, 1 pulmonary, 1 CVA, 1 active infection, 1 general debilitation), four patients (11%) were felt to have disease that did not warrant transplant (stage 1 (n=3) or biochemical relapse post 1^st ASCT). Seven patients (18%) chose not to proceed to transplant. The majority declined due to social concerns (travel, not wanting to bother family or financial concerns n=4) and three felt that since they had a good response to standard therapy that transplant was too aggressive for them.

The median age, and disease stage for the groups are shown in Table 1 and did not appear to differ for the groups. Thirteen of the 14 patients transplanted at our center received a Melphalan dose of 140mg/m2. The median time to an ANC >500 was 11 days, the median time to platelet engraftment (>20) was 16 days. The median hospital stay was 1.5 days (range 0-24) with 8 patients treated primarily as an outpatient. All patients are alive with a median follow up of 270 days.

Just over half of all patients seen as candidates proceeded to transplant with toxicity profiles similar to those patients under 70. Of those who don’t proceed, the majority is due to either physician deferral or patient choice. What is as yet unclear is what percent of patients over the age of 70 are ultimately referred for transplant. These data suggest that transplant is feasible, well tolerated and remains an option for the majority of patients seen in this age group. We believe that age over 70 should not be a contraindication to ASCT referral since it is clear that medically appropriate patients primarily choose to undergo ASCT despite the potential risks associated with such an approach. A clinical trial that focuses on patients of the age group may be warranted at this time to determine the efficacy of such an approach.