My question is transplant or maintenance only.
I have finished my induction therapy and will begin harvesting next month.
My oncologist that I've been through the induction with thinks I should harvest but feels with all the new medicines on the horizon that I should hold off on a transplant and do a maintenance shot of Velcade every two weeks.
The specialist who is doing the harvesting believes as of now that the history at this point is to do a transplant, although he is leaving that decision up to me.
I've done very well with 5 months of induction and if I can avoid a month in the hospital and recovery that would be great. My family really can't afford to lose me for a month.
Any thoughts?
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Re: Stem cell transplant or just maintenance therapy?
Do you have any special elements like chromosome deletions? Have you reached a very good partial response (VGPR) or better?
Re: Stem cell transplant or just maintenance therapy?
I had 80% plasma cell percentage in the bone marrow; monosomy for 13q and duplication 1q.
Just had last induction after 4 5 months of induction therapy. M spike is 0.1 g/dL (1 g/L), but waiting for last blood work. IgG went from 4000 to 300. Lambda lights are normal now. No paraprotein seen in 24-hour urine now. Fortunately my kidneys and bones stayed ok, except for back pain, which both doctors think was due to the high bone marrow plasma cell percentage.
Was anemic and still at 10.9 on hemoglobin, red blood cells 345. Low albumin still. Had a pulmonary embolism during treatment.
Just had last induction after 4 5 months of induction therapy. M spike is 0.1 g/dL (1 g/L), but waiting for last blood work. IgG went from 4000 to 300. Lambda lights are normal now. No paraprotein seen in 24-hour urine now. Fortunately my kidneys and bones stayed ok, except for back pain, which both doctors think was due to the high bone marrow plasma cell percentage.
Was anemic and still at 10.9 on hemoglobin, red blood cells 345. Low albumin still. Had a pulmonary embolism during treatment.
Re: Stem cell transplant or just maintenance therapy?
Hi Cindy Ann:
Getting down to 0.1 M-spike on induction after an 80% plasma involvement is fantastic. Congratulations on that, and I wish you continued good results.
On your question, you have asked perhaps the most hotly debated question (or if not, certainly in the top 5) on the Beacon.
Interestingly, the regimen / sequencing that you describe, Velcade maintenance after induction (no autologous stem cell transplant), I do not believe has had a study with posted results. There was a study in the last European meeting, however, that did show positive results for Velcade maintenance versus no maintenance. I believe it was called Velcade vs. observation), that study included an autologous stem cell transplant (ASCT).
On average, the autologous stem cell transplant does help (based on published clinical trial results). You have no way of knowing for certain at this stage whether or not you are average, or if the ASCT will help at all. You are right in the range where there is no clear data (at least overwhelming data) on which way to go. You are correct to include your personal preferences and lifestyle issues. But I will offer the following couple of thoughts.
Keep in mind that the leading doctors are evaluating ASCT upfront, or ASCT at first relapse. The thought is that ASCT at first relapse might be as good or almost as good. Recent IFM data suggests that stem cell transplant upfront is better in terms of overall survival. The ASCT at first relapse, however, is not WAY behind. If you are thinking no stem cell transplant, then that would be somewhat farther behind than ASCT upfront (based on the existing standard of care drugs, but not the new drugs approved this past year).
Second, I would, in your shoes, be a little more comfortable to go straight to maintenance with a CR or negative minimum residual disease. Some people get there in maintenance, which for you would be ideal. I might consider asking the doctor what he (she) thought about doing something else (e.g., a couple of rounds of Kyprolis, Revlimid, and dex) to get there.
Lastly, ideally, the very best case would be that you get a quite a long first remission on maintenance, and when you need to go on treatment again, that there will be newer and better regimens that would potentially get you even a longer period of remission, after first relapse. I think that is the ideal approach that your doctor is contemplating.
Good luck in your decision, and please let us know what you decide, as it is very relevant to decisions affecting many people based on recent advances.
Getting down to 0.1 M-spike on induction after an 80% plasma involvement is fantastic. Congratulations on that, and I wish you continued good results.
On your question, you have asked perhaps the most hotly debated question (or if not, certainly in the top 5) on the Beacon.
Interestingly, the regimen / sequencing that you describe, Velcade maintenance after induction (no autologous stem cell transplant), I do not believe has had a study with posted results. There was a study in the last European meeting, however, that did show positive results for Velcade maintenance versus no maintenance. I believe it was called Velcade vs. observation), that study included an autologous stem cell transplant (ASCT).
On average, the autologous stem cell transplant does help (based on published clinical trial results). You have no way of knowing for certain at this stage whether or not you are average, or if the ASCT will help at all. You are right in the range where there is no clear data (at least overwhelming data) on which way to go. You are correct to include your personal preferences and lifestyle issues. But I will offer the following couple of thoughts.
Keep in mind that the leading doctors are evaluating ASCT upfront, or ASCT at first relapse. The thought is that ASCT at first relapse might be as good or almost as good. Recent IFM data suggests that stem cell transplant upfront is better in terms of overall survival. The ASCT at first relapse, however, is not WAY behind. If you are thinking no stem cell transplant, then that would be somewhat farther behind than ASCT upfront (based on the existing standard of care drugs, but not the new drugs approved this past year).
