For those who follow the Mayo Clinic's "mSMART" diagnostic and treatment recommendations, the guidelines for relapsed multiple myeloma were recently updated. Here is a link to the guidelines:
http://msmart.org/Relapsed%20Myeloma.pdf
The guidelines are for first and second relapse. Three separate "risk" categories of patients are defined based primarily (but not solely) on a patient's chromosomal abnormalities. However, these risk categories are used only to a limited extent in guiding the treatment recommended for first or second relapse.
For patients in first relapse, recommendations are based on whether or not a patient has had a transplant, been on maintenance therapy (and the type of maintenance therapy), and is eligible for a transplant going forward.
For patient's in second relapse, recommendations are driven strongly by what treatments the patient has had thus far -- that is, to which treatments they stopped responding to in the past -- and whether or not they have developed plasma cell leukemia (PCL) or extensive extramedullary disease (EMD) (plasma tumors outside the bone).
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Re: New Mayo (mSMART) guidelines for relapsed myeloma
Thank you, Beacon Staff, for sharing Mayo's smart guidelines for relapse. I'm trying to figure which categories I will fit into upon my relapse.
Or would I fall into the category of CyBorD (cyclophosphamide, Velcade, dex) since I had been on Revlimid maintenance for two years?
Thanks for your help,
Coach Hoke
- I'm standard risk (transplant eligible, but chose not to do one).
- Original induction therapy was Velcade-dexamethasone for seven months
- Again chose not to transplant after reaching a good partial remission (0.9 g/dL initial M-spike to 0.2 g/dL)
- Did two years of Revlimid maintenance (M-spike remained consistently at 0.2 g/dL; all other numbers remained in normal range).
- Stopped all drugs
Or would I fall into the category of CyBorD (cyclophosphamide, Velcade, dex) since I had been on Revlimid maintenance for two years?
Thanks for your help,
Coach Hoke
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coachhoke - Name: coachhoke
- When were you/they diagnosed?: Apri 2012
- Age at diagnosis: 71
Re: New Mayo (mSMART) guidelines for relapsed myeloma
Coach Hoke,
I can't speak specifically to the new Mayo guidelines, but I think one needs to be a little careful when looking at published treatment protocols for folks like us that are transplant eligible but choose not to have one. See this thread:
"Transplant refusal & myeloma treatment protocols," forum disc. started Sep 23, 2014.
I can't speak specifically to the new Mayo guidelines, but I think one needs to be a little careful when looking at published treatment protocols for folks like us that are transplant eligible but choose not to have one. See this thread:
"Transplant refusal & myeloma treatment protocols," forum disc. started Sep 23, 2014.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: New Mayo (mSMART) guidelines for relapsed myeloma
I'm just trying to gather as much information as possible so that I can make intelligent decisions. I'm certain that there are others out there who are transplant eligible and chose not to have it done (like Multibilly and me). I'm also certain that others have stopped maintenance after two years (like me).
I'm now trying to make intelligent plans for my relapse when it occurs (as, unfortunately, we all know it will happen someday).
Coach Hoke
I'm now trying to make intelligent plans for my relapse when it occurs (as, unfortunately, we all know it will happen someday).
Coach Hoke
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coachhoke - Name: coachhoke
- When were you/they diagnosed?: Apri 2012
- Age at diagnosis: 71
Re: New Mayo (mSMART) guidelines for relapsed myeloma
Coachhoke,
Keeping in mind Multibilly's caveat that choosing not to do a transplant when you are still transplant eligible is not exactly the same thing as not being transplant eligible, your interpretation of the guidelines as they apply to your situation seems to be correct.
In particular, the applicable recommendation would appear to be:
"Repeat first-line treatment if remission off therapy is after more than 12 months; If not, CyBorD if relapsing after IMiD-based treatment; otherwise, Pomalyst / dex or KRd [Kyprolis, Revlimid, and dex]"
(Note that we expanded some abbreviations used in the original wording of the recommendation. Also, IMiD-based treatment means treatment with Revlimid, thalidomide, or Pomalyst [Imnovid].)
