Hi all,
I am undergoing treatment with Velcade, cyclophosphamide, and dexamethasone (VCD, CyBorD) and looking ahead to probably having an autologous stem cell transplant (SCT), my first). I've been very lucky with VCD. It's worked well and I've had minimal side effects.
What sort of effect can I expect the stem cell transplant to have on my key disease markers, such as my paraprotein level (M-spike), free light chain levels, and kappa-lambda free light chain ratio? (Those are the figures I usually focus on, but maybe there are others I should be thinking about?)
I am new to The Myeloma Beacon forum and I may have missed any topics on my particular area of interest?
Many thanks in advance for any replies.
All the best,
Brian (from the United Kingdom)
Forums
8 posts
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Re: Stem cell transplant after VCD / CyBorD
Hello, Brian:
At the top of this section of the forum is a post with useful links to previous forum discussions, organized by topic, including the subject of autologous stem cell transplants. Browsing those discussions will give some background of different input from different people.
At this date, according to the International Myeloma Working Group (IWMG) having an ASCT after initial induction is still the recommended approach for transplant eligible patients. That is for patients including standard risk, intermediate risk, and high risk.
According to the studies, there is a progression and overall survival advantage of having the ASCT. That being said, however, on a high level, there are two major issues. First, not all patients are helped by the ASCT. You have no way of knowing going in, whether or not you will have a "normal" response, where you get a deeper reduction of myeloma markers, or not. The studies show that it helps the "average" patient. You have no way of knowing ahead of time whether or not you will be average, or on the good side or the bad side of the curve.
Second, it is a difficult procedure, and many have safely used the word, "ordeal" to describe it. Some patients "skate" through it, though that is relatively rare. Just an opinion: If you are in stringent complete response (sCR) and are standard risk, that might be a basis on postponing the ASCT until after first relapse. If you are less than sCR, and/or have high risk cytogenetics, I think most doctors would recommend the ASCT. Good luck to you.
At the top of this section of the forum is a post with useful links to previous forum discussions, organized by topic, including the subject of autologous stem cell transplants. Browsing those discussions will give some background of different input from different people.
At this date, according to the International Myeloma Working Group (IWMG) having an ASCT after initial induction is still the recommended approach for transplant eligible patients. That is for patients including standard risk, intermediate risk, and high risk.
According to the studies, there is a progression and overall survival advantage of having the ASCT. That being said, however, on a high level, there are two major issues. First, not all patients are helped by the ASCT. You have no way of knowing going in, whether or not you will have a "normal" response, where you get a deeper reduction of myeloma markers, or not. The studies show that it helps the "average" patient. You have no way of knowing ahead of time whether or not you will be average, or on the good side or the bad side of the curve.
Second, it is a difficult procedure, and many have safely used the word, "ordeal" to describe it. Some patients "skate" through it, though that is relatively rare. Just an opinion: If you are in stringent complete response (sCR) and are standard risk, that might be a basis on postponing the ASCT until after first relapse. If you are less than sCR, and/or have high risk cytogenetics, I think most doctors would recommend the ASCT. Good luck to you.
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JPC - Name: JPC
Re: Stem cell transplant after VCD / CyBorD
My husband underwent induction with cyclophosphamide, Velcade, and dexamethasone (CyBorD), as well, and had a stem cell transplant on June 3rd of this year. He is now in complete remission – clean bone marrow and normal labs. He also had a great response to his induction, with minimal if any side effects, but to feel better.. 
Wishing you the best.
Wishing you the best.-
dogmom - Who do you know with myeloma?: husband
- When were you/they diagnosed?: December 2015
- Age at diagnosis: 58
Re: Stem cell transplant after VCD / CyBorD
Hi,
Many thanks for the replies to my post. They have been very helpful in increasing my level of understanding concerning stem cell transplants.
Best wishes.
Many thanks for the replies to my post. They have been very helpful in increasing my level of understanding concerning stem cell transplants.
Best wishes.
Re: Stem cell transplant after VCD / CyBorD
I'm three cycles into my Velcade, Revlimid, and dexamethasone treatment and have had a very positive response so far. My M-spike is down to zero, and all other markers are now in the normal range. I don't know if I've achieved a complete response (CR) because I haven't had a bone marrow biopsy done, but all other blood work would point in that direction.