Second, I would, in your shoes, be a little more comfortable to go straight to maintenance with a CR or negative minimum residual disease. Some people get there in maintenance, which for you would be ideal. I might consider asking the doctor what he (she) thought about doing something else (e.g., a couple of rounds of Kyprolis, Revlimid, and dex) to get there.
Lastly, ideally, the very best case would be that you get a quite a long first remission on maintenance, and when you need to go on treatment again, that there will be newer and better regimens that would potentially get you even a longer period of remission, after first relapse. I think that is the ideal approach that your doctor is contemplating.
Good luck in your decision, and please let us know what you decide, as it is very relevant to decisions affecting many people based on recent advances.
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JPC - Name: JPC
Re: Stem cell transplant or just maintenance therapy?
Thanks for your great reply.
The induction therapy was Aloxi, dex, Cytoxan, and Velcade. I'm not very good at the terminology. I have had 2 more treatments since my last bloodwork, so I'm hoping when I see them I am in complete remission. My current doctor did want me to zero out, but now I am in the specialist's hands with harvesting. If I do the stem cell transplant, it won't be till May. My son's wedding is in April and I wanted the time to get my strength for that.
The plan is for the specialist to put me on maintenance until I decide what to do in May. If I don't do the transplant, I'm sure he will pick another maintenance plan other than just Velcade.
I just want to do the right thing as I have no real caretaker and am actually trying to help my mother who lives with me and has Parkinsons and is very weak. Granddaughter and daughter live with me as well. Financial situation is pretty bad as well.
I will keep you posted on all the latest lab work.
Thanks!
The induction therapy was Aloxi, dex, Cytoxan, and Velcade. I'm not very good at the terminology. I have had 2 more treatments since my last bloodwork, so I'm hoping when I see them I am in complete remission. My current doctor did want me to zero out, but now I am in the specialist's hands with harvesting. If I do the stem cell transplant, it won't be till May. My son's wedding is in April and I wanted the time to get my strength for that.
The plan is for the specialist to put me on maintenance until I decide what to do in May. If I don't do the transplant, I'm sure he will pick another maintenance plan other than just Velcade.
I just want to do the right thing as I have no real caretaker and am actually trying to help my mother who lives with me and has Parkinsons and is very weak. Granddaughter and daughter live with me as well. Financial situation is pretty bad as well.
I will keep you posted on all the latest lab work.
Thanks!
Re: Stem cell transplant or just maintenance therapy?
Hi Cindy,
Welcome to the forum. I thought I would add a few additional bits of information that may help you in your decision making.
Regarding the French (IFM) clinical trial that JPC mentioned, it is discussed at length in this forum thread that Cheryl started:
"Initial results: key stem cell transplant clinical trial" (started Nov 5, 2015)
The study found that, as expected, early stem cell transplantation increases time to relapse (progression-free survival), but it does not have any overall survival advantage versus delayed stem cell transplantation.
Also, regarding the Velcade study that JPC mentioned, you can find the abstract here:
C Straka et al, "Results from two phase III studies of bortezomib (BTZ) consolidation vs observation (OBS) post-transplant in patients (pts) with newly diagnosed multiple myeloma (NDMM)," ASCO 2015 annual meeting abstract (link to abstract)
It is a study of post-transplant Velcade consolidation therapy. One group of patients in the study got 4 35-day cycles of Velcade consolidation therapy. The other group of patients got no consolidation therapy.
The patients who got the Velcade consolidation therapy did have a longer time to relapse. However, there was no difference in overall survival between the two groups.
When you step back and look more generally at studies like these, what you generally find is a very simple result. If some patients in a study receive more intensive therapy – an extra treatment, or longer treatment – and other patients in the study do not, then the patients receiving more intensive therapy usually will have a longer time to relapse.
What you also see in most of these studies, however, is that more intensive therapy only sometimes leads to longer overall survival.
Good luck with your decision!
Welcome to the forum. I thought I would add a few additional bits of information that may help you in your decision making.
Regarding the French (IFM) clinical trial that JPC mentioned, it is discussed at length in this forum thread that Cheryl started:
"Initial results: key stem cell transplant clinical trial" (started Nov 5, 2015)
The study found that, as expected, early stem cell transplantation increases time to relapse (progression-free survival), but it does not have any overall survival advantage versus delayed stem cell transplantation.
Also, regarding the Velcade study that JPC mentioned, you can find the abstract here:
C Straka et al, "Results from two phase III studies of bortezomib (BTZ) consolidation vs observation (OBS) post-transplant in patients (pts) with newly diagnosed multiple myeloma (NDMM)," ASCO 2015 annual meeting abstract (link to abstract)
It is a study of post-transplant Velcade consolidation therapy. One group of patients in the study got 4 35-day cycles of Velcade consolidation therapy. The other group of patients got no consolidation therapy.
The patients who got the Velcade consolidation therapy did have a longer time to relapse. However, there was no difference in overall survival between the two groups.
When you step back and look more generally at studies like these, what you generally find is a very simple result. If some patients in a study receive more intensive therapy – an extra treatment, or longer treatment – and other patients in the study do not, then the patients receiving more intensive therapy usually will have a longer time to relapse.
What you also see in most of these studies, however, is that more intensive therapy only sometimes leads to longer overall survival.
Good luck with your decision!
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