Nicoletta: If I was your daughter and I had relapsing remitting MS, would you support me in having HSCT?
Dr David Rog, Consultant Neurologist: I think it’s very context dependent, so my view about HSCT at the moment is that we should treat patients with MS with licensed disease modifying treatments, first line. That doesn’t necessarily mean to say that that’s an incremental approach. It very much depends on the patient’s views, their risk/benefit perception, other medical conditions, aspirations, disease history, prognostic factors as in is the person likely to do badly or do we think the patient will do badly if they don’t have their disease brought under control, their illness under control quickly. There are all those factors in there. So again, trying to answer your question, I would want a member of my family to have the best available treatment for which they’re prepared to take the risk that is licensed. If that treatment or those groups of treatments didn’t work, then I would see HSCT as a potential rescue therapy option.
Dr David Rog: So I don’t think in different terms than I would in terms of my patients, with whom I’m not related.
Nicoletta: So whilst HSCT is exciting, you’re perhaps cautiously optimistic, it isn’t perhaps the miracle cure that some people with MS might think it is at this stage?
Dr David Rog: I think the difficult issue about HSCT previously has been lots of different sources of stem cells, lots of different conditioning regimes, and so on, and I think it’s important to understand, based upon the previous experience and results of previous trials, what we think is the optimal option for patients with MS and then to trial that and to follow those patients up very carefully. So you’ll be aware that there is a study at the moment looking at one standard of care, one very effective treatment for MS, against stem cell, autologous stem cell transplants, and that will help to inform, hopefully, us in terms of what the relative benefits and risks are of a standard high effectiveness therapy against stem cell transplants. The other thing I would say is that a lot of people think that having had disability for a period of time, and perhaps being less mobile, for example, and having MS for 20 years, 25 years, 30 years, that a stem cell transplant will reverse the disability that’s occurred for some considerable time, and unfortunately I don’t see any evidence that that’s the case. So I think at the moment, the type of patients that seem to do best from stem cell transplants are younger, people that have had MS for less time, people with lower levels of disability and in one of the retrospective studies, people that had had fewer treatments, disease modifying treatments before they went on to stem cell transplantation. So that needs to be unpicked and we need to understand, I think, giving people the risk/benefit calculation is, as with every other part of medicine, is going to be an individualised process and I think that’s what we need to start working out. If there is a role in which patients and what are the relevant risks in each patient group and what are the potential benefits.
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Dr David Rog is a consultant neurologist at the Salford Royal NHS Trust. He gained his MD in liverpool and he completed his neurological training between 2002 and 2006 on the North West rotation at Lancashire Teaching Hospitals Trust and Greater Manchester Neuroscience Centre. Dr Rog is the Chairman of the Clinical Research Steering Group at Salford Royal and the Nervous System Theme lead for Greater Manchester Comprehensive Local Research Network.