Using information technology to integrate tobacco use treatment in routine oncology care: Lessons learned from the U.S. Cancer Center Cessation Initiative Cancer Centers.

Background: Cancer patients who receive evidence-based tobacco-dependence treatment are more likely to quit and remain abstinent, but tobacco treatment programs (TTPs) are not consistently offered. In 2017, the U.S. National Cancer Institute, through the Cancer Moonshot, funded the Cancer Center Cessation Initiative (C3I). C3I supports 52 cancer centers to implement and expand evidence-based tobacco treatment in routine oncology care. Integration into routine care involves the use of health information technology (IT), including modifying electronic health records and clinical workflows. Here, we examine C3I cancer centers' IT leadership involvement and experiences in tobacco-dependence treatment implementation. Method: This qualitative study of C3I-funded cancer centers integrated data from online surveys and in-person, semistructured interviews with IT leaders. We calculated descriptive statistics of survey data and applied content analysis to interview transcripts. Results: Themes regarding IT personnel included suggestions to involve IT early, communicate regularly, understand the roles and influence of the IT team, and match program design with IT funding and resources. Themes regarding electronic health record (EHR) modifications included beginning modifications early to account for long lead time to make changes, working with IT to identify and adapt existing EHR tools for TTP or designing tools that will support a desired workflow developed with end-users, and working with IT personnel to make sure TTPs comply with system and state policies (e.g., privacy laws). Conclusions: The experiences of C3I cancer centers regarding the use of health IT to enhance tobacco-dependence treatment program implementation can guide cancer centers and community oncology practices to potentially enhance TTP implementation and patient outcomes.

Almost a quarter of patients first diagnosed with cancer report current cigarette smoking. There are tobacco treatment programs (TTPs) that effectively help patients quit smoking to improve cancer treatment response, survival, and quality-of-life. In 2017, the U.S. National Cancer Institute (NCI) funded the Cancer Center Cessation Initiative (C3I) and supported 52 cancer centers to implement these TTPs. A key component of these programs is the information technology (IT) necessary to refer patients to the program and document their progress. As coordinators of C3I, our team conducted interviews with IT leaders at these cancer centers to learn about the implementation of the programs. IT leaders suggested that IT teams be involved early in the program implementation process and that leaders communicate with the IT team regularly to address necessary changes to referral and documentation systems. IT teams are important to involve early and regularly throughout the TTP implementation process because they have unique knowledge of how funding, policy, and existing technological tools will impact the implementation and success of the program. Our findings emphasize the importance of involving IT teams early in the planning process for such programs. Studies such as this focusing on the experiences and knowledge of specific team members, such as the IT team, enhance tobacco-dependence treatment program implementation and can guide cancer centers and community oncology practices to implement these programs to improve patient outcomes.

The Impact of the COVID-19 Pandemic on Tobacco Treatment Program Implementation at National Cancer Institute-Designated Cancer Centers.

INTRODUCTION: The COVID-19 pandemic disrupted cancer screening and treatment delivery, but COVID-19's impact on tobacco cessation treatment for cancer patients who smoke has not been widely explored. AIMS AND METHODS: We conducted a sequential cross-sectional analysis of data collected from 34 National Cancer Institute (NCI)-designated cancer centers participating in NCI's Cancer Center Cessation Initiative (C3I), across three reporting periods: one prior to COVID-19 (January-June 2019) and two during the pandemic (January-June 2020, January-June 2021). Using McNemar's Test of Homogeneity, we assessed changes in services offered and implementation activities over time. RESULTS: The proportion of centers offering remote treatment services increased each year for Quitline referrals (56%, 68%, and 91%; p = .000), telephone counseling (59%, 79%, and 94%; p = .002), and referrals to Smokefree TXT (27%, 47%, and 56%; p = .006). Centers offering video-based counseling increased from 2020 to 2021 (18% to 59%; p = .006), Fewer than 10% of centers reported laying off tobacco treatment staff. Compared to early 2020, in 2021 C3I centers reported improvements in their ability to maintain staff and clinician morale, refer to external treatment services, train providers to deliver tobacco treatment, and modify clinical workflows. CONCLUSIONS: The COVID-19 pandemic necessitated a rapid transition to new telehealth program delivery of tobacco treatment for patients with cancer. C3I cancer centers adjusted rapidly to challenges presented by the pandemic, with improvements reported in staff morale and ability to train providers, refer patients to tobacco treatment, and modify clinical workflows. These factors enabled C3I centers to sustain evidence-based tobacco treatment implementation during and beyond the COVID-19 pandemic. IMPLICATIONS: This work describes how NCI-designated cancer centers participating in the Cancer Center Cessation Initiative (C3I) adapted to challenges to sustain evidence-based tobacco use treatment programs during the COVID-19 pandemic. This work offers a model for resilience and rapid transition to remote tobacco treatment services delivery and proposes a policy and research agenda for telehealth services as an approach to sustaining evidence-based tobacco treatment programs.

