-Dr. McCarthy,
thank you for answering our questions here at the beacon!!! My question is, when do you think is the best time for a transplant in myeloma? With the novel agents, myeloma could be surpressed some time without a transplant. This has been a major topic on this year's ash. Do you think, that even in younger patients maintenance therapy without SCT could be a recommended therapy? Or do that patients face several problems, for example the collection of stem cells for the auto transplant will be a severe problem. Or the risk of development of a second cancer will be higher.
Thank you again,
Thomas
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Re: Time for transplant
Hi Thomas I,
The exact timing for transplant is a bit of a moving target. For younger patients who would be considered transplant-eligible, treating to best response, collecting blood or marrow stem cells and transplant has been a standard approach. With the advent of lenalidomide use, it became clear that blood stem cells needed to be collected after 4 cycles of lenalidomide due to the suppressive effects of lenalidomide on stem cell collections. There is a French and American study that is being led by Dr. Paul Richardson in the USA and Dr. Michel Attal from the French Myeloma Intergroup (IFM). This study examines induction therapy followed by stem cell collection and then a randomization to transplant versus more chemotherapy. The chemotherapy arm could get transplant at relapse. So, we should have an answer as to which patients would benefit most from upfront transplant versus waiting.
So, I recommend that patients undergo stem cell collection early if transplant eligible for early versus late transplant. For high risk patients, early transplant with consideration for maintenance therapy is a reasonable option.
Patents with multiple myeloma develop second cancers which is likely due to the nature of the disease and then are further at risk after receiving chemotherapy which could cause damage to normal tissue. We are uncertain as to the exact risk of second cancers, if at all with some of the newer agents. So we will have to wait and see over time. This points out the importance of multiple myeloma patients who have well controlled disease undergoing routine health maintenance such as colonoscopies as recommended by the primary care physician.
The exact timing for transplant is a bit of a moving target. For younger patients who would be considered transplant-eligible, treating to best response, collecting blood or marrow stem cells and transplant has been a standard approach. With the advent of lenalidomide use, it became clear that blood stem cells needed to be collected after 4 cycles of lenalidomide due to the suppressive effects of lenalidomide on stem cell collections. There is a French and American study that is being led by Dr. Paul Richardson in the USA and Dr. Michel Attal from the French Myeloma Intergroup (IFM). This study examines induction therapy followed by stem cell collection and then a randomization to transplant versus more chemotherapy. The chemotherapy arm could get transplant at relapse. So, we should have an answer as to which patients would benefit most from upfront transplant versus waiting.
So, I recommend that patients undergo stem cell collection early if transplant eligible for early versus late transplant. For high risk patients, early transplant with consideration for maintenance therapy is a reasonable option.
Patents with multiple myeloma develop second cancers which is likely due to the nature of the disease and then are further at risk after receiving chemotherapy which could cause damage to normal tissue. We are uncertain as to the exact risk of second cancers, if at all with some of the newer agents. So we will have to wait and see over time. This points out the importance of multiple myeloma patients who have well controlled disease undergoing routine health maintenance such as colonoscopies as recommended by the primary care physician.
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Dr. Philip McCarthy - Name: Philip McCarthy Jr., M.D.
Re: Time for transplant
Hello i want to ask a question about the stem cell transplant. My mother, 44 years old, has finished her first cycles of Velcade and has already has her blood stem cells been harvested. She stopped Velcade about 3 months ago and in the period of these months she was taking a drug for her bones. Meanwhile our doctor had informed us that we had to wait these 3 months until the hospital has a free bed for this procedure. The problem is that when we saw him last week, he said that it would take another month, meaning 4 months of delay, and told my mother to take Revlimid every day for 21 days with 1 week pause. Does this cause any serious problems?(I mean the from use of Revlimid before the transplant and not after and the the time that SCT will be done) Another thing is that, from what the doctor informed us, that the IgG counts didn't drop nor rise with the ending of the Velcade threatmeant, meaning that wasn't perfect neither a bad thing. I don't know if anyone has a same experience but it would be helpfull if you have any information. If SCT must be done immediatly, should i search for another hospital for a chance of getting it sooner?
Thanks for your time and sorry for any grammatic errors (I'm from Greece and i don't have the chance of using English very often)
Thanks for your time and sorry for any grammatic errors (I'm from Greece and i don't have the chance of using English very often)
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Evangelos - Name: Evangelos
- Who do you know with myeloma?: my mother
- When were you/they diagnosed?: about 9 months ago
- Age at diagnosis: 44
Re: Time for transplant
Dear Evangelos,
The Revlimid question is a terrific one. I am assuming you are alluding to the possibility of an increased risk of secondary cancers with Revlimid and transplant in close proximity to one another. Revlimid therapy is commonly used as an induction therapy before transplant. There are no data that Revlimid given before transplant increases the risk of subsequent cancers. I think it would be perfectlysafe to receive Revlimid prior to tranplant.
As far as the IgG levels not dropping, do you mean that the levels did not drop with treatment or that they dropped during treatment and have not risen since the last treatment was given?
As far as the need for immediate transpant, that largely is dependent on the characteristics of your Mother's disease at diagnosis (aggressive vs. less aggressive), response to therapy, whether there has been disease progression during the delay. If your mother had low-risk disease at diagnosis, a good response to Velcade-based therapy, and has experienced no disease progression since stopping treatment, she may be able to wait it out. If she had high-risk disease, a sub-optimal response to Velcade-based therapy, or disease progression since stopping treatment, I would go for a Revlimid regimen to reduce disease burden followed by transplant.
