Hi,
How common is a second stem cell transplant? What if one does not have any stem cells left? If we collect stem cells again, would they be worse than the "virgin" stem cells?
Our case is high-risk deletion p53. Unfortunately, at the time of stem cell collections, my Dad was very weak physically (and psychologically battered from hair loss, etc.), and thus did not manage to collect enough stem cells for second transplant.
We were also very efficient at that time that we did not worry about second transplant since we did not know whether we would make it on the first anyway.
His numbers have been stable now, but this raises further questions of many what-ifs.
Thank you.
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Re: Second stem cell transplant
Hello tpt:
You have raised a couple of important issues that I recall having come across in my readings that I would like to comment on.
Generally, for any initial induction treatment (including not only ASCT, but other treatments), where you got a good response (say CR or VGPR), then the response will be associated with a remission period (even if its VGPR, the word remission would still be used), the remission period would end, and you would be in first relapse. If the initial response was evaluated to be good, the same treatment could potentially be used at first remission. For the majority of patients, there would be a response to repeating the initial successful induction treatment. The depth of response would probably be almost as good (or rarely as good). The remission period, however, would be less, and the typical number for the shorter period of remission would be 60%. This seems to be true both before the age of novel agents, and seems to be holding through for now in the periods of novel agents. The approaches of maintenance and consolidation are complicating the issues, but for now this general principle seems to be holding.
Putting some numbers on it. For a patient treated with 4 rounds of Revlimid, Velcade, and dexamethasone (RVD) and an ASCT with no maintenance (a traditional standard of care), if you had a 5-year duration of first remission, that would be quite good for standard risk patients. If you did the exact same thing, you would expect a 3 year duration of second remission. If you are in that case, 3 years would be an average number, and you might get a very different number, but it would be a reasonable expectation to plan for. If you tolerated the ASCT pretty well the first time, it is something you might consider.
If you only got barely 2 years of first remission, however, getting 15 months in second remission is not that wonderful in that it would take 6 to 9 months to recover from it. If you got the 15 months, that would not be a wonderful response. If the period was short enough (12 months or 6 months), you would be considered refractory to that treatment.
The thing is, however, there are improved drugs that came out and are coming out. Doctors report that the old 60% ratio of second duration can be improved too if the treatment is improved with better drugs, perhaps to over 80% or higher. What many doctors are coming to feel is that getting that period of first remission as high as possible is very important. That is why the trend seems to be going to maintenance and consolidation (continuous treatment) at most centers, even for patients with an ASCT.
For stem cell collection after ASCT, my understanding is that it is very possible in some cases, but problematic in others. If you achieved CR after ASCT, and recovered well, in a certain sense that might be actually a better time to collect (say you were not CR before the ASCT). It is better to have as low as possible % of plasma cells at time of collection. Your immune system may need time to recover (say 9 months to a year). If you could get the collection done before a relapse, that would be better than waiting until after it relapses to collect. You do hear, however, some people having insurance issues in this case, for collecting when you are in CR, and you are just looking to "bank" the stem cells that may never be needed in the future.
A major issue, however, is that Revlimid suppresses stem cell production. If you are on Revlimid maintenance, you might need to come off the Revlimid 8 - 10 weeks (including the Revlimid holiday and the week for collection) or more to collect, and it might be a difficult collection. If that was the time your M-spike started to creep back up, you might be regretting it. I understand that at experienced centers, if the doctor decides to go with the ASCT, they will attempt the collection in the most problematic of conditions, and in most cases can get what they need.
Kindly understand that these are gross generalizations with some thoughts for you to consider, but hopefully this helps in terms of giving you some items to discuss with your myeloma specialist.
Good Luck.
You have raised a couple of important issues that I recall having come across in my readings that I would like to comment on.
Generally, for any initial induction treatment (including not only ASCT, but other treatments), where you got a good response (say CR or VGPR), then the response will be associated with a remission period (even if its VGPR, the word remission would still be used), the remission period would end, and you would be in first relapse. If the initial response was evaluated to be good, the same treatment could potentially be used at first remission. For the majority of patients, there would be a response to repeating the initial successful induction treatment. The depth of response would probably be almost as good (or rarely as good). The remission period, however, would be less, and the typical number for the shorter period of remission would be 60%. This seems to be true both before the age of novel agents, and seems to be holding through for now in the periods of novel agents. The approaches of maintenance and consolidation are complicating the issues, but for now this general principle seems to be holding.
Putting some numbers on it. For a patient treated with 4 rounds of Revlimid, Velcade, and dexamethasone (RVD) and an ASCT with no maintenance (a traditional standard of care), if you had a 5-year duration of first remission, that would be quite good for standard risk patients. If you did the exact same thing, you would expect a 3 year duration of second remission. If you are in that case, 3 years would be an average number, and you might get a very different number, but it would be a reasonable expectation to plan for. If you tolerated the ASCT pretty well the first time, it is something you might consider.
If you only got barely 2 years of first remission, however, getting 15 months in second remission is not that wonderful in that it would take 6 to 9 months to recover from it. If you got the 15 months, that would not be a wonderful response. If the period was short enough (12 months or 6 months), you would be considered refractory to that treatment.
The thing is, however, there are improved drugs that came out and are coming out. Doctors report that the old 60% ratio of second duration can be improved too if the treatment is improved with better drugs, perhaps to over 80% or higher. What many doctors are coming to feel is that getting that period of first remission as high as possible is very important. That is why the trend seems to be going to maintenance and consolidation (continuous treatment) at most centers, even for patients with an ASCT.
For stem cell collection after ASCT, my understanding is that it is very possible in some cases, but problematic in others. If you achieved CR after ASCT, and recovered well, in a certain sense that might be actually a better time to collect (say you were not CR before the ASCT). It is better to have as low as possible % of plasma cells at time of collection. Your immune system may need time to recover (say 9 months to a year). If you could get the collection done before a relapse, that would be better than waiting until after it relapses to collect. You do hear, however, some people having insurance issues in this case, for collecting when you are in CR, and you are just looking to "bank" the stem cells that may never be needed in the future.
A major issue, however, is that Revlimid suppresses stem cell production. If you are on Revlimid maintenance, you might need to come off the Revlimid 8 - 10 weeks (including the Revlimid holiday and the week for collection) or more to collect, and it might be a difficult collection. If that was the time your M-spike started to creep back up, you might be regretting it. I understand that at experienced centers, if the doctor decides to go with the ASCT, they will attempt the collection in the most problematic of conditions, and in most cases can get what they need.
Kindly understand that these are gross generalizations with some thoughts for you to consider, but hopefully this helps in terms of giving you some items to discuss with your myeloma specialist.
Good Luck.
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JPC - Name: JPC
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• Page 1 of 1
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