My husband began treatment April 2013 after having smoldered myeloma for about a year. He is currently on Kyprolis, Rev, and Dex., and has responded well so far to his treatment (although it has been difficult to tolerate for him at times). The original plan was 4 cycles of CRD followed by ASCT.
After the second cycle of treatment, his M-spike has moved from 3.0 to 1.1, and his IgG is in the normal range. Free light chains were reduced to 1/8 of their initial value. We are now waiting on the numbers following his 3rd cycle of treatment.
My question is; what are the drawbacks, if any, to postponing ASCT if his numbers get very close to normal (all but the M-spike and free light chains are now in the normal range)? We are planning on proceeding with the stem cell harvesting early August regardless, but are not sure whether to proceed to ASCT. If it's not absolutely necessary, we'd like to wait, but want to understand what the risks/tradeoffs may be.
Thanks!
Sandy
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5 posts
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SandyC63 - Name: SandyC
- Who do you know with myeloma?: My Husband
- When were you/they diagnosed?: 2012
- Age at diagnosis: 51
Re: ASCT now, or wait?
Hi Sandy,
The question as to whether to do a stem cell transplant immediately after initial therapy, or to wait until relapse, is actually one of the big open questions right now when it comes to the treatment of myeloma. In fact, there are one or two big clinical trials going on right now to determine what's the best strategy.
About ten years ago, before treatment with the newer myeloma therapies became common, there was good evidence that doing a transplant early, right after initial therapy, made sense. There was a major French trial that showed that the early transplant approach improved survival.
But now that responses to initial treatment are so much better with the newer myeloma treatments, it is no longer as clear that doing a transplant early makes sense.
I think you will find that many myeloma specialists, however, will recommend an early transplant, rather than waiting, if a patient does not achieve a complete response to initial therapy.
Some physicians also will recommend an early transplant if a patient is somewhat older, and may not be in good enough health to undergo a transplant later, at relapse.
There is an extensive discussion on this topic, which you may find helpful, at this thread:
https://myelomabeacon.org/forum/steve-s-story-and-should-i-get-a-sct-t946.html
See in particular the comments from Dr. Shain, who, although he admits to favoring early transplant, does a great job of discussing the various sides of the issue.
The question as to whether to do a stem cell transplant immediately after initial therapy, or to wait until relapse, is actually one of the big open questions right now when it comes to the treatment of myeloma. In fact, there are one or two big clinical trials going on right now to determine what's the best strategy.
About ten years ago, before treatment with the newer myeloma therapies became common, there was good evidence that doing a transplant early, right after initial therapy, made sense. There was a major French trial that showed that the early transplant approach improved survival.
But now that responses to initial treatment are so much better with the newer myeloma treatments, it is no longer as clear that doing a transplant early makes sense.
I think you will find that many myeloma specialists, however, will recommend an early transplant, rather than waiting, if a patient does not achieve a complete response to initial therapy.
Some physicians also will recommend an early transplant if a patient is somewhat older, and may not be in good enough health to undergo a transplant later, at relapse.
There is an extensive discussion on this topic, which you may find helpful, at this thread:
https://myelomabeacon.org/forum/steve-s-story-and-should-i-get-a-sct-t946.html
See in particular the comments from Dr. Shain, who, although he admits to favoring early transplant, does a great job of discussing the various sides of the issue.
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JimNY
Re: ASCT now, or wait?
Hello Sandy 111,
This is a good... often asked question. I think you will find going to the link mentioned by JimNY valuable. In June 2013 there is no absolutly right answer as to when an autologous stem cell transplant should be performed. There are some clear indications...those patients who do not achieve at least a VGPR from standard chemotherapy should probably have an autologous stem cell transplant 1st line or "upfront" rather than delaying it until 1st relapse.
The reasoning is that there are many many studies showing better outcomes e.g. longer progression free survival and overall survival for patients who can achieve at least a VGPR with frontline therapy.
Those studies were done at a time when the only way that a patient could achieve a VGPR or CR was with a transplant. In 2013 fifty percent or more of patients can get a VGPR or better with standard therapy e.g. RVD. This leaves the oncologist uncertain as to whether a CR obtained from a transplant has the same benefits as a CR obtained from standard treatment e.g RVD or some other combination therapy.
There are three studies internationally looking at this question but it will be several years before we have the answer. In the meantime many experts feel that it is reasonable to postpone transplant until the first relapse ( with the important exception noted above). There is no data (as far as I know) supporting the postponement of transplant until the 2nd or 3rd relapse and I would not recommend that. If a choice to postpone transplant is made I tell my patients that I strongly recommend that when the disease relapses (as it unfortunately invariably does) thay should have the transplant.
Thank you for sharing your story with the Beacon and its readers.
This is a good... often asked question. I think you will find going to the link mentioned by JimNY valuable. In June 2013 there is no absolutly right answer as to when an autologous stem cell transplant should be performed. There are some clear indications...those patients who do not achieve at least a VGPR from standard chemotherapy should probably have an autologous stem cell transplant 1st line or "upfront" rather than delaying it until 1st relapse.
The reasoning is that there are many many studies showing better outcomes e.g. longer progression free survival and overall survival for patients who can achieve at least a VGPR with frontline therapy.
Those studies were done at a time when the only way that a patient could achieve a VGPR or CR was with a transplant. In 2013 fifty percent or more of patients can get a VGPR or better with standard therapy e.g. RVD. This leaves the oncologist uncertain as to whether a CR obtained from a transplant has the same benefits as a CR obtained from standard treatment e.g RVD or some other combination therapy.
There are three studies internationally looking at this question but it will be several years before we have the answer. In the meantime many experts feel that it is reasonable to postpone transplant until the first relapse ( with the important exception noted above). There is no data (as far as I know) supporting the postponement of transplant until the 2nd or 3rd relapse and I would not recommend that. If a choice to postpone transplant is made I tell my patients that I strongly recommend that when the disease relapses (as it unfortunately invariably does) thay should have the transplant.
Thank you for sharing your story with the Beacon and its readers.
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Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: ASCT now, or wait?
Suggest you read this thread for some good insights. You will find doctors and folks on this site that will advocate ASCT right away, as only a last-ditch salvage therapy or never at all. You need to find your own path and what you and your husband feel comfortable with, given your goals in life.
https://myelomabeacon.org/forum/looking-for-feedback-on-recommended-first-round-treatment-t1502.html
Best of luck.
https://myelomabeacon.org/forum/looking-for-feedback-on-recommended-first-round-treatment-t1502.html
Best of luck.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: ASCT now, or wait?
Thanks for responding to my question, and for providing related threads of conversation. It seems that this continues to be a big question.
My husband's numbers have seemed to stabilize with an m-spike of around 1.1 after the 3rd cycle. We'll learn what happened after cycle 4 soon.
While we still are not sure exactly of what we'll do at this point, we will be going to Mayo to have the stem cells harvested the first week of August. It looks more likely that ASCT is more likely if the m-spike does not move down any further.
Thanks again for giving us so much to consider.
My husband's numbers have seemed to stabilize with an m-spike of around 1.1 after the 3rd cycle. We'll learn what happened after cycle 4 soon.
While we still are not sure exactly of what we'll do at this point, we will be going to Mayo to have the stem cells harvested the first week of August. It looks more likely that ASCT is more likely if the m-spike does not move down any further.
Thanks again for giving us so much to consider.
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SandyC63 - Name: SandyC
- Who do you know with myeloma?: My Husband
- When were you/they diagnosed?: 2012
- Age at diagnosis: 51
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