Barts-MS rose-tinted-odometer ★ ★ ★
The good news is that the use of autologous HSCT to treat autoimmune diseases rose (by 19%) in the European Bone Marrow Transplant registry in 2018. Importantly, this rise was predominantly due to HSCT treatment for multiple sclerosis. This would indicate that at least at the very right of the bell curve there is increasing use of a more aggressive approach to treating MS. If this indicates that the bell curve has shifted to the right it means that more pwMS are being treated with highly effective treatments and I suspect that many are getting onto these as first-line therapies.
What will this mean at a population level? I suspect that over time the prognosis of MS will improve and an increasing number of patients treated with IRTs (cladribine, alemtuzumab and HSCT) will be rendered free of detectable disease in the longterm. If and whether we will be able to claim that a proportion of these pwMS are cured of having MS will depend on the MS community coming up with a widely accepted definition of what an MS cure looks like.
How IRTs actually work will remain a moot point. Immunologists will claim that they deplete pathogenic autoimmune T and B lymphocytes and reset regulatory immunological networks. Proponents of the EBV hypothesis will claim they all work by targeting pathogenic memory B cells that harbour EBV. Sorting out these competing theories will really require targeted EBV studies, the sort that has been developed by Atara Bio. Another strategy will be using anti-viral agents active against EBV; this will include both existing and new anti-EBV therapies.
If I have to bet on the outcome I would favour the EBV hypothesis. There are simply too many holes in the autoimmune theory of MS and the epidemiology backing EBV as the cause of MS is now so overwhelming that the wider MS community is finally getting behind EBV vaccination as a possible preventive strategy. I hope you agree.
Passweg et al. and the European Society for Blood and Marrow Transplantation (EBMT). The EBMT activity survey on hematopoietic-cell transplantation and cellular therapy 2018: CAR-T’s come into focus. Bone Marrow Transplant. 2020 Feb 17.
Hematopoietic-cell transplantation (HCT) is widely used for acquired and congenital disorders of the hematopoietic system. Number of transplants performed in Europe and associated countries continues to rise with 47,468 HCT in 42,901 patients [19,630 allogeneic (41%) and 27,838 autologous (59%)] reported by 701 centers in 50 countries in 2018. Main indications were myeloid malignancies 10,679 (25%; 97% allogeneic), lymphoid malignancies 27,318 (64%; 20% allogeneic), solid tumors 1625 (4%; 2.9% allogeneic), and nonmalignant disorders 3063 (7%; 81% allogeneic). This year’s analysis focuses on cellular therapies with the marked growth in CAR T-cell therapies from 151 in 2017 to 301 patients reported in 2018. Other cellular therapy numbers show less significant changes. Important trends in HCT include a 49% increase in allogeneic HCT for chronic phase CML (although transplant numbers remain low) and a 24% increase in aplastic anemia. In autologous HCT, there is an ongoing increase in autoimmune diseases (by 19%), predominantly due to activity in multiple sclerosis. This annual report reflects current activity and highlights important trends, useful for health care planning.