Is relapse a foregone conclusion?
I was diagnosed with multiple myeloma three years ago this month. They are still saying complete remission. I had two transplants up front, after they decided to treat. My maintenance program is Velcade and dex.
In April of this year, I had to have a pneumonectomy. Last month, I had a squamous cell carcinoma removed. I am not a smoker or a druggie. I am just a sixty-eight year old man trying to make sense out of this whole thing.
By the way, I pray often for the people who have cancer, especially multiple myeloma.
G-Dad Preston
Forums
Re: Is relapse a foregone conclusion?
As of now, multiple myeloma is not curable. For the vast majority of us, that means that there will be a relapse followed by a change in the protocol followed by further relapses and further treatment changes. There are some individuals that have gone 10 or more years without a relapse and have no measurable myeloma in their system. Those individuals may be considered cured, but that is very rare. Just because there is a relapse does not mean you are about to succumb to the disease. The new drugs and changes in protocol can put you back into a remissive state that may last for an extended period of time. Generally, after the initial remission, later ones do not last as long but again, that is a generalization. People are living longer with the disease than the did before novel agents and the enhanced induction treatment preceding SCT, than they did just 10 years ago. The FDA has approved 3 new drugs since I was diagnosed in 2009 and there are a couple that should be approved this coming year. There is also a pipeline of new targeted treatments that are different from those that currently exist. So there are more options once a relapse does occur than existed just 6 years ago.
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Ron Harvot - Name: Ron Harvot
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: Feb 2009
- Age at diagnosis: 56
Re: Is relapse a foregone conclusion?
I think myeloma caught early will be considered a chronic illness in the near future; you will likely die from it, but it won't be next week, next month nor next year; look at a decade or more if otherwise healthy.
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Little Monkey - Name: Little Monkey
- Who do you know with myeloma?: Father-stage 1 multiple myeloma
- When were you/they diagnosed?: March/April of 2015
Re: Is relapse a foregone conclusion?
Good morning:
I think this question goes to the concept of "treat to minimum residual disease (MRD) negative". There was one recent study where achieving MRD in a group of 30 patients had the entire population going 3 years without relapse. MRD negative seems to have a better result over a population than what CR used to have, where some high risk categories could reach CR, but have a quick relapse. Part of the concept is to increase the sensitivity of testing. Right now, I believe that 8 color flow cytometry can get a sensitivity of about one to five in a million plasma cells. The research is expected to increase the sensitivity ten fold in the coming few years.
So being able to reach MRD negative may be a step towards making multiple myeloma a chronic disease. It appears that with a standard of care approach, plus Revlimid maintenance, the recent CALGB study is getting an average population to about 4 years to first relapse. That study, however, did not treat to MRD negative. Another recent study out of the University of Chicago with Dr. Jakubowiak used Kyprolis, Revlimid, and dexamethasone (KRD) induction, ASCT, KRD consolidation, and KRD maintenance – which is a lot of drugs. But he reports getting 80% of the study patients to MRD negative.
So, yes, it would appear that relapse is inevitable. However, there appear to be approaches on the horizon that may get most people over 5 years to first relapse (with a mean to first relapse of several years more).
In addition to Dr. Jakubowiak's approach, there as studies active with adding elotuzumab, daratumumab, and panobinostat (Farydak) to Revlimid, Velcade, and dex (RVD). The results are not ripe yet, but the first indicator as to whether these options would be effective would be depth of response. It would probably need to be phase 2 multi-center studies that bring these options to the fore. Hopefully researchers are pulling together these concepts as we speak.
Just from reading study results, and without any understanding of the underlying biology, my personal opinion is that Dr. Jakubowiak's study, plus bringing in daratumumab, will likely be one of the better treatment options. And having reached a very deep response for most newly diagnosed multiple myeloma (NDMM) patients, perhaps the KRD maintenance can be trimmed back to something milder, possibly using immunotherapy drugs (e.g. peptide vaccines) that are in the pipeline.
So, best case, I think LM is correct. However, the question is how long will it take to get there. And can there be better approaches developed for the relatively few patients that present with very aggressive disease (at initial diagnosis). Regards,
I think this question goes to the concept of "treat to minimum residual disease (MRD) negative". There was one recent study where achieving MRD in a group of 30 patients had the entire population going 3 years without relapse. MRD negative seems to have a better result over a population than what CR used to have, where some high risk categories could reach CR, but have a quick relapse. Part of the concept is to increase the sensitivity of testing. Right now, I believe that 8 color flow cytometry can get a sensitivity of about one to five in a million plasma cells. The research is expected to increase the sensitivity ten fold in the coming few years.
So being able to reach MRD negative may be a step towards making multiple myeloma a chronic disease. It appears that with a standard of care approach, plus Revlimid maintenance, the recent CALGB study is getting an average population to about 4 years to first relapse. That study, however, did not treat to MRD negative. Another recent study out of the University of Chicago with Dr. Jakubowiak used Kyprolis, Revlimid, and dexamethasone (KRD) induction, ASCT, KRD consolidation, and KRD maintenance – which is a lot of drugs. But he reports getting 80% of the study patients to MRD negative.
So, yes, it would appear that relapse is inevitable. However, there appear to be approaches on the horizon that may get most people over 5 years to first relapse (with a mean to first relapse of several years more).
