Agree that no one knows the indication for BMT in the next 10-20 years. I believe there will be more limited use of transplant for several reasons. I say this having been in a transplant clinic for a year. Most of all, the inability to separate GVL from GVHD has led to serious comorbidities in the post-transplant setting. One only need to see a serious case of GVHD to put things into perspective. Don't get me wrong, there are people who do well. Those who don't crashes and burn.
1) Depending on academic/community setting, all in all, approx. 60% or more of the transplant business are derived via high dose chemo with stem cell rescue used in MM and lymphomas. In the next 10-20 years, I believe the advancement in therapeutics will further restrict the role of SCT. We are already seeing daratumumab which has good single agent activity. In lymphoma, CART technology is improving. Ibrutinib in CLL is a breakthrough although there is still a small group that will transform as a representation of aggressive biology. It's a matter of time before head to head trial is conducted but I would imagine there is less appetite for such a comparison since transplant is a big business in MM and depending on the practice setting, lymphomas may be seen by transplanters as well with vested interest to keep the field alive. Most likely, these transplanters will look how best to sequence and integrate these novel therapeutics with transplantation
2) Before TKIs, the transplant units in the past had many CMLs getting allograft. With the exception of few refractory patients, allograft for CML is a thing of the past.
3) The role of allograft will likely be important in acute leukemias, high grade MDS, myeloproliferative/myelofibrosis and the incredibly rare bone marrow failure syndromes e.g aplastic anemia. Having said, CART technology is intriguing and at this time, many are thinking of how to use CART to cytoreduce disease burden as a bridge towards transplant or for post-transplant control in a similar manner as DLIs. Although not in the horizon, further improvement of CART technology and immunological approaches in the next 30-40 years raise further questions to the utility of SCT.
On the flip side, the refinement of alternative donors e.g haploidentical donors and to a more limited extent, cord blood, has increased donor pool that has previously limited the uptake of patients to transplants.