Integrating Tobacco Treatment Into Oncology Care: Reach and Effectiveness of Evidence-Based Tobacco Treatment Across National Cancer Institute-Designated Cancer Centers.

PURPOSE: Quitting smoking improves patients' clinical outcomes, yet smoking is not commonly addressed as part of cancer care. The Cancer Center Cessation Initiative (C3I) supports National Cancer Institute-designated cancer centers to integrate tobacco treatment programs (TTPs) into routine cancer care. C3I centers vary in size, implementation strategies used, and treatment approaches. We examined associations of these contextual factors with treatment reach and smoking cessation effectiveness. METHODS: This cross-sectional study used survey data from 28 C3I centers that reported tobacco treatment data during the first 6 months of 2021. Primary outcomes of interest were treatment reach (reach)-the proportion of patients identified as currently smoking who received at least one evidence-based tobacco treatment component (eg, counseling and pharmacotherapy)-and smoking cessation effectiveness (effectiveness)-the proportion of patients reporting 7-day point prevalence abstinence at 6-month follow-up. Center-level differences in reach and effectiveness were examined by center characteristics, implementation strategies, and tobacco treatment components. RESULTS: Of the total 692,662 unique patients seen, 44,437 reported current smoking. Across centers, a median of 96% of patients were screened for tobacco use, median smoking prevalence was 7.4%, median reach was 15.4%, and median effectiveness was 18.4%. Center-level characteristics associated with higher reach included higher smoking prevalence, use of center-wide TTP, and lower patient-to-tobacco treatment specialist ratio. Higher effectiveness was observed at centers that served a larger overall population and population of patients who smoke, reported a higher smoking prevalence, and/or offered electronic health record referrals via a closed-loop system. CONCLUSION: Whole-center TTP implementation among inpatients and outpatients, and increasing staff-to-patient ratios may improve TTP reach. Designating personnel with tobacco treatment expertise and resources to increase tobacco treatment dose or intensity may improve smoking cessation effectiveness.

Frailty-adjusted therapy in Transplant Non-Eligible patients with newly diagnosed Multiple Myeloma (FiTNEss (UK-MRA Myeloma XIV Trial)): a study protocol for a randomised phase III trial.

INTRODUCTION: Multiple myeloma is a bone marrow cancer, which predominantly affects older people. The incidence is increasing in an ageing population.Over the last 10 years, patient outcomes have improved. However, this is less apparent in older, less fit patients, who are ineligible for stem cell transplant. Research is required in this patient group, taking into account frailty and aiming to improve: treatment tolerability, clinical outcomes and quality of life. METHODS AND ANALYSIS: Frailty-adjusted therapy in Transplant Non-Eligible patients with newly diagnosed Multiple Myeloma is a national, phase III, multicentre, randomised controlled trial comparing standard (reactive) and frailty-adjusted (adaptive) induction therapy delivery with ixazomib, lenalidomide and dexamethasone (IRD), and to compare maintenance lenalidomide to lenalidomide+ixazomib, in patients with newly diagnosed multiple myeloma not suitable for stem cell transplant. Overall, 740 participants will be registered into the trial to allow 720 and 478 to be randomised at induction and maintenance, respectively.All participants will receive IRD induction with the dosing strategy randomised (1:1) at trial entry. Patients randomised to the standard, reactive arm will commence at the full dose followed by toxicity dependent reactive modifications. Patients randomised to the adaptive arm will commence at a dose level determined by their International Myeloma Working Group frailty score. Following 12 cycles of induction treatment, participants alive and progression free will undergo a second (double-blind) randomisation on a 1:1 basis to maintenance treatment with lenalidomide+placebo versus lenalidomide+ixazomib until disease progression or intolerance. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the North East-Tyne & Wear South Research Ethics Committee (19/NE/0125) and capacity and capability confirmed by local research and development departments for each participating centre prior to opening to recruitment. Participants are required to provide written informed consent prior to trial registration. Trial results will be disseminated by conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: ISRCTN17973108, NCT03720041.

