Rethinking Transplant Eligibility in Multiple Myeloma in the MRD Era

C. Ola Landgren, MD, PhD, explains why the long-standing question of transplant eligibility in multiple myeloma may be giving way to a more individualized one: does the patient actually need a transplantation? In this interview from the 2026 International Myeloma Society Annual Meeting, Landgren, professor of medicine, chief of the Myeloma Division, and director of the Sylvester Myeloma Institute at Sylvester Comprehensive Cancer Center, part of the University of Miami Miller School of Medicine, discusses how the treatment landscape has changed and what those changes mean for the role of transplantation.

When Landgren was in fellowship, myeloma treatment centered almost entirely on chemotherapy, with bone marrow transplantation as part of that chemotherapy-based approach. In recent years, immunotherapies have entered the field and been partnered with small molecules, and these combinations are driving patients into very deep treatment responses, including minimal residual disease (MRD) negativity. Landgren notes that this same pattern is being seen both in patients traditionally classified as transplant eligible and in those considered transplant ineligible.

The concept of transplantation began in the United Kingdom nearly 50 years ago, says Landgren, when delivering very high-dose chemotherapy was found to add benefit over giving a low dose. For decades since, the field has split patients according to whether they can tolerate this approach, which is the basis of transplant eligibility. Landgren questions whether that distinction still needs to be made, and why it must be decided right away at diagnosis. Instead, he describes treating patients upfront with the best available drugs and, for those who achieve MRD negativity, considering whether a transplantation is needed at all.

He points to the MIDAS study (NCT04934475), published in The New England Journal of Medicine, which showed the same MRD negativity rates whether or not transplantation was used, with a side effect profile that strongly favored not using transplantation. Landgren's group also led the ADVANCE study (NCT04268498), which examined this question as well.

Looking ahead, Landgren anticipates greater individualization of myeloma therapy built on these concepts. With bispecific antibodies, cereblon E3 ligase modulators (CELMoDs), and other agents moving into earlier lines of therapy, he describes the current moment as the beginning of a major shift in the field, one in which myeloma care moves past the old terminology of transplant eligibility.