# Stem Cell Transplantation for Multiple Myeloma: What a Landmark Global Study of 61,000+ Patients Means for You

Multiple myeloma is a cancer of plasma cells that has become increasingly treatable over the past two decades, and a global study of more than 61,000 patients now provides the clearest picture yet of how one key treatment—autologous stem cell transplantation—performs in the real world. The study, which drew on data from 629 transplant centers across five WHO regions between 2013 and 2017, found that the average overall survival after transplant was 90.2 months (about 7.5 years), with a worldwide non-relapse mortality rate of just 1%–3% at one year. Patients who achieved a complete response before transplant, had good performance status, and received lenalidomide maintenance therapy after transplant experienced the best outcomes. The findings confirm that stem cell transplantation is a safe and effective therapy for newly diagnosed multiple myeloma, though significant regional differences in outcomes point to the influence of healthcare access, patient characteristics, and maintenance treatment availability.

# Stem Cell Transplantation for Multiple Myeloma: What a Landmark Global Study of 61,000+ Patients Means for You

## Table of Contents

- Key Points
- Background: Why This Research Matters
- Study Methods: How the Research Was Conducted
- Key Findings: Patient Characteristics at a Glance
- Key Findings: Overall Survival and Relapse Outcomes
- Key Findings: Regional Differences Around the World
- Key Findings: Which Factors Predict Better Outcomes?
- Clinical Implications: What This Means for Patients
- Study Limitations: What This Research Couldn't Prove
- Recommendations: Actionable Advice for Patients
- Frequently Asked Questions
- Source Information

## Key Points

- In a study of over 61,000 newly diagnosed multiple myeloma patients, median overall survival after autologous stem cell transplant was 90.2 months (about 7.5 years).
- Non-relapse mortality was low: 0.6% at 3 months and 2.5% at 2 years, meaning more than 97 out of 100 patients survived the procedure itself during that period.
- In the same study, complete response before transplant, good performance status, and lenalidomide maintenance after transplant were linked to better outcomes.
- Three-year overall survival varied by region from 84.3% to 68.6%, likely due to healthcare access, patient characteristics, and maintenance availability.
- The study was observational and cannot prove cause and effect; maintenance data was available for only 11% of the whole group, limiting that analysis.

## Background: Why This Research Matters

Multiple myeloma (MM) is a blood cancer that develops when plasma cells—a type of white blood cell responsible for producing antibodies—multiply out of control in the bone marrow. These abnormal cells crowd out healthy blood cells and can cause damage to bones, kidneys, and the immune system. In 2020, multiple myeloma was the **third most common blood cancer worldwide**, accounting for 176,404 of the 1,278,362 blood cancers diagnosed globally, or roughly 14% of all blood cancer cases.

The exact cause of multiple myeloma remains unknown, but researchers have identified several risk factors. These include male sex, Black race, older age, living in developed countries, having a family history of the disease, exposure to radiation, and obesity. Studies have consistently shown wide variation in the burden of myeloma worldwide, with higher incidence and mortality seen in men and in countries with a higher Human Development Index.

Treatment has evolved dramatically over the past decade. Thanks to newer targeted therapies and improved transplantation techniques, the five-year overall survival rate for multiple myeloma has **doubled to approximately 54%**. One of the most important treatment tools is autologous hematopoietic cell transplantation (AHCT), a procedure in which a patient's own blood-forming stem cells are collected before high-dose chemotherapy, then returned to the body to rebuild the bone marrow and restore healthy blood cell production.

Despite the widespread use of AHCT, there was a striking lack of real-world data comparing how this treatment performs across countries. Most of what doctors knew came from clinical trials, which often include highly selected patients. To fill that knowledge gap, the Worldwide Network for Blood and Marrow Transplantation (WBMT)—a federation of stem cell transplantation societies—launched this study. AHCT activity in plasma cell disorders has increased dramatically over the years, from 10,675 procedures in 2002 to 23,701 in 2016, but utilization has been concentrated in high-income regions and remains limited in Africa and the Eastern Mediterranean Region.

The researchers wanted to answer a specific question: when stem cell transplantation is actually used in everyday practice across the globe, how well do patients do, and what factors are most strongly linked to good outcomes?