Operationalizing Leadership and Clinician Buy-In to Implement Evidence-Based Tobacco Treatment Programs in Routine Oncology Care: A Mixed-Method Study of the U.S. Cancer Center Cessation Initiative.

BACKGROUND: Delivering evidence-based tobacco dependence treatment in oncology settings improves smoking abstinence and cancer outcomes. Leadership engagement/buy-in is critical for implementation success, but few studies have defined buy-in or described how to secure buy-in for tobacco treatment programs (TTPs) in cancer care. This study examines buy-in during the establishment of tobacco treatment programs at National Cancer Institute (NCI)-designated cancer centers. METHODS: We utilized a sequential, explanatory mixed-methods approach to analyze quantitative data and qualitative interviews with program leads in the U.S.-based NCI Moonshot-supported Cancer Center Cessation Initiative (n = 20 Centers). We calculated descriptive statistics and applied structural coding and content analysis to qualitative data. RESULTS: At least 75% of participating centers secured health care system administrative, clinical, and IT leadership buy-in and support. Six themes emerged from interviews: engaging leadership, access to resources, leveraging federal funding support to build leadership interest, designating champions, identifying training needs, and ensuring staff roles and IT systems support workflows. CONCLUSIONS: Buy-in among staff and clinicians is defined by the belief that the TTP is necessary, valuable, and evidence based. Recognizing and securing these dimensions of buy-in can facilitate implementation success, leading to improved cancer outcomes.

Coordinating Centers as a Strategy for Accelerating Cancer Epidemiology Consortia: Best Practices.

Purposeof Review: This review highlights six "best practices" for cancer epidemiology coordinating centers to facilitate the success of a research consortium. Recent Findings: Evidence from emerging literature regarding the Science of Team Science suggests that coordinating centers can more effectively foster collaborative cancer epidemiology research in consortia by (1) establishing collaboration as a shared goal at the start, (2) providing scientific expertise complementary to the research sites that adapts over the course of the project, (3) enacting anti-racist and inclusive approaches in all consortium decisions and activities, (4) fostering early-stage investigator career development, (5) engaging stakeholders including cancer survivors as peers, and (6) delivering reliable logistical support and technology tools with planned process evaluation so that researchers can collaboratively focus on the science. Summary: By drawing on the Science of Team Science, coordinating centers can accelerate research progress and increase the impact of cancer epidemiology consortia.

Recent Changes in the Patterns of Breast Cancer as a Proportion of All Deaths According to Race and Ethnicity.

BACKGROUND: Recent reports suggest that racial differences in breast cancer incidence rates have decreased. We examined whether these findings apply to breast cancer mortality while considering age, period, and cohort influences on both absolute and relative measures of breast cancer mortality. METHODS: Using publicly available datasets (CDC WONDER, Human Mortality Database), we developed an age-period-cohort model of breast cancer mortality and breast cancer deaths as a proportion of all deaths during 1968-2019 among all women and by 5 race/ethnicity groups with sufficient numbers for estimation: Hispanic (all races), American Indian/Alaska Native and Asian/Pacific Islanders (regardless of ethnicity), non-Hispanic Black, and non-Hispanic White. RESULTS: Initially increasing after 1968, age-adjusted breast cancer mortality rates have decreased among all racial/ethnic groups since 1988. The age-adjusted percent of all deaths due to breast cancer also has been declining for non-Hispanic White women since about 1990 while increasing or holding steady for other race/ethnic groups. In 2019, the age-adjusted percent of deaths due to breast cancer for women was highest for Asian/Pacific Islanders (5.6%) followed by non-Hispanic Black (4.5%), Hispanic (4.4%), non-Hispanic White (4.1%), and American Indian/Alaska Native women (2.6%). CONCLUSIONS: Breast cancer mortality disparities are now greater on both relative and absolute scales for non-Hispanic Black women, and using the relative scale for Asian/Pacific Islander and Hispanic women, compared with non-Hispanic White women for the first time in 50 years.

