‘First Remission is the Best Remission’, Dr. Parameswaran Hari On Myeloma and Treatment of Relapse: Myeloma Cure Panel Highlights Part 2
Dr. Hari feels that the first remission is the best remission and patients should be treated aggressively to keep the disease from progressing in order to enjoy a longer first remission.
He goes on to speak about stringent complete remission or CR. To confirm this, the patient is subjected to biochemical tests, M protein detection, light chain studies, bone marrow biopsy and the newly discovered multicolor-fluorocytometry. The new technique is highly sensitive and counts only the bad plasma cells/myeloma cells. The patient is said to be in stringent CR when no myeloma cells are detected in the above mentioned tests.
So what about the argument that an aggressive approach can lead to increased toxicity? Dr. Hari feels that this argument is not without cause. In cases where patient has MGUS there is all probability that this might not progress to full blown myeloma. However, in cases where there is progression of disease, it is necessary to get it down immediately with aggressive treatment.
Treatment of Relapse
The treatment of patients who have a relapse depends on many factors and Dr. Hari explains these,
- How aggressive the relapse is? If it is an early relapse, then it is in all probability an aggressive tumor that has come back and this is bad. If it is a rapid relapse, where there is an increase in myeloma cells quickly, then also, this is bad news. A third type of relapse can be extra-medullary relapse where there is fluid retention around lungs and other organs. The bottom line is that all relapse is bad.
- How strong is the patient? Patients should be part of a surveillance program post their myeloma diagnosis and treatment so that they are continuously monitored. This enables early detection of myeloma relapse and early detection automatically means early treatment.
- What was the course of first treatment? For example, if the first treatment involved Revlimid for 3 years and then a non-Revlimid regimen, transplant can be considered. If the patient has undergone a transplant and has had an early relapse, say in 2 years, a second transplant with maintenance therapy can be prescribed, and so on.
- Type of side effect. Side effect profile of a person is very important variable while dealing with a myeloma relapse. For example, Velcade is often associated with severe neuropathy and patients, who are on Velcade, would have to be taken off these when in relapse.
Once these factors are analysed, there is the big job of planning the next course of treatment. There are various treatment protocols followed by various oncologists.
– One group of physicians opts for trying out single drugs sequentially. The patient is administered one of the myeloma drugs until the response diminishes. Once this happens, patient is put on the next.
– A second group of doctors opts for a more aggressive treatment protocol. The patient is put on a combination of drugs, bortezomib/Revlimid/dexamethasone. This aggressive approach provides quick response. This can be followed up with transplant and maintenance therapy.
The debate continues as to the use of combination drugs as compared to single drugs sequentially as well as the efficacy of a three drug and a 4-drug combination.
Dr. Hari has the best 2 and 3 year survival rates for myeloma patients. Myeloma patients under Dr. Hari’s care at the Medical College of Wisconsin are 13 times more likely to survive 2 years and 7.2 times more likely to survive 3 years than in an average SEER facility. The SEER (Surveillance, Epidemiology, and End Results) data from the National Cancer Institute provides survival data for many cancers including multiple myeloma.
Dr. Hari makes it clear that he prefers to approach multiple myeloma aggressively and quickly bring the disease under control.
Keep reading …I will return with Dr. Hari’s response to panelists’ questions in Part 3.