## Study Methods: How the Research Was Conducted

This was a large retrospective registry study, meaning researchers analyzed data that had already been collected from transplant centers around the world. The study included patients aged 18 years and older with newly diagnosed multiple myeloma who underwent their first AHCT between **2013 and 2017**. No personal information was transferred, and the need for additional informed consent was waived because the study involved secondary use of de-identified registry data.

Data came from nine national and international registries, coordinated through the WBMT:

- The Center for International Blood and Marrow Transplantation Research (CIBMTR) in the United States
- The Canadian registry, using the Ottawa Blood Disease Center MM Database (OBDCMMD)
- The Latin American Blood and Marrow Transplantation group (LABMT)
- The European Society for Blood and Marrow Transplantation (EBMT)
- The Australia and New Zealand Transplant & Cellular Therapies Registry (ANZTCTR)
- The Asian Pacific Blood and Marrow Transplant Group (APBMT), which includes registries from Japan, Taiwan, Malaysia, and China
- The Eastern Mediterranean Blood and Marrow Transplant Group (EMBMT)

The researchers defined the study's endpoints clearly. The **primary endpoint was overall survival (OS)**—the length of time from transplant until death from any cause. **Secondary endpoints were progression-free survival (PFS)** (survival without relapse or progression of the myeloma), **relapse incidence (RI)** (the cumulative rate of disease returning), and **non-relapse mortality (NRM)** (death without evidence of relapse or progression).

Several key definitions were used throughout the study. High-risk cytogenetic abnormalities were defined as deletion 17p and/or the translocations t(4:14) and t(14:16); all other cytogenetic findings were classified as standard risk. Hematological responses were classified according to standard IMWG (International Myeloma Working Group) criteria, ranging from complete response (CR) to partial response (PR), minimal response or stable disease (MR/SD), and relapse or progression.

Statistical analysis was rigorous. Overall survival and progression-free survival were estimated using the Kaplan-Meier method, while relapse incidence and non-relapse mortality were analyzed in a competing-risk framework using Gray's test. Multivariate analysis (MVA) was performed using Cox proportional hazard models, which allow researchers to assess the effect of each factor while accounting for other variables simultaneously. All models included a random country effect to recognize that patients within the same country may be more similar to each other than to patients elsewhere. A landmark analysis at 3 months was used to assess the impact of maintenance therapy fairly—this approach ensures that only patients who survived and were still relapse-free at 3 months are analyzed, reducing bias.

## Key Findings: Patient Characteristics at a Glance

A total of **103,847 first AHCT procedures for multiple myeloma** were reported to the WBMT activity survey between 2013 and 2017. Outcome information was available for **61,725 newly diagnosed patients** (59.5%) treated at **629 transplant centers** across five WHO regions. This is one of the largest real-world analyses of stem cell transplantation in myeloma ever conducted.

Use of AHCT increased over the study period, from **11,317 transplants in 2013 (18.3% of the total) to 13,498 in 2017 (21.9%)**. The average number of transplants per year increased in all regions except the Eastern Mediterranean Region (EMR).

The median age at diagnosis was 59.9 years. There was notable regional variation, with the lowest median age in the Eastern Mediterranean Region (52.5 years) and Malaysia (54.3 years), and the highest in Ottawa, Canada (61.5 years). The median age at the time of AHCT was 60.8 years (interquartile range 54.6–65.8), with only **5.1% of patients older than 70 years** at transplant. The United States had the highest proportion of patients over 70 (9.8%), while Malaysia (0%) and the Eastern Mediterranean Region (0.6%) had the lowest.

Looking at disease characteristics, the most common immunoglobulin subtypes were:

- IgG subtype: 54.0% of patients
- Light chain subtype: 24.4%
- IgA subtype: 18.6%

Disease stage at diagnosis (measured by the International Staging System, or ISS) was reported in 54.5% of patients. Among those, **38.0% had ISS stage I** (the least advanced), 34.8% had ISS stage II, and 27.1% had ISS stage III (the most advanced). Cytogenetic risk status—information about chromosome abnormalities in the myeloma cells—was available for 44.5% of patients, and **30.3% of those were classified as high-risk**.

Patient performance status, measured by the Karnofsky score, was ≤90% in 72.0% of patients at the time of transplant. This means that most patients had some degree of functional limitation before their transplant. The proportion varied widely by region, from just 44.3% in Latin America to 92.4% in Ottawa, Canada, suggesting differences in how patients are selected for transplantation in different healthcare systems.

