My husband has been on the Rev/Dex/Vel for 14 weeks now, but his m-spike has only gone down from the initial 2.8 to 1.4. His oncologist said last week that she considers this to only be a "fair" response. She wants to go through a total of 8 3-week cycles (total of 24 weeks of chemo) of this and then consider the SCT, even if his m-spike only goes to 1.0.
I suppose I am a bit confused, but doesn't 1.0 seem a bit high to work with and proceed on to the SCT? I thought that number should be much lower, or does it not matter? Would another, different chemo therapy be in order before going the SCT route - where I know more chemo is introduced - but do so in an effort to get that m-spike down?
Thanks.
Jenn
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Jenn - Name: Jenn
- Who do you know with myeloma?: Husband
- When were you/they diagnosed?: September 2011
- Age at diagnosis: 45
Re: RVD - how long?
My husband was still over 1 (can't remember if it was 1.3 or 1.7) when he went in for his auto transplant last fall. He had finished 4 rounds of RVD. The doctor did say that the number was higher than he would prefer, so they hit him with some additional IV chemo the week before his treatment. I'm sorry that I can't remember the name of it. The rest of his transplant went as scheduled.
He had started with a very high m-spike before treatment (9?) and has a high risk subtype. His doctor did not expect him to get a full remission. His M spike has remained under 1 since the transplant 6 months ago. He feels well, and is now back on RVD, but at a much lower dose and frequency than before the transplant. Though we would rather he had been "cured", if his m-spike can remain at this level with the current meds - his quality of life is very good and he really isn't aware of having the disease, except on the Dex day when he's a little wired.
He had started with a very high m-spike before treatment (9?) and has a high risk subtype. His doctor did not expect him to get a full remission. His M spike has remained under 1 since the transplant 6 months ago. He feels well, and is now back on RVD, but at a much lower dose and frequency than before the transplant. Though we would rather he had been "cured", if his m-spike can remain at this level with the current meds - his quality of life is very good and he really isn't aware of having the disease, except on the Dex day when he's a little wired.
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rumnting - Who do you know with myeloma?: husband
- When were you/they diagnosed?: 4/9/11
- Age at diagnosis: 54
Re: RVD - how long?
Hi Jen,
The optimum number of chemotherapy cycles prior to proceeding to ASCT is more than 6 cycles. Eight to twelve cycles seems to be the norm. Your oncologist is right on with using a regimen of 8 cycles. Good news for you to know she is clinically on target to achieve the best results.
You mention 14 weeks, that sounds like your hubby has had only 3 cycles maybe? My suggestion would be to wait another 3 cycles before getting anxious as it appears from what you wrote that all numbers are moving in the right direction (declining) and that should be very good news for him and you.
IOW's therapy is working and you can long forward to having good results to be able to proceed to the ASCT.
With regards to the 1.0..yes the optimum is zero, and you could request additional cycles if you do 8 and it gets to one, if you want to try 2-4 more cycles to see if you can drive the numbers down under one.
You are right to want to achieve as low as minimal residual disease (MRD) as you can get prior to the ASCT, as it appears those who have the least MRD on average have longer PFS.
Good Luck to you & your hubby.
The optimum number of chemotherapy cycles prior to proceeding to ASCT is more than 6 cycles. Eight to twelve cycles seems to be the norm. Your oncologist is right on with using a regimen of 8 cycles. Good news for you to know she is clinically on target to achieve the best results.
You mention 14 weeks, that sounds like your hubby has had only 3 cycles maybe? My suggestion would be to wait another 3 cycles before getting anxious as it appears from what you wrote that all numbers are moving in the right direction (declining) and that should be very good news for him and you.
IOW's therapy is working and you can long forward to having good results to be able to proceed to the ASCT.
With regards to the 1.0..yes the optimum is zero, and you could request additional cycles if you do 8 and it gets to one, if you want to try 2-4 more cycles to see if you can drive the numbers down under one.
You are right to want to achieve as low as minimal residual disease (MRD) as you can get prior to the ASCT, as it appears those who have the least MRD on average have longer PFS.
Good Luck to you & your hubby.
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suzierose - Name: suzierose
- When were you/they diagnosed?: 2 sept 2011
Re: RVD - how long?
Greetings from the sunny Northwest.....for a few hours this morning at least !
I have addressed this question several times over the past year. It is very important and often misunderstood by patients and physicians alike.
There is no required paraprotein level or level of malignant plasma cells in the marrow for stem cell mobilzation and collection. Simply put though.... lower is better. No question about it.
A complete remission(CR) at the time of stem cell collection is great but many patients will
not have achieved CR prior to collection and transplant. In the original report on RVD (the chemotherapy treatment your husband is getting) 74% of patients were able to get to a VGPR or better. But.....one out of four patients did not get to a VGPR or better with RVD. So far your hurband has a partial response (PR)...a fall in the m-spike by 50% or more.
