[DexMed]

Multiple myeloma risk classification

by DexMed on Sat Jan 10, 2015 2:34 pm

I have turned symptomatic (anemia: Hgb 8.9; calcium: 10.1; FLC ratio: 400; and BMB 33%) after smoldering for 5 years. My M-spike increased from 1.4 g/dL to 2.2 g/dL (14 g/L to 22 g/L) the past 6 months. I am 67.

BMB FISH: Gain of chromosome 1q21 and loss of chromosome 13q14.3 and 13q34 puts me in intermediate risk category (??) based on mSmart (Mayo) guidelines.

The mSmart treatment guidelines for intermediate risk are CyBorD (cyclophosphamide, Velcade, and dex) for 4 cycles before SCT. For high risk, the recommended treatment is RVD (Revlimid, Velcade, dex), and for standard risk it is Revlimid + dex (RD).

My questions:

1. Am I high or intermediate risk?
2. Is CyBorD the correct initial induction treatment if I am eligible for SCT?
3. Are the mSmart guidelines generally followed across the U.S.?

[Multibilly]

Re: Multiple myeloma risk classification

by Multibilly on Sun Jan 11, 2015 9:53 am

Vince,

There is more to multiple myeloma risk classification than just cytogenetics. I suggest you read through this earlier Beacon article regarding how the IMWG treats the subject of risk classification:

"Experts Publish Consensus Risk Classification For Multiple Myeloma," The Myeloma Beacon, Sep 13, 2013.

There really is no set treatment that is recommended based on only risk classification. A good multiple myeloma specialist is going to weigh a lot of different factors (age, comorbidities, their own experiences with given drugs, etc) when selecting a particular regimen and dose for a given patient.

Also, different multiple myeloma specialists have their own specific drug cocktail biases (and their own philosophies when it comes to transplants). IMHO, while many specialists respect the mSMART criteria and the work that the Mayo does, the mSMART guidelines are by no means a cookbook that all multiple myeloma specialists in the USA follow.

These differences in treatment approaches are also why I think it's a good idea to get an opinion from two different multiple myeloma specialists when it comes to selecting an initial treatment.

[DexMed]

Re: Multiple myeloma risk classification

by DexMed on Sun Jan 11, 2015 2:33 pm

Dear Multibilly:

I appreciate you taking time to respond, in detail, to my questions about the risk stratification. The interesting part of the article you referred to is the "Cure Approach or Control Approach" quote below:

"The researchers explain that such decisions are also dependent upon the treatment philosophy of the physician, who can take either a cure approach (aggressive treatment with the aim of achieving a complete response) or a control approach (less aggressive treatment with a focus on disease control and quality of life) toward treating the disease."

I have not yet taken any treatment for about 5 smoldering years. It appears, now, it may start after the rest of the BMB cytogenetic results are known.

The cost is another element. I understand that most initial therapy cocktails are generally covered by Medicare+Rx plans. Those which include Revlimid can become expensive (relatively, if one does not qualify for Chronic Disease Fund type help). So, the main decision is which cocktail to use: Revlimid- or Velcade-based (RVD or VCD or RD as initial therapy).

Do you know of any Revlimid vs Velcade cost comparisons?

Thanks.

[Multibilly]

Re: Multiple myeloma risk classification

by Multibilly on Sun Jan 11, 2015 4:05 pm

Sorry, I can't help you out with treatment pricing tradeoffs for Medicare. But you can easily find discussions on the topic using the Advanced Search function of this forum. If the cost of Revlimid is a concern, there are other drug combos other than the non-Revlimid-inclusive ones you already mentioned, including Vd, PAD/VDD, etc.

You may also want to read Charlie's post that he just put up on the topic of Revlimid and Medicare:

https://myelomabeacon.org/forum/medicare-part-d-multiple-myeloma-t4719.html#p27514

[DexMed]

Re: Multiple myeloma risk classification

by DexMed on Sun Jan 11, 2015 7:52 pm

Thanks, Multibilly, for helping out with your responses.