Overall health at transplant, as measured by the Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI), was low (score 0) in 52% of patients, intermediate (scores 1–2) in 25%, and high (score ≥3) in 23%. This index captures how many additional health problems a patient has—such as heart, lung, liver, or kidney conditions—that could affect transplant outcomes.

Regarding disease status before transplant, most patients underwent AHCT in a **very good partial response (VGPR) (38.0%) or partial response (PR) (36.2%)**. Complete response (CR) was documented in 19.1%, minimal response or stable disease in 4.7%, and relapse or progression in 1.8%. The percentage of patients achieving VGPR or better before transplant ranged from 76% in Latin America to 39% in Australia and New Zealand—a substantial difference that likely reflects different treatment protocols and timing of transplant.

The most common conditioning regimen—the high-dose chemotherapy given before stem cells are returned—was **melphalan at a dose of 200 mg/m²**, used in 70% of patients overall. However, only 60.4% of patients in Malaysia received this full dose, compared to 89.6% in Ottawa, Canada. A minority of patients (6.7%) underwent tandem (double) transplantation, with the proportion ranging from 10.1% in Europe to 1.3% in the United States.

Critically, **post-transplant maintenance therapy with lenalidomide was used in 51% of the 6,801 patients for whom maintenance information was available**—representing only 11.0% of the entire study population. This low overall percentage highlights a significant gap: most patients in this global cohort did not receive or have documented lenalidomide maintenance, despite it being a proven strategy to prevent relapse.

## Key Findings: Overall Survival and Relapse Outcomes

After a median follow-up of 41 months (interquartile range 19–60 months), the results confirmed that AHCT is a highly effective treatment for newly diagnosed multiple myeloma. The **median overall survival was 90.2 months (95% CI 88.2–93.6)**—meaning half of patients lived longer than 7.5 years after their transplant. Survival rates at specific time points were also encouraging:

- Overall survival at 24 months: **88.4%** (95% CI 88.1–88.7)
- Overall survival at 72 months: **63.4%** (95% CI 62.7–64.0)

Progression-free survival—the time patients lived without their myeloma returning or worsening—was also substantial, though shorter than overall survival, reflecting that most patients eventually experience disease progression:

- Median PFS: **36.5 months** (95% CI 36.1–37.0)
- PFS at 24 months: **64.6%** (95% CI 64.1–65.0)
- PFS at 72 months: **28.6%** (95% CI 28.0–29.2)

The relapse incidence increased steadily over time: **2.4% at 3 months, 33% at 24 months** (95% CI 32.5–33.4), and 65.5% (95% CI 64.9–66.1) at 72 months. This means that about two-thirds of patients experienced disease relapse or progression within six years of their transplant—a reminder that while AHCT is powerful, it rarely cures multiple myeloma by itself, which is why maintenance therapy is so important.

In stark contrast to the relapse rates, the **non-relapse mortality (NRM) was very low**: 0.6% at 3 months, **2.5% at 24 months** (95% CI 2.3–2.6), and 5.9% at 72 months. Non-relapse mortality refers to deaths from causes other than the cancer itself—such as infections, organ failure, or complications of the transplant. A 2.5% non-relapse mortality rate at two years means the procedure itself is quite safe, with more than 97 out of 100 patients surviving the transplant itself during that period.

## Key Findings: Regional Differences Around the World

One of the most striking findings of this study was the substantial variation in outcomes between regions. The **three-year overall survival ranged from 84.3% to 68.6%** across regions—a difference of nearly 16 percentage points that was statistically significant (p<0.001). The United States had the longest median overall survival, while Malaysia had the shortest.

Progression-free survival showed similar patterns. At 36 months, PFS was highest in **Japan (62.5%) and lowest in Malaysia (43.3%)**. These differences were mirrored in relapse rates: Japan had the lowest cumulative 36-month relapse incidence at **31.7%**, while the Eastern Mediterranean Region had the highest at **52.3%**—meaning more than half of patients in that region had experienced relapse within three years of transplant.

Non-relapse mortality also varied, though paradoxically, the **highest NRM at 36 months was observed in Japan (5.8%) and the lowest in the EMR (2.0%)**. This inverse pattern likely reflects different patient selection criteria and reporting practices across registries, rather than differences in the quality of transplant care.

The abstract's summary of regional ranges is worth emphasizing: worldwide, NRM at 12 months was just **1%–3%**, but overall survival at 36 months ranged from **69% to 84%**, relapse incidence at 12 months ranged from **12% to 24%**, and PFS at 36 months ranged from **43% to 63%**. These broad ranges point to real differences in patient populations, treatment before and after transplant, and healthcare resources.