So what the recommendation means for you will depend on how long your relapse will be after you stopped treatment with Revlimid. One also could ask what exactly your "first-line treatment" was: Was it Velcade-dex, or the Revlimid that you took most recently?
Strictly speaking, Velcade-dex was your first-line treatment. But, if you relapse, say, four years after you stopped treatment with Revlimid, one could ask if the recommendation to "repeat first-line treatment" means you should repeat the Velcade-dex, or the Revlimid.
Our guess is that the appropriate interpretation is Velcade-dex in your case, but there probably is scope for reading the recommendation differently.
The recommendation for what to do if you relapsed within 12 months would appear to be CyBorD, as you mentioned.
Hope this helps a bit. Sorry we can't give you a totally definitive answer.
Keeping in mind Multibilly's caveat that choosing not to do a transplant when you are still transplant eligible is not exactly the same thing as not being transplant eligible, your interpretation of the guidelines as they apply to your situation seems to be correct.
In particular, the applicable recommendation would appear to be:
"Repeat first-line treatment if remission off therapy is after more than 12 months; If not, CyBorD if relapsing after IMiD-based treatment; otherwise, Pomalyst / dex or KRd [Kyprolis, Revlimid, and dex]"
(Note that we expanded some abbreviations used in the original wording of the recommendation. Also, IMiD-based treatment means treatment with Revlimid, thalidomide, or Pomalyst [Imnovid].)
So what the recommendation means for you will depend on how long your relapse will be after you stopped treatment with Revlimid. One also could ask what exactly your "first-line treatment" was: Was it Velcade-dex, or the Revlimid that you took most recently?
Strictly speaking, Velcade-dex was your first-line treatment. But, if you relapse, say, four years after you stopped treatment with Revlimid, one could ask if the recommendation to "repeat first-line treatment" means you should repeat the Velcade-dex, or the Revlimid.
Our guess is that the appropriate interpretation is Velcade-dex in your case, but there probably is scope for reading the recommendation differently.
The recommendation for what to do if you relapsed within 12 months would appear to be CyBorD, as you mentioned.
Hope this helps a bit. Sorry we can't give you a totally definitive answer.
Re: New Mayo (mSMART) guidelines for relapsed myeloma
Thanks, Beacon Staff, I appreciate you trying to fit this round peg into a square hole.
I try to read everything I can from California, to Minnesota, to Arkansas, to N.Y., to Bethesda (now the Sloan Kettering crew), to Boston, to France, to Israel, to Italy (Durie, Rajkumar, Morgan, Langren and Korde, Richardson, Miguel, Palumbo ,and others).
As of right now, my plan on disease progression is to restart Revlimid; then add dex or prednisone, then add Velcade. Plan B is Pomalyst. Plan C would be KRd (Kyprolis, Revlimid, dexamethasone).
Coach Hoke
I try to read everything I can from California, to Minnesota, to Arkansas, to N.Y., to Bethesda (now the Sloan Kettering crew), to Boston, to France, to Israel, to Italy (Durie, Rajkumar, Morgan, Langren and Korde, Richardson, Miguel, Palumbo ,and others).
As of right now, my plan on disease progression is to restart Revlimid; then add dex or prednisone, then add Velcade. Plan B is Pomalyst. Plan C would be KRd (Kyprolis, Revlimid, dexamethasone).
Coach Hoke
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coachhoke - Name: coachhoke
- When were you/they diagnosed?: Apri 2012
- Age at diagnosis: 71
Re: New Mayo (mSMART) guidelines for relapsed myeloma
I'm in the same boat as you, Coach Hoke and Multibilly. I had been on VRD for two years. I stopped the VRD regimen in September of 2014 and now I get a dose of Zometa every three months, for how much longer is still up for debate. When I relapse, my plan is to go back to the regimen of VRD. From there we will see.
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gmarv54
7 posts
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