Discussants: Matt Kalaycio, MD¹; Sagar Lonial, MD²

From Cleveland Clinic, Cleveland, OH¹; Emory University, Atlanta, GA²

Address for correspondence: Matt Kalaycio, MD, Cleveland Clinic Main Campus, Mail Code R32, 9500 Euclid Avenue, Cleveland, OH 44195

E-mail: kalaycm@ccf.org

Biographical sketch:

Dr. Kalaycio has been published in numerous scientific publications including Bone Marrow Transplantation, Journal of Clinical Oncology, and Leukemia. He also is the editor of a book on leukemia and co-editor of a book on clinical malignant hematology. His research interests focus on testing new treatments for leukemia.

Dr. Kalaycio received his degree from West Virginia University School of Medicine in Morgantown. He completed his residency in internal medicine at Mercy Hospital of Pittsburgh and fellowships in hematology and medical oncology and bone marrow transplantation at Cleveland Clinic.

Dr. Lonial is involved in numerous professional organizations including the American Society of Clinical Oncology, American Society of Hematology, and the American Society for Blood and Marrow Transplantation. He serves as Vice Chair of the Myeloma Committee in the Eastern Cooperative Oncology Group and as Chair of the Steering Committee for the Multiple Myeloma Research Consortium. Additionally, he is on the board of directors for the International Myeloma Society, and on the scientific Advisory Board for the International Myeloma Foundation.

Transplant Eligibility

Dr. Kalaycio: Sagar, I have this question, and I go over it more than once with my colleagues. I'm interested in your take on it. Many papers and many protocols distinguish between the transplant eligible and the nontransplant eligible patient.

I hear different definitions about that. As a stem cell transplanter myself, I tend to think people are more eligible than others might think. I wonder if in your practice, you make that distinction between transplant eligible and nontransplant eligible. If you do, how so?

Dr. Lonial: That’s a really good question. I think It's a really confusing area because we are being held hostage to the European definition of transplant eligible and non-eligible, which is basically, age 65.^1,2 We know that in the United States we'll transplant people much older than they will in Europe, we just use a reduced dose of melphalan. My way of categorizing people here is actually different from the simple eligible/non-eligible dichotomy. I break down patients into three categories.

The first category is the young fit patient, which is usually the patient who is under age 65. The second category is the older fit patient, which is probably between 65 and 75, and may even go a little bit older than that, depending upon fitness. The third category is the frail patient. The frail category actually has no age definition, because I've said no to 55 year olds for transplant, and I’ve said yes to 77 year olds for transplant. The frail category is defined now using the frailty index, published by Palumbo et al.³ In general for me it tends to be people between ages 75 and 78 at the lower end, and then above that.

I think about people who are in the frail category as not being able to tolerate a transplant, and so I'm going to treat them with a different treatment approach in a much more gentle way, with the same goal of trying to achieve a complete response. With the other two categories, the young fit and the older fit patient, I'm going to try to induce with a three-drug regimen, and use that as their stress test to see whether they can go forward to the next step in terms of collection of stem cells and transplant.

Dr. Kalaycio: I'm familiar with Palumbo's article and his frailty index. We've not applied it in the clinic. It sounds like you have.

Dr. Lonial: Yes, I think it's not so straightforward in the sense that it is not just a bunch of laboratory values. It really does require you to do a little bit of work in terms of activities of daily living, and things along those lines. It is a pretty good validated tool for identifying patients who are at higher risk of toxicity from treatment. It's going to be used increasingly now in clinical trials for phase III patients, as well as for the International Myeloma Working Group description about how to approach treatment.³ It really is a nice objective tool for how to evaluate that.