My multiple myeloma specialist is recommending an autologous stem cell transplant. However, after meeting with him yesterday, I'm not sure that is the best direction, I didn't think he had a real compelling argument for proceeding. From what I've read, it doesn't seem like a huge benefit from where I currently am with the disease. So I will probably have my stem cells harvested and wait and see with drug maintenance going forward. I would be interested in others thoughts on the topic.
My multiple myeloma specialist is recommending an autologous stem cell transplant. However, after meeting with him yesterday, I'm not sure that is the best direction, I didn't think he had a real compelling argument for proceeding. From what I've read, it doesn't seem like a huge benefit from where I currently am with the disease. So I will probably have my stem cells harvested and wait and see with drug maintenance going forward. I would be interested in others thoughts on the topic.
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Kebo - Name: Kebo
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2008
- Age at diagnosis: 51
Re: Stem cell transplant after VCD / CyBorD
I'm curious about this also. My mom is in almost the same spot / same induction drugs. Wondering about whether to have the stem cell transplant.. Looking at pros / cons.
By the way, this forum is great.
By the way, this forum is great.
Re: Stem cell transplant after VCD / CyBorD
Hello, folks. I have commented on this before in this thread and others. Just to quickly add a point or two. There is presently a study by the French myeloma group (IFM) and Dana Farber on early vs delayed transplant. I just did a quick search and could not find a recent update. When they say "delayed" transplant, they mean that for transplant-eligible patients, it could be done after first relapse, versus initial induction. Overall, they are still recommending it be done in one of those two settings. Looking forward, however, if you did not elect to go transplant up front, and you got a good long first remission (say 5 to 7 years), then the thinking regarding transplant may be different, based on new research and drugs yet to come out, and better, less harsh treatments may displace transplant.
My recollection is that early transplant had about 1 year to 18 months advantage in progression-free survival. Early transplant also had an overall survival advantage, that was closer (both in the vicinity of 8 years). This was based on "interim" data, that will certainly be updated over time. So the difference was not so great to rule out delayed transplant, if you were so inclined to lean that way. My own opinion (to repeat) based on early data on minimal residual disease (MRD) studies, is that if you made the jump to MRD negative, and had no adverse cytogenetics, then the risk of deferring transplant is low (it seems to me). Recent studies on minimal residual disease have shown that about half the persons in complete response (CR) were MRD positive. I am not sure about the relationship between stringent complete response (sCR) and MRD, but would be interested to find that out.
One more funny thing about MRD. It is possible to have an M-spike and be minimal residual disease negative. That depends on how your individual myeloma generates the M-spike. My wife was at the verge of MRD negativity (10 to the neg 5 standard), but still had an M-spike. From my reading, this will occur in a minority of patients. Most will have the M-spike go to zero, before the traces of residual disease disappear. After two more rounds of consolidation, the M-spike went away and MRD went also to non-detect. It is probably not yet fully sanctioned by completed studies, but getting to MRD negative may be a good justification to postpone a stem cell transplant until first relapse. The study referred to above does suggest that you probably do not lose too much by deferring a transplant to first relapse, however, that would be impossible to predict on an individual level.
The flip side to this line of thought, of course, is if you have reached a partial response (PR) or very good partial response (VGPR), or complete response with moderate or high risk cytogenetics, then the potential advantage (statistically over a population) becomes more pronounced, and more doctors would lean in the stem cell transplant direction, in that case.
Good luck to all.
My recollection is that early transplant had about 1 year to 18 months advantage in progression-free survival. Early transplant also had an overall survival advantage, that was closer (both in the vicinity of 8 years). This was based on "interim" data, that will certainly be updated over time. So the difference was not so great to rule out delayed transplant, if you were so inclined to lean that way. My own opinion (to repeat) based on early data on minimal residual disease (MRD) studies, is that if you made the jump to MRD negative, and had no adverse cytogenetics, then the risk of deferring transplant is low (it seems to me). Recent studies on minimal residual disease have shown that about half the persons in complete response (CR) were MRD positive. I am not sure about the relationship between stringent complete response (sCR) and MRD, but would be interested to find that out.