The purpose of a stem cell transplant is to deepen the response further in patients who have already reached a CR or VGPR and to achieve CR or VGPR in those patients who have not already done so. The majority of transplant centers (and the literature) recommend having stem cell collection followed by a stem cell transplant after the first 4-6 cycles of chemotherapy for newly diagnosed myeloma.
If your husband is going to have a stem cell transplant he should be evaluated by the transplant center sooner rather than later. The longer he is on chemotherapy (particularly Revlimid) the harder it can be to collect stem cells. A common concern among transplant physicians is that myeloma patients are sent to the transplant center after too many cycles of chemotherapy and that makes performing the transplant harder. In addition it should be remembered that it takes weeks to months just to arrange the transplant process. The insurance company must approve a SCT, the patient must be screened to determine if they will be able to undergo the rigors of a transplant, caregivers must be located, living quarters and travel arrangements made. ALL transplant centers require that a patient live within 30-60 minutes of the transplant center during the SCT process. The SCT process takes a minimum of two months. The bottom line is that getting an SCT is a complex process and working closely and early on with the transplant center is important.
Your oncologist is on track and thinking the right things......a CR is the goal and predicts for longer disease free survival and overall survival. But, I would suggest though that your husband see a transplant center in the near future to get the transplant process underway.
Best of luck with this damn disease....
I have addressed this question several times over the past year. It is very important and often misunderstood by patients and physicians alike.
There is no required paraprotein level or level of malignant plasma cells in the marrow for stem cell mobilzation and collection. Simply put though.... lower is better. No question about it.
A complete remission(CR) at the time of stem cell collection is great but many patients will
not have achieved CR prior to collection and transplant. In the original report on RVD (the chemotherapy treatment your husband is getting) 74% of patients were able to get to a VGPR or better. But.....one out of four patients did not get to a VGPR or better with RVD. So far your hurband has a partial response (PR)...a fall in the m-spike by 50% or more.
The purpose of a stem cell transplant is to deepen the response further in patients who have already reached a CR or VGPR and to achieve CR or VGPR in those patients who have not already done so. The majority of transplant centers (and the literature) recommend having stem cell collection followed by a stem cell transplant after the first 4-6 cycles of chemotherapy for newly diagnosed myeloma.
If your husband is going to have a stem cell transplant he should be evaluated by the transplant center sooner rather than later. The longer he is on chemotherapy (particularly Revlimid) the harder it can be to collect stem cells. A common concern among transplant physicians is that myeloma patients are sent to the transplant center after too many cycles of chemotherapy and that makes performing the transplant harder. In addition it should be remembered that it takes weeks to months just to arrange the transplant process. The insurance company must approve a SCT, the patient must be screened to determine if they will be able to undergo the rigors of a transplant, caregivers must be located, living quarters and travel arrangements made. ALL transplant centers require that a patient live within 30-60 minutes of the transplant center during the SCT process. The SCT process takes a minimum of two months. The bottom line is that getting an SCT is a complex process and working closely and early on with the transplant center is important.
Your oncologist is on track and thinking the right things......a CR is the goal and predicts for longer disease free survival and overall survival. But, I would suggest though that your husband see a transplant center in the near future to get the transplant process underway.
Best of luck with this damn disease....
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Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: RVD - how long?
Dr Libby!!
I truly looove your last sentence!!
A multiple myeloma expert, like yourself, stated that collection of stem cells is an " art form", and that the art comes in based on which mobilizing agents are used during the harvesting of cells, even when the patient may have had more than 4 cycles of chemo with myelosuppressive agents, such as lenalidomide.
It seems that plerixafor really helps boost mobilization, when the patient is on lenalidomide.
http://www.nature.com/bmt/journal/v46/n3/full/bmt2010118a.html
If a patient opts to delay their SCT until the first relapse does that improve the mobilzation of stem cells at transplant center, as they will have been primarily in the PFS stage, and not on myelosuppresive agents for awhile?
Your emphasis point that it is not essential to have a CR to proceed to SCT and that patients with PR or VGPR also are able to go forward with a SCT was noted. Good thing to have in mind.
You mentioned the SCT process can be as long as 2 months, is that 8 weeks also true if the insurance folks are cut out as the middleman or is it mostly post-SCT recovery?
And DITTO ...
'damn disease'
I truly looove your last sentence!!
A multiple myeloma expert, like yourself, stated that collection of stem cells is an " art form", and that the art comes in based on which mobilizing agents are used during the harvesting of cells, even when the patient may have had more than 4 cycles of chemo with myelosuppressive agents, such as lenalidomide.
It seems that plerixafor really helps boost mobilization, when the patient is on lenalidomide.
http://www.nature.com/bmt/journal/v46/n3/full/bmt2010118a.html
If a patient opts to delay their SCT until the first relapse does that improve the mobilzation of stem cells at transplant center, as they will have been primarily in the PFS stage, and not on myelosuppresive agents for awhile?