In addition to Dr. Jakubowiak's approach, there as studies active with adding elotuzumab, daratumumab, and panobinostat (Farydak) to Revlimid, Velcade, and dex (RVD). The results are not ripe yet, but the first indicator as to whether these options would be effective would be depth of response. It would probably need to be phase 2 multi-center studies that bring these options to the fore. Hopefully researchers are pulling together these concepts as we speak.
Just from reading study results, and without any understanding of the underlying biology, my personal opinion is that Dr. Jakubowiak's study, plus bringing in daratumumab, will likely be one of the better treatment options. And having reached a very deep response for most newly diagnosed multiple myeloma (NDMM) patients, perhaps the KRD maintenance can be trimmed back to something milder, possibly using immunotherapy drugs (e.g. peptide vaccines) that are in the pipeline.
So, best case, I think LM is correct. However, the question is how long will it take to get there. And can there be better approaches developed for the relatively few patients that present with very aggressive disease (at initial diagnosis). Regards,
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JPC - Name: JPC
Re: Is relapse a foregone conclusion?
Hi JPC,
I'm very interested to read more about the study by Dr. Jakubowiak that you mentioned. Do you have a link or a reference? Very impressive results, even when considering the rough regimen. Among other things, I'm curious about characteristics of the patient population for the study...
Thanks,
Mike
I'm very interested to read more about the study by Dr. Jakubowiak that you mentioned. Do you have a link or a reference? Very impressive results, even when considering the rough regimen. Among other things, I'm curious about characteristics of the patient population for the study...
Thanks,
Mike
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mikeb - Name: mikeb
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2009 (MGUS at that time)
- Age at diagnosis: 55
Re: Is relapse a foregone conclusion?
Mike,
Here is the slide deck summarizing the results that JPC was probably referring to
https://myelomabeacon.org/docs/asco2015/8510.pdf
It was an ASCO 2015 presentation. It is listed on this page,
https://myelomabeacon.org/asco-2015-multiple-myeloma-oral-presentations/
which has all myeloma-related oral presentations that were given at this year's ASCO meeting.
The abstract for the presentation can be viewed here:
http://abstracts.asco.org/156/AbstView_156_150628.html
Here is the slide deck summarizing the results that JPC was probably referring to
https://myelomabeacon.org/docs/asco2015/8510.pdf
It was an ASCO 2015 presentation. It is listed on this page,
https://myelomabeacon.org/asco-2015-multiple-myeloma-oral-presentations/
which has all myeloma-related oral presentations that were given at this year's ASCO meeting.
The abstract for the presentation can be viewed here:
http://abstracts.asco.org/156/AbstView_156_150628.html
Re: Is relapse a foregone conclusion?
Hello Beacon Staff, and MikeB:
I had read the ASCO abstract but had not seen the slide deck, which has a little more detailed information than I had seen before, which I would like to review, and will review. So thank you very much for replying to Mike for me, and Mike, I am sorry that I am not as quick as the Beacon staff.
I briefly scanned the inclusion and exclusion criteria. You may read it more critically than I, but it does look to me like the normal stuff for this type of study. You need to be transplant eligible, which excludes the older and frail persons, however, you also need to be healthy enough, or get healthy enough to reach the transplant. Accordingly, in that regard, I expect that stats are somewhat better than for the larger overall population, however, if you read other studies, that's typically the way they report it for the transplant focused studies.
Regards,
I had read the ASCO abstract but had not seen the slide deck, which has a little more detailed information than I had seen before, which I would like to review, and will review. So thank you very much for replying to Mike for me, and Mike, I am sorry that I am not as quick as the Beacon staff.
I briefly scanned the inclusion and exclusion criteria. You may read it more critically than I, but it does look to me like the normal stuff for this type of study. You need to be transplant eligible, which excludes the older and frail persons, however, you also need to be healthy enough, or get healthy enough to reach the transplant. Accordingly, in that regard, I expect that stats are somewhat better than for the larger overall population, however, if you read other studies, that's typically the way they report it for the transplant focused studies.
Regards,
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JPC - Name: JPC
Re: Is relapse a foregone conclusion?
Hi Beacon Staff and JPC,
Thanks for the links. I'm on the road now, but will read the references as soon as I can. Sounds interesting for sure!
Mike
Thanks for the links. I'm on the road now, but will read the references as soon as I can. Sounds interesting for sure!
Mike
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mikeb - Name: mikeb
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2009 (MGUS at that time)
- Age at diagnosis: 55
Re: Is relapse a foregone conclusion?
Is relapse a foregone conclusion even if a person has reached MRD negative status?
Re: Is relapse a foregone conclusion?
Spirit,
MRD negative status indicates a particularly deep - good result from treatment. There have been studies that suggest that it will likely lead to longer progression free survival but the jury is still out with regard to overall survival. That being said, MRD negative status does not equate to a cure and therefore, it is likely that at some point the patient will relapse. That relapse may be many years away and the patient may have a long drug free period during the remission.
Ron
MRD negative status indicates a particularly deep - good result from treatment. There have been studies that suggest that it will likely lead to longer progression free survival but the jury is still out with regard to overall survival. That being said, MRD negative status does not equate to a cure and therefore, it is likely that at some point the patient will relapse. That relapse may be many years away and the patient may have a long drug free period during the remission.
Ron
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Ron Harvot - Name: Ron Harvot
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: Feb 2009
- Age at diagnosis: 56
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