For young patients with smoldering multiple myeloma who wish to be treated with lenalidomide, how do you go about harvesting their cells for an autologous transplant?

I have serious reservations with treating smoldering myeloma with lenalidomide and in general, discourage it. That is likely a discussion for another day, but my thoughts on this have been summarized here.

In general, we are able to secure permission for 'collect and store', and so I would prefer to collect stem cells after 4-6 cycles. If insurance will not pay for it, then you are in a bit of a bind. Might I recommend continuing active surveillance anyhow?

We are learning more about the natural history of SMM. Certainly for an SMM patient that is classified as "high risk", I would consider lenalidomide treatment if none of the many trials were available for this individual. In our own practice, we try exceedingly hard not to treat SMM patients off trial. However, we have two randomized studies using lenalidomide that have shown a decrease in progression to symptomatic MM (Mateos et al., PMID 23902483, Lonial et al., PMID 31652094). I agree that the issue of insurance coverage for stored cells is a problem, not just in SMM but in MM in general. I think most centers tend to collect and store, which is probably the right thing to do, outside of cost considerations, except in individuals who are ...