My mother has just started Rev/Dex treatment. She is 71 yrs old, but in extremely good physical condition for her age and has no comorbidities. Her doctor says she is "high risk" due to FISH detected monosomy 13, & t(4;14) and told us that multiple myeloma patients with her cytogenetics have a prognosis of approx. 24 months. This confuses me, as I've read several recent articles citing the effectiveness (improved PFS and OS) of Velcade (bortezomib) in patients with t(4;14) ... especially when initial B2M levels are low (we were just informed that her "pre treatment" B2M is 1.8). I understand that multiple myeloma is a very 'individual' disease in which there are no guarantees for any risk category, but I'm looking for encouraging news and hope wherever I can find it! =)
I would also like to know whether a patient is considered "high risk" based on FISH detected monosomy 13 & t(4;14) alone, or, with the current availability of Velcade & other new treatments, would MyPRS be required to accurately determine risk category & guide treatment decisions?
Thank you so much,
Lisa B.
Forums
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Lisa B. - Name: Lisa B.
- Who do you know with myeloma?: My mother, Barbara Henson
- When were you/they diagnosed?: 10-28-11
- Age at diagnosis: 71
Re: Monosomy 13, t(4;14) question
Risk in myeloma is a bit of moving target, because of therapies like Velcade (bortezomib) and Revlimid (lenalidomide).
By the book del 13 by FISH alone is not a high risk genetic anomaly regardless of therapy. It is only a high risk when identified by metaphase cytogenetics.
t(4;14) is a high risk anomaly and may have a slightly worse prognosis when paired with del13 (even on FISH). I am of the belief that your mother falls into an "intermediate risk' category.
The reason I state it this way is that the Velcade may overcome certain high risk criteria or at least improve outcomes- maybe not as good as standard risk, but improvements. Generally, for patients with high risk features, I tend to use Velcade-based regimens.
However, there may be competing needs or clinical reasons that your oncologist has chosen to use Revlimid over Velcade. These may included the side effect profile of Velcade vs Revlimid or social constraints. Moreover, generally speaking, transplant ineligible patients are frequently started on Revlimid + dexamethasone (Rev/dex).
The role of Revlimid is a bit more gray. One study in newly diagnosed patients demonstrated that people with high risk disease did not do as well on Rev/dex as standard risk patients (Kapoor et al Bolld 2009). However, this included all high risk patients, not isolating del13 and/or t(4;14). That being said, another study dealing with relapsed patients demonstrated that del 13 and t(4;14) did not impact response or time to progression (Bahlis et al 2010). So, as you can imagine, it is not a black and white picture.
When selecting a therapy there are always the combined goals of quality and quantity of life. Revlimid tends to be a much better tolerated medication over the long term and is much easier to take. Therefore, in this setting, it remains an appropriate option.
Regarding MyPRS ... I have begun to use it in my practice and, yes, it has been validated in patient data sets including Rev/dex, not just the Total Therapy associated with Arkansas. However, I do not use MyPRS in a vacuum. I also take into account the more traditional risk stratification measures as well.
If you have concerns alway feel free to ask for a referral to a center of excellence for a second opinion.
By the book del 13 by FISH alone is not a high risk genetic anomaly regardless of therapy. It is only a high risk when identified by metaphase cytogenetics.
t(4;14) is a high risk anomaly and may have a slightly worse prognosis when paired with del13 (even on FISH). I am of the belief that your mother falls into an "intermediate risk' category.
The reason I state it this way is that the Velcade may overcome certain high risk criteria or at least improve outcomes- maybe not as good as standard risk, but improvements. Generally, for patients with high risk features, I tend to use Velcade-based regimens.
However, there may be competing needs or clinical reasons that your oncologist has chosen to use Revlimid over Velcade. These may included the side effect profile of Velcade vs Revlimid or social constraints. Moreover, generally speaking, transplant ineligible patients are frequently started on Revlimid + dexamethasone (Rev/dex).
The role of Revlimid is a bit more gray. One study in newly diagnosed patients demonstrated that people with high risk disease did not do as well on Rev/dex as standard risk patients (Kapoor et al Bolld 2009). However, this included all high risk patients, not isolating del13 and/or t(4;14). That being said, another study dealing with relapsed patients demonstrated that del 13 and t(4;14) did not impact response or time to progression (Bahlis et al 2010). So, as you can imagine, it is not a black and white picture.
When selecting a therapy there are always the combined goals of quality and quantity of life. Revlimid tends to be a much better tolerated medication over the long term and is much easier to take. Therefore, in this setting, it remains an appropriate option.
Regarding MyPRS ... I have begun to use it in my practice and, yes, it has been validated in patient data sets including Rev/dex, not just the Total Therapy associated with Arkansas. However, I do not use MyPRS in a vacuum. I also take into account the more traditional risk stratification measures as well.
If you have concerns alway feel free to ask for a referral to a center of excellence for a second opinion.
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Dr. Ken Shain - Name: Ken Shain, M.D., Ph.D.
Beacon Medical Advisor
Re: Monosomy 13, t(4;14) question
Dear Dr. Shain,
THANK YOU!!! Your response helps me tremendously!
I've read many of your responses and they are always ultra-thorough, yet understandable and compassionate, yet realistic. I am so impressed with you and the other fine doctors who sacrifice personal time to respond to myeloma forum posts. It means more to me than I can express in words!!!!
THANK YOU!
Lisa B.
THANK YOU!!! Your response helps me tremendously!
I've read many of your responses and they are always ultra-thorough, yet understandable and compassionate, yet realistic. I am so impressed with you and the other fine doctors who sacrifice personal time to respond to myeloma forum posts. It means more to me than I can express in words!!!!
THANK YOU!
Lisa B.
-
Lisa B. - Name: Lisa B.
- Who do you know with myeloma?: My mother, Barbara Henson
- When were you/they diagnosed?: 10-28-11
- Age at diagnosis: 71
3 posts
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