One more funny thing about MRD. It is possible to have an M-spike and be minimal residual disease negative. That depends on how your individual myeloma generates the M-spike. My wife was at the verge of MRD negativity (10 to the neg 5 standard), but still had an M-spike. From my reading, this will occur in a minority of patients. Most will have the M-spike go to zero, before the traces of residual disease disappear. After two more rounds of consolidation, the M-spike went away and MRD went also to non-detect. It is probably not yet fully sanctioned by completed studies, but getting to MRD negative may be a good justification to postpone a stem cell transplant until first relapse. The study referred to above does suggest that you probably do not lose too much by deferring a transplant to first relapse, however, that would be impossible to predict on an individual level.
The flip side to this line of thought, of course, is if you have reached a partial response (PR) or very good partial response (VGPR), or complete response with moderate or high risk cytogenetics, then the potential advantage (statistically over a population) becomes more pronounced, and more doctors would lean in the stem cell transplant direction, in that case.
Good luck to all.
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JPC - Name: JPC
Re: Stem cell transplant after VCD / CyBorD
Hi Brian,
Sorry I'm late to this discussion; I came across it while looking for something else. However, you may find this journal article useful in terms of understanding what sort of response you may get from a stem cell transplant in addition to the VCD / CyBorD you've already received:
Areethamsirikul, N, et al, "CyBorD induction therapy in clinical practice", Bone Marrow Transplantation, Jan 2015 (full text of article)
Abstract:
Cyclophosphamide, bortezomib and dexamethasone (CyBorD) is a highly active three-drug induction regimen for untreated transplant-eligible multiple myeloma patients. Although CyBorD has been evaluated only in the phase 2 setting in a limited number of patients, its high efficacy and ease of administration have led to its widespread use. Given that clinical trial efficacy can overestimate real-life effectiveness, we reviewed our institutional experience with 109 newly diagnosed patients who were treated with CyBorD in a non-clinical trial setting. After a median of four cycles, overall response rate (ORR) and very good partial response rate or better (greater than or equal to VGPR) were 95 and 66%, respectively, comparable to phase 2 studies of CyBorD and other three/four-drug induction regimens. All patients subsequently underwent successful stem cell collection and upgraded responses to ORR 98% and greater than or equal to VGPR 79% post transplant. At a median follow-up of 19.8 months after diagnosis, the 2-year OS probability was 95.3% (95%CI: 89–98). The presence of concurrent plasmacytoma at diagnosis was the only prognostic factor predicting poorer survival (HR=5.56; 95%CI: 0.92–33.74; P=0.03). CyBorD was well-tolerated, with no severe peripheral neuropathy and minimal hematologic toxicity. Therefore, CyBorD is a convenient, well-tolerated, highly effective induction regimen in preparation for autologous SCT in real-life clinical practice.
Sorry I'm late to this discussion; I came across it while looking for something else. However, you may find this journal article useful in terms of understanding what sort of response you may get from a stem cell transplant in addition to the VCD / CyBorD you've already received:
Areethamsirikul, N, et al, "CyBorD induction therapy in clinical practice", Bone Marrow Transplantation, Jan 2015 (full text of article)
Abstract:
Cyclophosphamide, bortezomib and dexamethasone (CyBorD) is a highly active three-drug induction regimen for untreated transplant-eligible multiple myeloma patients. Although CyBorD has been evaluated only in the phase 2 setting in a limited number of patients, its high efficacy and ease of administration have led to its widespread use. Given that clinical trial efficacy can overestimate real-life effectiveness, we reviewed our institutional experience with 109 newly diagnosed patients who were treated with CyBorD in a non-clinical trial setting. After a median of four cycles, overall response rate (ORR) and very good partial response rate or better (greater than or equal to VGPR) were 95 and 66%, respectively, comparable to phase 2 studies of CyBorD and other three/four-drug induction regimens. All patients subsequently underwent successful stem cell collection and upgraded responses to ORR 98% and greater than or equal to VGPR 79% post transplant. At a median follow-up of 19.8 months after diagnosis, the 2-year OS probability was 95.3% (95%CI: 89–98). The presence of concurrent plasmacytoma at diagnosis was the only prognostic factor predicting poorer survival (HR=5.56; 95%CI: 0.92–33.74; P=0.03). CyBorD was well-tolerated, with no severe peripheral neuropathy and minimal hematologic toxicity. Therefore, CyBorD is a convenient, well-tolerated, highly effective induction regimen in preparation for autologous SCT in real-life clinical practice.
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