## Key Findings: Which Factors Predict Better Outcomes?

The investigators conducted both univariate and multivariate analyses to identify which patient and disease characteristics were most strongly associated with outcomes. Univariate analysis (looking at each factor in isolation) showed that Karnofsky performance score, sex, myeloma subtype, ISS stage, cytogenetic risk, HCT-CI comorbidity score, disease status at transplant, conditioning regimen, graft source, age, and maintenance therapy were all significantly associated with overall survival. Notably, the interval from diagnosis to transplant, graft source, and tandem transplant were **not** significantly associated with survival.

Encouragingly, outcomes improved over time even within this relatively short study window. The **36-month overall survival increased from 80% (95% CI 79%–81%) in 2013 to 84% (95% CI 83%–85%) in 2017**, indicating continual improvement in how transplantation is delivered.

The multivariate analysis—which accounts for multiple factors simultaneously—included 52,568 patients with complete data and identified the following as the most important risk factors for worse overall survival and progression-free survival:

- Active relapse at transplant (hazard ratio [HR] 5.23 for OS and 3.44 for PFS)—by far the strongest predictor of poor outcome
- Minimal response or stable disease at transplant (HR 1.99 for OS, 1.84 for PFS)
- No maintenance therapy after transplant (HR 1.79 for OS, 1.72 for PFS)
- IgA subtype (HR 1.47 for OS, 1.82 for PFS)
- Karnofsky score ≤90% (HR 1.33 for OS, 1.10 for PFS)
- Melphalan 140 mg/m² instead of 200 mg/m² (HR 1.25 for OS, 1.16 for PFS)
- Very good partial response rather than complete response at transplant (HR 1.21 for OS, 1.28 for PFS)
- Light chain myeloma subtype (HR 1.14 for OS, 1.08 for PFS)
- Older age (HR 1.1 for OS and 1.03 for PFS per 10-year increase)

For non-relapse mortality, the strongest risk factors were **not being in complete response at transplant** (hazard ratios ranging from 1.47 to 2.5 depending on the degree of response), **melphalan 140 mg/m² instead of 200 mg/m²** (HR 1.64), **Karnofsky score ≤90%** (HR 1.40), and **older age at transplant** (HR 1.36). A more recent calendar year of transplant was associated with better OS, PFS, and lower relapse incidence.

A second multivariate analysis was performed on a subset of **20,355 patients** who had complete information on cytogenetic risk, HCT-CI, and ISS stage. This analysis revealed that a higher comorbidity index was significantly associated with worse overall survival (**HR 1.30 for high HCT-CI and 1.15 for intermediate HCT-CI**) but was not linked to progression-free survival or relapse risk. Both **high-risk cytogenetics (HR 2.13) and advanced ISS stage (HR 2.13 for stage III and 1.51 for stage II)** were strongly associated with worse overall survival, shorter PFS, and higher relapse incidence.

Finally, a landmark analysis at 3 months restricted to patients with maintenance information confirmed that **lenalidomide maintenance was associated with improved overall survival and progression-free survival**—a key finding that reinforces current guidelines recommending maintenance therapy after transplant.

## Clinical Implications: What This Means for Patients

This study delivers several messages that matter for patients facing a new multiple myeloma diagnosis and considering stem cell transplantation.

**First, transplantation is safe.** The non-relapse mortality of just 0.6% at 3 months and 2.5% at two years means that for most patients, the procedure itself carries a very low risk of death. Even patients with significant comorbidities can undergo transplant with manageable risk, though those with higher comorbidity scores do have worse overall survival.

**Second, the depth of response before transplant matters enormously.** Patients who achieved a complete response before their transplant had far better outcomes than those who went into transplant with residual disease. The hazard ratio of 5.23 for overall survival among patients transplanted while in active relapse is dramatic—these patients face more than five times the risk of death compared to patients in complete response. This underscores the importance of maximizing response with induction therapy before proceeding to transplant, and for some patients, potentially considering additional treatment to deepen their response first.

**Third, maintenance therapy saves lives.** The finding that no maintenance therapy was associated with an HR of 1.79 for overall survival means that patients who did not receive maintenance had nearly 80% higher risk of death during the follow-up period. Only 51% of patients with available maintenance data received lenalidomide, suggesting that many patients globally are missing out on this proven therapy. This finding is particularly relevant for patients discussing post-transplant treatment plans with their physicians.