Your emphasis point that it is not essential to have a CR to proceed to SCT and that patients with PR or VGPR also are able to go forward with a SCT was noted. Good thing to have in mind.
You mentioned the SCT process can be as long as 2 months, is that 8 weeks also true if the insurance folks are cut out as the middleman or is it mostly post-SCT recovery?
And DITTO ...
'damn disease'
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suzierose - Name: suzierose
- When were you/they diagnosed?: 2 sept 2011
Re: RVD - how long?
Hello Suzierose,
Regarding your followup questions:
Mobilization will generally be more successful if a patient has not received chemotherapy (especially Revlimid) for 1-3 months. But ......delaying the stem cell collection unti 1st relapse is never recommended. Virtually all transplant centers strongly recommend that stem cells be collected during "upfront/frontline/1st line" treatment and that one should not wait to collect until a patient relapses.
It is important to keep in mind that relapsed patients (even with 1st relapse) generally do not respond as well to salvage treatment as newly diagnosed patients. This means it will be harder to get a patient to a PR, VGPR or CR in the 1st, 2nd and 3rd relapse.
Mozobil (plerixafor) is a exciting breakthrough drug but it is very very expensive and there are still some patients that cannot be collected even with the addition of Mozobil.
No matter who pays for the stem cell transplant the process of stem cell collection followed by stem cell transplant requires a minimum of 6-8 weeks. During that 6-8 weeks all transplant centers require that the patient live within 30-60 minutes of the transplant center and that she/he have a caregiver with them 24/7 unless they are hospitalized. The reason for this is that if a SCT patient becomes ill the best place for them to be cared for is at the transplant center not a local hospital or ER.
Regarding your followup questions:
Mobilization will generally be more successful if a patient has not received chemotherapy (especially Revlimid) for 1-3 months. But ......delaying the stem cell collection unti 1st relapse is never recommended. Virtually all transplant centers strongly recommend that stem cells be collected during "upfront/frontline/1st line" treatment and that one should not wait to collect until a patient relapses.
It is important to keep in mind that relapsed patients (even with 1st relapse) generally do not respond as well to salvage treatment as newly diagnosed patients. This means it will be harder to get a patient to a PR, VGPR or CR in the 1st, 2nd and 3rd relapse.
Mozobil (plerixafor) is a exciting breakthrough drug but it is very very expensive and there are still some patients that cannot be collected even with the addition of Mozobil.
No matter who pays for the stem cell transplant the process of stem cell collection followed by stem cell transplant requires a minimum of 6-8 weeks. During that 6-8 weeks all transplant centers require that the patient live within 30-60 minutes of the transplant center and that she/he have a caregiver with them 24/7 unless they are hospitalized. The reason for this is that if a SCT patient becomes ill the best place for them to be cared for is at the transplant center not a local hospital or ER.
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Dr. Edward Libby - Name: Edward Libby, M.D.
Beacon Medical Advisor
Re: RVD - how long?
Dr. Libby, I definitely needed that explanation on what response level was acceptable for the stem cell collection process, so thank you for your response.
To clarify, my husband is nearing the end of his fifth cycle of R/V/D. We have met with the transplant team at the hospital (Henry Ford in Detroit) where the transplant will take place, and thankfully it is about 50 minutes away from our home. (U of M is two hours). We have another appointment with the team in four weeks to begin the scheduling, begin the insurance process and set the wheels in motion if my husband has reached the point that the doctors are satisfied with. By then that appointment should be during his seventh cycle.
He is currently planning on having the collection take place as soon as it feasible and he gets the green light from all parties involved.
Thank you to the others that responded as well. Valuable information and I appreciate it.
To clarify, my husband is nearing the end of his fifth cycle of R/V/D. We have met with the transplant team at the hospital (Henry Ford in Detroit) where the transplant will take place, and thankfully it is about 50 minutes away from our home. (U of M is two hours). We have another appointment with the team in four weeks to begin the scheduling, begin the insurance process and set the wheels in motion if my husband has reached the point that the doctors are satisfied with. By then that appointment should be during his seventh cycle.
He is currently planning on having the collection take place as soon as it feasible and he gets the green light from all parties involved.
Thank you to the others that responded as well. Valuable information and I appreciate it.
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Jenn - Name: Jenn
- Who do you know with myeloma?: Husband
- When were you/they diagnosed?: September 2011
- Age at diagnosis: 45
Re: RVD - how long?
In reading the string of questions and responses here, I'm curious about the collection do stem cells for transplant.
My wife has had two treatments do Velcade and is currently hospitalized with tumor lysis. It looks like she will be okay although there were a couple days where it was touch and go.
What should I look for as the best time for the doctors to harvest stem cells for transplant?
My wife has had two treatments do Velcade and is currently hospitalized with tumor lysis. It looks like she will be okay although there were a couple days where it was touch and go.
What should I look for as the best time for the doctors to harvest stem cells for transplant?
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MMhusband
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