Patient-Reported Outcome Results From the Open-Label, Randomized Phase III Myeloma X Trial Evaluating Salvage Autologous Stem-Cell Transplantation in Relapsed Multiple Myeloma.

PURPOSE: Salvage autologous stem-cell transplantation (sASCT) in patients with multiple myeloma (MM) relapsing after a prior autologous stem-cell transplantation leads to increased remission duration and overall survival. We report a comprehensive study on patient-reported outcomes, including quality of life (QoL) and pain in sASCT. METHODS: Patients were randomly assigned to either sASCT or nontransplantation consolidation (NTC). Pain and QoL were assessed as secondary outcomes using validated QoL instruments (European Organisation for Research and Treatment of Cancer QLQ-C30 and myeloma-specific module, QLQ-MY20; the Brief Pain Inventory [Short Form]; and the Leeds Assessment of Neuropathic Symptoms and Signs [Self-Assessment] scale). RESULTS: A total of 288 patients (> 96%) consented to the QoL substudy. The median follow-up was 52 months. The European Organisation for Research and Treatment of Cancer QLQ-C30 Global health status scores were higher (better) in the NTC group at 100 days after random assignment (P = .0496), but not at later time points. Pain interference was higher (worse) in the sASCT group than in the NTC group at 6 months after random assignment (P = .0267), with patients with sASCT reporting higher scores for Pain interference with daily living for up to 2 years after random assignment. Patients reporting lower concerns about adverse effects of treatment after sASCT had a time to progression advantage. CONCLUSION: Patients with sASCT with relapsed MM demonstrated a comparative reduction in QoL and greater impact of treatment adverse effects lasting for 6 months and up to 2 years for pain, after which patients who had received sASCT reported better outcomes. Patients who experienced lower adverse effects after sASCT had longer time to progression and overall survival, showing the need to improve symptom management peritransplantation. To our knowledge, this study provides the most comprehensive picture of QoL before and after sASCT in patients with relapsed MM.

Pathogenic TFG Mutations Underlying Hereditary Spastic Paraplegia Impair Secretory Protein Trafficking and Axon Fasciculation.

Length-dependent axonopathy of the corticospinal tract causes lower limb spasticity and is characteristic of several neurological disorders, including hereditary spastic paraplegia (HSP) and amyotrophic lateral sclerosis. Mutations in Trk-fused gene (TFG) have been implicated in both diseases, but the pathomechanisms by which these alterations cause neuropathy remain unclear. Here, we biochemically and genetically define the impact of a mutation within the TFG coiled-coil domain, which underlies early-onset forms of HSP. We find that the TFG (p.R106C) mutation alters compaction of TFG ring complexes, which play a critical role in the export of cargoes from the endoplasmic reticulum (ER). Using CRISPR-mediated genome editing, we engineered human stem cells that express the mutant form of TFG at endogenous levels and identified specific defects in secretion from the ER and axon fasciculation following neuronal differentiation. Together, our data highlight a key role for TFG-mediated protein transport in the pathogenesis of HSP.

Diversity in eMental Health Practice: An Exploratory Qualitative Study of Aboriginal and Torres Strait Islander Service Providers.

BACKGROUND: In Australia, mental health services are undergoing major systemic reform with eMental Health (eMH) embedded in proposed service models for all but those with severe mental illness. Aboriginal and Torres Strait Islander service providers have been targeted as a national priority for training and implementation of eMH into service delivery. Implementation studies on technology uptake in health workforces identify complex and interconnected variables that influence how individual practitioners integrate new technologies into their practice. To date there are only two implementation studies that focus on eMH and Aboriginal and Torres Strait Islander service providers. They suggest that the implementation of eMH in the context of Aboriginal and Torres Strait Islander populations may be different from the implementation of eMH with allied health professionals and mainstream health services. OBJECTIVE: The objective of this study is to investigate how Aboriginal and Torres Strait Islander service providers in one regional area of Australia used eMH resources in their practice following an eMH training program and to determine what types of eMH resources they used. METHODS: Individual semistructured qualitative interviews were conducted with a purposive sample of 16 Aboriginal and Torres Strait Islander service providers. Interviews were co-conducted by one indigenous and one non-indigenous interviewer. A sample of transcripts were coded and thematically analyzed by each interviewer and then peer reviewed. Consensus codes were then applied to all transcripts and themes identified. RESULTS: It was found that 9 of the 16 service providers were implementing eMH resources into their routine practice. The findings demonstrate that participants used eMH resources for supporting social inclusion, informing and educating, assessment, case planning and management, referral, responding to crises, and self and family care. They chose a variety of types of eMH resources to use with their clients, both culturally specific and mainstream. While they referred clients to online treatment programs, they used only eMH resources designed for mobile devices in their face-to-face contact with clients. CONCLUSIONS: This paper provides Aboriginal and Torres Strait islander service providers and the eMH field with findings that may inform and guide the implementation of eMH resources. It may help policy developers locate this workforce within broader service provision planning for eMH. The findings could, with adaptation, have wider application to other workforces who work with Aboriginal and Torres Strait Islander clients. The findings highlight the importance of identifying and addressing the particular needs of minority groups for eMH services and resources.

