Multiple Myeloma an incurable disease, but I have spent the last 25 years in remission using a blend of conventional oncology and evidence-based nutrition, supplementation, and lifestyle therapies from peer-reviewed studies that your oncologist probably hasn't told you about.
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“At least in terms of progression-free survival (PFS).” That’s the point! Autologous stem cell transplantation does result, on average, in a longer progression-free survival but not a longer overall survival (OS).
To be clear, an ASCT may result in a longer first remission (this is a “PFS”). But according to dozens of studies, MM patients who have an ASCT to not live longer.
The newly diagnosed multiple myeloma patient, then, must decide what is most important to them. A longer average PFS or a longer OS? Oh, an by-the-way, an ASCT will trash your quality of life for a time.
The put “quality-of-life” in MM speak, according to research, a high-dose autologous stem cell transplant (HD-ASCT) will, on average, result in more damage aka a higher risk of short, long-term and late stage side effects.
The FDA approved autologous stem cell transplantation long before the development of “novel” mm chemo regimens. While it is clear to me that the risk vs. reward trade-off when comparing ASCT and novel therapies is clear to me- let’s face it. I am a layman. I am not a drug company. I am only one person.
The bottom line is that the “control” side of the cure vs. control debate in mm is managing your mm with novel therapies only when required.
The “cure” side of the cure vs. control debate is aggressive potentially curative therapies like an ASCT. (I’ll never understand why ASCT is referred to as potentially curative– no mm patient has ever been cured with an ASCT…)
“Although not often openly acknowledged, “cure vs control” is the dominant philosophical difference behind many of the strategies, trials, and debates related to the management of myeloma.
Should we treat patients with myeloma with multidrug, multitransplant combinations with the goal of potentially curing a subset of patients, recognizing that the risk of adverse events and effect on quality of life will be substantial?
Or should we address myeloma as a chronic incurable condition with the goal of disease control, using the least toxic regimens, emphasizing a balance between efficacy and quality of life, and reserving more aggressive therapy for later?”
“RECENT FINDINGS: Almost 40 years after the publication of the first study on safety and efficacy of HDM and ASCT in MM patients, and despite the introduction of several drugs and combinations with various targets on the plasma cell and the surrounding microenvironment, HDM-ASCT still stands as a standard of care for the upfront treatment of newly diagnosed MM patients.
Indeed, all attempts to replace HDM-ASCT with novel-agent-based, non-transplant strategies have failed to demonstrate their efficacy, at least in terms of progression-free survival.
SUMMARY: Despite such a long history in MM, a number of open issues regarding HDM-ASCT still exist, from the choice between using transplant in first-line therapy or at relapse to the use of tandem HDM-ASCT in high-risk patients. With the introduction of more and more effective multidrug regimens and of novel immunotherapeutic approaches, the challenge between transplant and non-transplant is not over yet.
“Patients with myeloma should talk to their clinicians about getting the most out of the first treatment they receive for the disease, as it can affect their long-term outcomes, says Patricia Mangan, a hematology nurse practitioner at the University of Pennsylvania Abramson Cancer Center.
“One thing to stress is that typically, your first remission is the longest,” Mangan said during a presentation at the NCCN 2020 Virtual Congress on Hematologic Malignancies Nursing Forum. “Once you choose to treat someone with myeloma, you want to do it as aggressively as they can tolerate to get the biggest bang for your buck.”
Mangan explained that not all myeloma needs to be treated right away. However, if patients experience any of the following, it might be time for them to start a drug regimen:
The first line of treatment for patients with myeloma is typically a three-drug regimen including a proteasome inhibitor, immunomodulating agent, and steroids or dexamethasone. If a patient is eligible, they may then undergo an autologous stem cell transplant.
\“Once someone is diagnosed and they need to start treatment, there’s a quick decision of: Is this person potentially eligible for stem cell transplant or not? Do they have comorbid issues? Are they not fit or too old to undergo transplant?” Mangan said.
These questions need to be answered at the start of treatment, and a decision of transplant or no transplant should be made as soon as possible.
Patients who are able to get transplants will do so, and then likely be given maintenance therapy to keep the disease at bay. Conversely, those who are not transplant candidates can be given aggressive therapy upfront, and then, “start to peel off some of that initial treatment to get them on a maintenance of that to maintain remission,” Mangan said.
Remission after the first treatment tends to be the longest and most durable. However, most patients with myeloma will eventually relapse.
Luckily, there are now more options than ever before for the second- and third-line treatment of the disease.
“We can keep people doing well for a long period of time … our myeloma patients are survivors,” Mangan said. “They’re living much longer with each new year of treatments that come out.”
A version of this article was originally published on OncNursingNews.com as, “Frontline Treatment Decisions Are Crucial in Myeloma.”