**Fourth, regional disparities warrant attention.** The differences in outcomes—particularly the lower survival and higher relapse rates in some regions—likely reflect a combination of factors: differences in patient characteristics at diagnosis, access to novel induction therapies, availability of maintenance drugs, and macroeconomic factors such as national health expenditure. The study's findings highlight that improving access to transplant and post-transplant care in underserved regions should be a global health priority.

## Study Limitations: What This Research Couldn't Prove

Every large registry study has limitations, and the authors were transparent about several important ones.

**Missing data was a significant issue.** ISS stage was only available for 54.5% of patients, cytogenetic risk for 44.5%, and HCT-CI for 71.8%. Perhaps most importantly, **maintenance therapy information was available for only 11.0% of the entire cohort** (6,801 of 61,725 patients). While the characteristics of patients with and without maintenance data were similar except for transplant year, this limited the analysis of maintenance's true impact in the global population.

The study was retrospective and observational, meaning it can show associations but **cannot prove causation**. For example, the finding that patients who received lenalidomide maintenance lived longer could theoretically reflect that healthier patients or those with less aggressive disease were more likely to receive maintenance—though the landmark analysis and multivariate adjustments help mitigate this concern.

There were also differences in how registries reported data. The CIBMTR in the United States, for instance, only provided information on patients transplanted within 12 months of diagnosis, while other registries had no time interval restriction. This could influence comparisons between regions. The multivariate analyses were based on complete cases only, which may introduce bias if patients with missing data differ systematically from those with complete data.

Additionally, the time interval from diagnosis to transplant was **not** found to be significantly associated with outcomes in this study. While reassuring, this finding should be interpreted cautiously given the registry constraints on diagnosis timing windows.

Finally, the study period ended in 2017. The multiple myeloma treatment landscape has continued to evolve since then, with new drugs like daratumumab, carfilzomib, and pomalidomide becoming more widely used, both before and after transplant. The current outcomes may be even better than what this study reports, though real-world data on more recent years will be needed to confirm that.

## Recommendations: Actionable Advice for Patients

Based on this comprehensive global study and the current standards of care it reinforces, patients and families dealing with multiple myeloma can take away several practical points:

1.
**Ask about stem cell transplantation early.** For newly diagnosed multiple myeloma, AHCT remains a cornerstone of treatment. Discuss with your hematologist whether you are a candidate for transplant, and if so, the optimal timing in your treatment journey.
1.
**Aim for the deepest possible response before transplant.** The data clearly show that achieving a complete response before AHCT is linked to substantially better survival. If your current treatment isn't achieving deep responses, ask your doctor whether adjusting your induction therapy is appropriate.
1.
**Take maintenance therapy seriously.** Lenalidomide maintenance after transplant was strongly associated with improved overall survival and progression-free survival. If your doctor recommends maintenance therapy, understand that it's not optional—it is a proven strategy to reduce the risk of relapse and extend your life.
1.
**If you have high-risk features, seek expert care.** Patients with high-risk cytogenetics (such as deletion 17p or translocations t(4;14) or t(14;16)) and advanced ISS stage face tougher odds. These patients should preferably be treated at centers experienced in managing high-risk myeloma, and should ask about clinical trials or intensified approaches that may improve their outlook.
1.
**Maintain your overall health.** Performance status and comorbidity scores were independent predictors of survival. Staying as active as possible, managing other health conditions (diabetes, heart disease, lung disease), and optimizing your fitness before transplant may improve your outcomes.
1.
**If you live in a region with limited transplant access, advocate for yourself.** The study found considerable variation in transplant rates, outcomes, and maintenance usage worldwide. Understanding the guidelines and standards of care can empower you to ask the right questions about whether transplant, full-dose conditioning, and post-transplant maintenance are being offered to you.
1.
**Recognize that outcomes are improving.** Survival improved steadily even between 2013 and 2017. Combined with newer therapies introduced since then, the future for multiple myeloma patients continues to brighten.

## Frequently Asked Questions

### What is autologous stem cell transplantation for multiple myeloma?

It is a procedure where your own blood-forming stem cells are collected, then high-dose chemotherapy is given, and the cells are returned to rebuild your bone marrow. In a global study of over 61,000 newly diagnosed patients, this transplant was safe and effective, with a median overall survival of 90.2 months, or about 7.5 years.

