Upfront autologous hematopoietic cell transplantation (HCT) should remain the standard approach for all young patients with multiple myeloma, according to a pooled analysis published in the journal Leukemia.1

Previous research has demonstrated that upfront autologous HCT significantly prolongs progression-free survival compared with chemotherapy plus lenalidomide in patients with newly diagnosed multiple myeloma. Although salvage autologous HCT at the time of first relapse may effectively rescue those who did not receive upfront transplantation, the long-term benefit of upfront autologous HCT vs salvage transplantation in patients who initially received systemic therapy remains unclear.

Therefore, investigators conducted a pooled analysis of 2 phase 3 trials (RV-MM-209 and EMN-441) to evaluate the impact of upfront autologous HCT compared with chemotherapy plus lenalidomide followed by salvage autologous HCT in young, treatment-naive patients with multiple myeloma.

Overall, 268 patients were randomly assigned to receive 2 courses of melphalan with autologous HCT and 261 to chemotherapy plus lenalidomide.

After a median follow-up of 46 months, upfront autologous HCT was associated with a 47% reduction in the risk of first progression or death (hazard ratio [HR], 0.53; P < .001), as well as a 47% reduced risk of second progression or death (HR, 0.53; P < .001), compared with systemic therapy.

In addition, patients who received upfront autologous HCT had a 49% reduced risk of death (HR, 0.51; P < .001) vs those given initial therapy with chemotherapy plus lenalidomide; 4-year overall survival was 84% and 70%, respectively.

Investigators observed a survival advanced in both patients with a good prognosis and in those with a bad prognosis. 

Slightly more than half (53%) of patients who experienced relapse after systemic therapy received autologous HCT at first relapse. The analysis demonstrated that upfront autologous HCT significantly improved survival by 49% compared with salvage transplantation (HR, 0.51; P = .007).