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Routine Tandem Transplantation for Patients with Myeloma
- Kevin Imrie, MD; and
- Ralph M. Meyer, MD
- Toronto–Sunnybrook Regional Cancer Center; Toronto, Ontario M4N 3M5, Canada (Imrie) Hamilton Regional Cancer Centre; Hamilton, Ontario L8V 5C2, Canada (Meyer) Note added in proof: The data described are based on work completed in August 2002. The Hematology Site Group of the Cancer Care Ontario Practice Guidelines Initiative is aware of a published abstract (5) that includes an updated analysis of the trial reported by Attal and Harousseau (2). The Hematology Site Group will incorporate these new data into an updated practice guideline. These new data have not resulted in changes to previous recommendations that are posted on our Web site (1).
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IN RESPONSE:
We agree that to assess the role of tandem transplantation in patients with multiple myeloma, potential benefits and risks need to be balanced and utilization of health care resources considered. In developing formal guidelines, it is essential that available evidence be systematically appraised. For our guideline, we completed a systematic literature review by using predefined criteria to select available literature. Greatest weight was given to articles or abstracts reporting results of randomized trials; case series were not considered. We regularly update this literature search and, if appropriate, consider guideline revisions to incorporate new evidence. An update of our guideline is available on our Web site (1).
We are aware of three randomized trials comparing single and tandem transplantation for patients with myeloma (2-4). All three trials have been reported in abstract form on many occasions; the most recent report of each trial is summarized in the table. We are unaware of any reports in full article form. Analysis of these trials requires an understanding of several methodologic details, such as eligibility criteria; details of the therapy; and, of importance, whether an intention-to-treat analysis including all randomly assigned patients was performed. This information can be difficult to properly evaluate from abstract presentations. Of these three studies, one (2) used a factorial design to also compare the use of bone marrow or peripheral blood as the source of stem cells, and another (3) included only a portion of the accrued patients in the analysis. The third trial (4) also used a factorial design (with the second question addressing the role of stem-cell purging) and reported the outcomes of only a portion of the patients entered.
Given the lack of consistent and compelling data demonstrating clear benefits associated with tandem transplantation, and the limitations inherent in interpreting reports in abstract form, our group has concluded that there is currently insufficient evidence to support a recommendation for routine use. We look forward to the eventual publication of the three trials mentioned here in article form and suspect that a meta-analysis would further clarify whether tandem transplantation is of benefit. While we agree that thalidomide may benefit patients with myeloma, randomized, controlled trials will be required to determine the optimum role of this agent.
Kevin Imrie, MD
Toronto–Sunnybrook Regional Cancer Center; Toronto, Ontario M4N 3M5, Canada
Ralph M. Meyer, MD
Hamilton Regional Cancer Centre; Hamilton, Ontario L8V 5C2, Canada
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