Guidelines for screening and management of late and long-term consequences of myeloma and its treatment.

A growing population of long-term survivors of myeloma is now accumulating the 'late effects' not only of myeloma itself, but also of several lines of treatment given throughout the course of the disease. It is thus important to recognise the cumulative burden of the disease and treatment-related toxicity in both the stable and active phases of myeloma, some of which is unlikely to be detected by routine monitoring. We summarise here the evidence for the key late effects in long-term survivors of myeloma, including physical and psychosocial consequences (in Parts 1 and 2 respectively), and recommend the use of late-effects screening protocols in detection and intervention. The early recognition of late effects and effective management strategies should lead to an improvement in the management of myeloma patients, although evidence in this area is currently limited and further research is warranted.

General practitioners as educators in adolescent health: a training evaluation.

BACKGROUND: General practitioners play an important role in the primary care of adolescents in both community and clinical settings. Yet studies show that GPs can lack confidence, skills and knowledge in adolescent health. This study evaluates the effectiveness of an innovative training intervention on medical participants' knowledge and confidence as adolescent health educators in a school setting. METHODS: 15 general practitioners, 12 general practice registrars and 18 medical students participated in an adolescent health education workshop followed by field experience in health education sessions in secondary schools. The mixed method design included a pre and post intervention survey and focus group interviews. RESULTS: Mean scores on the Confidence to Teach scale increased significantly (3.34 ± 0.51 to 4.09 ± 0.33) (p < .001) as did confidence to communicate with adolescents (3.64 ± 0.48 to 4.19 ± 0.33) (p < .001). Mean knowledge scores increased significantly (7.00 ± 1.22 to 8.98 ± 1.11) (p < .001). Participants highlighted the value of learning about adolescent health issues and generic teaching skills especially lesson planning and design, practicing experiential teaching strategies and finding the 'sweet spot' when communicating with adolescents. Some participants reported that these skills would transfer to the practice setting. CONCLUSION: An applied training intervention that uses evidence-based, experiential teaching strategies and focuses on developing knowledge and practical teaching skills appropriate for the health education of adolescents can enhance knowledge and confidence to engage in community-based adolescent health education.

New cancers after autotransplantations for multiple myeloma.

We describe baseline incidence and risk factors for new cancers in 4161 persons receiving autotransplants for multiple myeloma in the United States from 1990 to 2010. Observed incidence of invasive new cancers was compared with expected incidence relative to the US population. The cohort represented 13,387 person-years at-risk. In total, 163 new cancers were observed, for a crude incidence rate of 1.2 new cancers per 100 person-years and cumulative incidences of 2.6% (95% confidence interval [CI], 2.09 to 3.17), 4.2% (95% CI, 3.49 to 5.00), and 6.1% (95% CI, 5.08 to 7.24) at 3, 5, and 7 years, respectively. The incidence of new cancers in the autotransplantation cohort was similar to age-, race-, and gender-adjusted comparison subjects with an observed/expected (O/E) ratio of 1.00 (99% CI, .81 to 1.22). However, acute myeloid leukemia and melanoma were observed at higher than expected rates with O/E ratios of 5.19 (99% CI, 1.67 to 12.04; P = .0004), and 3.58 (99% CI, 1.82 to 6.29; P < .0001), respectively. Obesity, older age, and male gender were associated with increased risks of new cancers in multivariate analyses. This large data set provides a baseline for comparison and defines the histologic type specific risk for new cancers in patients with MM receiving postautotransplantation therapies, such as maintenance.