I hope this helps. Good luck!
Pete V.
The Revlimid question is a terrific one. I am assuming you are alluding to the possibility of an increased risk of secondary cancers with Revlimid and transplant in close proximity to one another. Revlimid therapy is commonly used as an induction therapy before transplant. There are no data that Revlimid given before transplant increases the risk of subsequent cancers. I think it would be perfectlysafe to receive Revlimid prior to tranplant.
As far as the IgG levels not dropping, do you mean that the levels did not drop with treatment or that they dropped during treatment and have not risen since the last treatment was given?
As far as the need for immediate transpant, that largely is dependent on the characteristics of your Mother's disease at diagnosis (aggressive vs. less aggressive), response to therapy, whether there has been disease progression during the delay. If your mother had low-risk disease at diagnosis, a good response to Velcade-based therapy, and has experienced no disease progression since stopping treatment, she may be able to wait it out. If she had high-risk disease, a sub-optimal response to Velcade-based therapy, or disease progression since stopping treatment, I would go for a Revlimid regimen to reduce disease burden followed by transplant.
I hope this helps. Good luck!
Pete V.
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Dr. Peter Voorhees - Name: Peter Voorhees, M.D.
Beacon Medical Advisor
Re: Time for transplant
My wife was just diagnosed with SMM. Though a skeletal survey was negative, a recently increasing IgG number alarmed her doctor. She is to undergo an MRI to be on the safe side that no bone is being involved. If the MRI shows positive results, we will have to decide what treatment course to follow.
We are struggling mightily between the "standard" and aggresive approaches such as the Total Therapy protocol used by the University of Arkansas. On one hand, a single SCT inevitably leads to relapse at relatively short time. Therefore it becomes a try and fail approach afterwards. It might also lead to drug resistance when more and more drugs are tried and then failed. The feeling of running out of ammunitions can be a huge negative psychologically, not to mention that it poses real risk to the patient's life.
On the other hand, according to UAMS, the Total Therapy approach gives you more upshot and longer progression-free time, leading to a plateau that indicates a potential "cure." The downside is certainly the toxicity that may damage a person permanently post-therapy, including second primary tumor.
My wife is in her 40's. Therefore the latter approach is very attractive because of its treatment potential. But she is also mindful that relapse is still a possibility with that approach besides the high toxicity and grueling treatment routine. Does anyone have any thoughts on this? I would be grateful if I can hear from any former UAMS Total Therapy patients. Thank you so much.
We are struggling mightily between the "standard" and aggresive approaches such as the Total Therapy protocol used by the University of Arkansas. On one hand, a single SCT inevitably leads to relapse at relatively short time. Therefore it becomes a try and fail approach afterwards. It might also lead to drug resistance when more and more drugs are tried and then failed. The feeling of running out of ammunitions can be a huge negative psychologically, not to mention that it poses real risk to the patient's life.
On the other hand, according to UAMS, the Total Therapy approach gives you more upshot and longer progression-free time, leading to a plateau that indicates a potential "cure." The downside is certainly the toxicity that may damage a person permanently post-therapy, including second primary tumor.
My wife is in her 40's. Therefore the latter approach is very attractive because of its treatment potential. But she is also mindful that relapse is still a possibility with that approach besides the high toxicity and grueling treatment routine. Does anyone have any thoughts on this? I would be grateful if I can hear from any former UAMS Total Therapy patients. Thank you so much.
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bens
Re: Time for transplant
> As far as the IgG levels not dropping, do you mean that the levels did not
> drop with treatment or that they dropped during treatment and have not
> risen since the last treatment was given?
Thank you for your reply Dr. Voorhees. I really appreciate it.
What I meant about my mother's IgG levels was that they didn't drop with the treatment. They remain stable, didn't drop nor rise. As far of the disease progression since stopping her treatment, it is something that I don't really know. Our doctor told her to take Revlimid in order to protect her body from any disease progression during the time that she has to wait until she can do her SCT. My mother's next blood tests will be done at Nov. 11, 2011, because these specific tests are been hold by our doctor, I will ask then if the disease had any progression or was all the time stable and take a copy of the tests.
Thank's again for answering my questions Dr. Voorhees.
Evangelos
> drop with treatment or that they dropped during treatment and have not
> risen since the last treatment was given?
Thank you for your reply Dr. Voorhees. I really appreciate it.
What I meant about my mother's IgG levels was that they didn't drop with the treatment. They remain stable, didn't drop nor rise. As far of the disease progression since stopping her treatment, it is something that I don't really know. Our doctor told her to take Revlimid in order to protect her body from any disease progression during the time that she has to wait until she can do her SCT. My mother's next blood tests will be done at Nov. 11, 2011, because these specific tests are been hold by our doctor, I will ask then if the disease had any progression or was all the time stable and take a copy of the tests.
Thank's again for answering my questions Dr. Voorhees.
Evangelos
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Evangelos - Name: Evangelos
- Who do you know with myeloma?: my mother
- When were you/they diagnosed?: about 9 months ago
- Age at diagnosis: 44
6 posts
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