Multiple Myeloma: The Role of Autologous Stem Cell Transplant

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Elie Fahed, MD, describes the process and rationale for autologous stem cell transplant in multiple myeloma, and Beth shares her experience with receiving one.

Elie Fahed, MD: The recommendation was a bone marrow transplant. Let me explain a little about what a bone marrow transplant means for myeloma treatment. Usually, it is called an autologous bone marrow transplant. We collect your own stem cells. We take them and put them in a freezer. This will allow us to give you a very high-dose chemotherapy, usually melphalan. By giving you this high-dose chemotherapy, we think we are killing a lot of your cancer cells. At the same time, we are killing some of your bone marrow cells. Because we already took your stem cells before treatment, we have them in the freezer. We take those and give them back to you. This way your bone marrow is able to recover and reconstitute with your red cells and immune cells. Believe it or not, we still use a bone marrow transplant as consolidation for multiple myeloma.

The big distinction for any new patient is whether we think they are eligible for a transplant or not. The artificial boundaries are somewhere between age 65 to 75 at presentation, depending on how fit the patient is—we consider other comorbidities they have, if there is just heart failure or any other issues. As oncologists, we try to make a determination if you are fit for a transplant. We treat you with chemotherapy but plan to go for a transplant next. If we make the determination that you are not a bone marrow transplant candidate, then we treat you with chemotherapy and plan to continue chemotherapy. At that time, at 29 or 30, you were clearly an excellent candidate for a bone marrow transplant. Can you tell us about your experience going through the transplant?

Elizabeth Ayen: Instead of going to Salt Lake City, where my oncologist was, I was able to get hooked up by my oncologist to care at the University of Colorado because that was close to my parents. They could take care of my kids; I had a 5-year-old and a 3-year-old at the time. Mark could then spend the time with me inpatient. He was given enough sick leave so that he was able to stay with me through the whole 30 days of inpatient, which was really nice, especially because he had just started a new job. We had just moved recently to another town in Wyoming, so that was really great to have him there with me every day.

Elie Fahed, MD: You ended up staying a full month inpatient?

Elizabeth Ayen: Yep, the whole 30 days. I went from the first of July until the end of July, so it was the whole 30 days. That was different back then, though; it was much more extensive as far as staying in at the hospital and treatment and different things than it is today. I feel like it is much simpler today, Dr. Fahed. Is it, compared with the past?

Elie Fahed, MD: We still have to go to a big city or a big town. We live now in Casper, Wyoming. We do not have that capacity here. We still have to go to Denver or Salt Lake City to do it. The majority of patients are out of hospitals in 10 days, but they have to stick around and be close enough for daily fasting. They might end up being away for two or three weeks, but they do not have to be inpatient.

Elizabeth Ayen: That is good.

Elie Fahed, MD: Some centers these days are doing it completely outpatient, but you cannot be at home. You have to be very close to the center, so maybe you are not in a hospital, but you are in a hotel or with family close to the cancer center getting your transplant treatment.

Elizabeth Ayen: My biggest concerns were, first of all, getting enough cells before we even started the transplant, which worked out really well for me. I took just two days to get enough cells for them to do the transplant. Once we were in hospital, obviously my concern was that once they reintroduced the cells, I would not respond, and I would not re-create those immune and red cells. It worked out well, but it was definitely hard. They had me drugged up pretty good, so I do not remember a lot of things. Mark remembers all of it because he was there the entire time. I don’t know, Mark, if you want to share a little about what that was like.

Elie Fahed, MD: Mark, tell us about your experience. It is not easy to go through transplant at a young age, away from your kids.

Mark Ayen: I remember one day, early on, I was talking to one of the nurses. She said to me, “Your wife won’t remember any of this because of all the various drugs and treatments.” I asked, “When do I get my drugs and treatment, so I don’t have to remember it?”

Elie Fahed, MD: You are absolutely right.

Mark Ayen: It was a brutal month, and she was sick. As I said, we had a 5-year-old and a 3-year-old who did not understand, necessarily, where Mom was all the time. We were able to bring them to the hospital for the first week, but once her system started to totally shut everything out, she was too sick, and we did not want to expose the kids to that.

I was doing duty during the day, trying to help her get through her treatment, and then I was going home at night and hanging out with my kids, doing the dad thing at the same time. It was painful to watch. The other thing I remember was that the day of the actual transplant, they said, “Today is the day. We are going to do the cells.” I was sitting in her room, talking on the phone with a friend of ours, and this nurse came in with this big syringe full of goo—I don’t know how else to describe it—and put it in, squirt it in. And she went, “All right, there are your cells,” and leaves. I remember telling my friend, “I guess that’s the transplant.”

Elie Fahed, MD: You were imagining a surgery of some sort, right?

Mark Ayen: Yeah. I thought there would be a marching band or balloons. I did not know what to expect, but it was very anticlimactic.

Elie Fahed, MD: It is a big procedure. You need to be in the hospital for a long time. The transplant itself is like an infusion of stem cells. It is very similar to blood transfusions, so it is underwhelming. Beth, I guess it was not the best experience for you. A few years ago, when we discussed doing another transplant if needed, you were not really excited about it.

Elizabeth Ayen: It took me about a year to get back to a normal sense of life. I was throwing up every day for a year after the transplant.

Elie Fahed, MD: For a year—wow. That is a little unusual. Maybe we have better nausea medication these days, but it is still not the easiest procedure to go through. My hope is that, in the next 10 or 20 years, we will keep improving our medications for multiple myeloma; maybe we will not need transplants anymore.

This transcript was edited for clarity.

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