### How safe is the transplant itself?

In a study of more than 61,000 patients, non-relapse mortality—death from causes other than the cancer—was low: 0.6% at 3 months and 2.5% at 2 years. That means more than 97 out of 100 patients survived the transplant itself during that period. Your own risk depends on your health and other conditions.

### What does a median overall survival of 90.2 months mean?

It means that in a global study of over 61,000 patients, half lived longer than 90.2 months (about 7.5 years) after transplant, and half did not. It is a group average, not a prediction for any one person. Your outcome can differ based on your disease features and treatment.

### Does maintenance therapy after transplant help?

Yes. In the same study, lenalidomide maintenance after transplant was linked to improved overall and progression-free survival. Patients who did not receive maintenance had nearly 80% higher risk of death during follow-up. However, maintenance information was available for only 11% of the whole group, so this finding has limits.

### What factors are linked to better outcomes after transplant?

In a study of over 61,000 patients, achieving a complete response before transplant, having good performance status, and receiving lenalidomide maintenance after transplant were linked to better outcomes. Active relapse at transplant was the strongest predictor of poor outcome, with more than five times the risk of death compared to complete response.

### Why do outcomes differ around the world?

In a study of over 61,000 patients across five regions, three-year overall survival ranged from 84.3% to 68.6%. These differences likely reflect healthcare access, patient characteristics, availability of maintenance treatment, and economic factors—not necessarily the quality of transplant care. The study authors say improving access in underserved regions should be a global priority.

### What should I ask my doctor about transplant?

Ask early whether you are a candidate for stem cell transplantation and the optimal timing. Discuss how to achieve the deepest possible response before transplant, since complete response is linked to better survival. Also ask about maintenance therapy after transplant, as it was associated with improved outcomes in a large global study.

### When should a patient with newly diagnosed multiple myeloma seek a second opinion before stem cell transplantation?

A second opinion is worth considering when the depth of response before transplant is uncertain, since patients transplanted in active relapse face more than five times the risk of death compared with those in complete response, and minimal response or stable disease also predicts worse survival. It is also reasonable when maintenance therapy after transplant has not been discussed, as no maintenance was linked to a 79% higher risk of death. Patients with high-risk cytogenetics or advanced ISS stage may also benefit from expert review. Diagnostic Detectives Network provides independent expert second opinions.

## Source Information

This patient-friendly article is based on peer-reviewed research originally published in the *American Journal of Hematology*.

**Original Article Title:** American J Hematol - 2024 - Garderet - Global characteristics and outcomes of autologous hematopoietic stem cell

**DOI:** [10.1002/ajh.27451](https://doi.org/10.1002/ajh.27451)

**Authors:** Laurent Garderet, Luuk Gras, Linda Koster, Laurien Baaij, Nada Hamad, Anita Dsouza, Noel Estrada-Merly, Parameswaran Hari, Wael Saber, Andrew J. Cowan, Minako Iida, Shinichiro Okamoto, Hiroyuki Takamatsu, Shohei Mizuno, Koji Kawamura, Yoshihisa Kodera, Bor-Sheng Ko, Christopher Liam, Kim Wah Ho, A. Sim Goh, S. Keat Tan, Alaa M. Elhaddad, Ali Bazarbachi, Qamar un Nisa Chaudhry, Rozan Alfar, Mohamed-Amine Bekadja, Malek Benakli, Cristobal Augusto Frutos Ortiz, Eloisa Riva, Sebastian Galeano, Francisca Bass, Hira S. Mian, Arleigh McCurdy, Feng Rong Wang, Ly Meng, Daniel Neumann, Mickey Koh, John A. Snowden, Stefan Schönland, Donal P. McLornan, Patrick John Hayden, Anna Sureda, Hildegard T. Greinix, Mahmoud Aljurf, Yoshiko Atsuta, and Dietger Niederwieser.

**Publication Details:** *American Journal of Hematology*, 2024; volume 99, pages 2084–2095. Published by Wiley Periodicals LLC. DOI: 10.1002/ajh.27451

**Funding/Access:** This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial, and no modifications or adaptations are made.

*Note: This patient-friendly summary was adapted from the original research article to make its findings accessible to patients and families. It is not a substitute for professional medical advice. Always consult your healthcare team about your individual treatment plan.*


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