Impact of pretransplant therapy and depth of disease response before autologous transplantation for multiple myeloma.

Patients with multiple myeloma (MM) who are eligible for autologous stem cell transplantation (ASCT) typically receive a finite period of initial therapy before ASCT. It is not clear if patients with suboptimal (less than a partial) response to initial therapy benefit from additional alternative therapy with intent to maximize pretransplant response. We identified 539 patients with MM who had an ASCT after having achieved less than a partial response (PR) to first-line induction chemotherapy between 1995 and 2010. These patients were then divided into 2 groups: those who received additional salvage chemotherapy before ASCT (n = 324) and those who had no additional salvage chemotherapy immediately before ASCT (n = 215). Additional pretransplant chemotherapy resulted in deepening responses in 68% (complete response in 8% and PR in 60%). On multivariate analysis there was no impact of pretransplant salvage chemotherapy on treatment-related mortality, risk for relapse, progression-free survival, or overall survival. In conclusion, for patients achieving less than a PR to initial induction therapy, including with novel agent combinations, additional pre-ASCT salvage chemotherapy improved the depth of response and pre-ASCT disease status but was not associated with survival benefit.

Evaluating a community-engaged vertically integrated teaching and learning pilot project.

OBJECTIVE: To evaluate a community engaged vertically integrated teaching and learning pilot project. METHOD: Thematic analysis of focus group interviews was used to examine 27 general practitioners' (GPs'), registrars' and medical students' perceptions of a vertically integrated workshop in adolescent health and subsequent small group health education sessions at two secondary schools. Pre- and postintervention surveys were used to measure changes to participants' knowledge, confidence, and attitudes towards registrars and students teaching in general practice. RESULTS: Knowledge scores (7.46 ± 1.17 vs 9.54 ± 1.17; t = -9.6, P <0.001), and scores on the Confidence to Teach (3.34 ± 0.51 vs 4.09 ± 0.33; t = -6.61, P <0.001), and Vertically Integrated Teaching (4.01 ± 0.40 vs 4.30 ± 0.42; t = -3.45, P <0.05) scales increased significantly following the intervention. Scale reliability ranged from 0.74 to 0.87. Participants enjoyed the collegiality of learning together in a vertically integrated model. The experience stimulated self-reflection on teaching skills and a desire for peer review of teaching. Suggestions for improving the intervention included building a clearer link between the facilitation skills learnt in the school setting and how to implement them in general practice, and providing more targeted support for GPs on facilitating sessions with multiple levels of learner involved. CONCLUSIONS: A community-engaged vertically integrated teaching and learning model has the potential to increase participants' confidence to teach in small groups, and create a more positive perception of registrars and students teaching in general practice. The concept would benefit from further longitudinal research with a wider sample.

Salvage second hematopoietic cell transplantation in myeloma.

Autologous hematopoietic cell transplantation (AHCT) as initial therapy of patients with multiple myeloma (MM) improves survival. However, data to support this approach for relapsed/progressive disease after initial AHCT (AHCT1) are limited. Using Center for International Blood and Marrow Transplant Research data, we report the outcomes of 187 patients who underwent a second AHCT (AHCT2) for the treatment of relapsed/progressive MM. Planned tandem AHCT was excluded. Median age at AHCT2 was 59 years (range, 28 to 72), and median patient follow-up was 47 months (range, 3 to 97). Nonrelapse mortality after AHCT2 was 2% at 1 year and 4% at 3 years. Median interval from AHCT1 to relapse/progression was 18 months, and median interval between transplantations was 32 months. After AHCT2, the incidence of relapse/progression at 1 and 3 years was 51% and 82%, respectively. At 3 years after AHCT2, progression-free survival was 13%, and overall survival was 46%. In multivariate analyses, those relapsing ≥36 months after AHCT1 had superior progression-free (P = .045) and overall survival (P = .019). Patients who underwent AHCT2 after 2004 had superior survival (P = .026). AHCT2 is safe and feasible for disease progression after AHCT1. In this retrospective study, individuals relapsing ≥36 months from AHCT1 derived greater benefit from AHCT2 compared with those with a shorter disease-free interval. Storage of an adequate graft before AHCT1 will ensure that the option of a second autologous transplantation is retained for patients with relapsed/progressive MM.