For otherwise transplant-eligible patients with myeloma, given developments of bispecifics and CAR-T, what is your age cutoff for consolidative autologous transplant?

For any lawyers reading this, there is no upper age cutoff for consideration of transplantation.

For the physicians and other healthcare providers reading this, it's much more nuanced. As the question poster alluded to, this isn't 2010 and we have many more treatment options available. I have many patients in their 70s who absolutely would prefer to avoid high-dose melphalan but who would be extremely interested in CAR-T or bsAbs at a subsequent relapse, if eligible. So I think the biggest factor here for a fit patient in their late 70s or early 80s is their preferences and the logistics (ability to find a caregiver, suitability of the caregiver themselves in terms of not having their health issues, etc.).

With that caveat in mind, I typica...

While high dose melphalan (HDM) followed by autologous stem cell transplant (ASCT) is a standard of care for fit myeloma patients as part of frontline therapy, there is a 5-fold variation in melphalan exposure leading to widely variable clinical responses, with 3 months of disease control on one extreme to functional cures on the other. Specifically, only 10% of patients are functionally cured, 5% have too high an exposure and die due to transplant-related toxicities, and approximately 20% are melphalan-resistant and relapse within 12 months of ASCT.

There is evidence to suggest that melphalan pharmacokinetics predict ASCT outcomes.

1. A higher melphalan area under the curve (AUC) leads to improved overall survival.
2. A low creatinine clearance a...