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Smoldering Myeloma (SMM) – Chemo now, later?

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“New studies (pre-habilitation) suggest that a multimodal approach that incorporates both physical and psychological prehabilitation interventions may be more effective than a unimodal approach that addresses just one or the other.”

Hi David, My name is Henry. I am 72 years old. I went to see two oncologists today. One from an academic hospital and one from a local hospital. She told me that I am currently between medium and high risk Smoldering Myeloma (SMM).

 In the university hospital they do not want to do preventive treatment to postpone Multyple Myeloma. Their argument is that you adapt prematurely with a drug that you badly need later on. I have followed the work of DR Gabriel and the Mayo clinic in Spain. 

They are currently running the LEN-DEX test with good results. Many specialists say that you should work as little toxicity as possible in the preliminary phase. 

My question to you is, I would like to try the half dose LEN-DEX and then see how it works out.

Would like your opinion. Greetings Henry

Hi Henry- 

You have several things to consider. 

First, it is clear from the studies that I have read, that low-dose Revlimid (lenalidomide)/Dexamethasone (Len-Dex) will slow or postpone your SMM (smoldering myeloma) from becoming  a diagnosis of multiple myeloma.

Understanding this, the question then becomes, is it your goal increase your PFS (progression-free survival- the time from now until your SMM progresses to MM) or your OS (overall survival) aka length of life?

I ask these two questions because my belief is that by saying “you adapt prematurely with a drug you need badly later on” the University Hospital is saying that chemo prevention can cause your smoldering myeloma aka monoclonal protein cells, your MM, to “adapt” and to develop resistance.  This adaptation is what all MM survivors eventually reach- multi-drug resistance (MDR). 

Secondly, research has shown that non-toxic, non-conventional therapies such as curcumin, EGCG, omega-3, etc. can reduce the risk of a MM diagnosis. Fellow smoldering multiple myeloma survivor named Margaret (her blog is called Margaret’s Corner- https://margaret.healthblogs.org) has been living with SMM for more than 15 years.  

Thirdly, if you undergo an anti-MM regimen of nutritional supplementation, anti-angiogenic nutrition, sauna, exercise, etc. you are “pre-habilitating or pre-habilitation” yourself and your MM. Research has shown that you will respond better to chemo if and when you choose to pre-habilitate first. Meaning, if you pre-habilitate now, you will respond better, live longer, if you do progress to MM. 

Lastly, if your SMM progresses to full MM, if you are undergoing diagnostic testing regularly (1 mo, 3 mo) you will identify full MM at a very early stage. Your prognosis at this early stage of MM is much, much better than the published averages. 95% of newly diagnosed MM patients are stage 2,3. 

If you would like to learn more about “pre-habilitation” I will send you the MGUS, SMM program. You have enrolled in the full MM program. Similar but different. 

You can undergo Len-Dex anytime. Pre-habilitating will only improve your response to chemo if you ever do advance to a full MM diagnosis. 

Please ask any and all questions Henry. I’ve covered a number of key issues above. 

David Emerson

  • Multiple Myeloma Survivor
  • MM Cancer Coach
  • Director The Galen Foundation

Recommended Reading:

Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes

“Cancer prehabilitation, a process on the continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment, includes physical and psychological assessments that establish a baseline functional level, identifies impairments, and provides targeted interventions that improve a patient’s health to reduce the incidence and the severity of current and future impairments.

There is a growing body of scientific evidence that supports preparing newly diagnosed cancer patients for and optimizing their health before starting acute treatments.

This is the first review of cancer prehabilitation, and the purpose was to describe early studies in the noncancer population and then the historical focus in cancer patients on aerobic conditioning and building strength and stamina through an appropriate exercise regimen.

More recent research shows that opportunities exist to use other unimodal or multimodal prehabilitation interventions to decrease morbidity, improve physical and psychological health outcomes, increase the number of potential treatment options, decrease hospital readmissions, and reduce both direct and indirect healthcare costs attributed to cancer.

Future research may demonstrate increased compliance with acute cancer treatment protocols and, therefore, improved survival outcomes. New studies suggest that a multimodal approach that incorporates both physical and psychological prehabilitation interventions may be more effective than a unimodal approach that addresses just one or the other.

In an impairment-driven cancer rehabilitation model, identifying current and anticipating future impairments are the critical first steps in improving healthcare outcomes and decreasing costs. More research is urgently needed to evaluate the most effective prehabilitation interventions, and combinations thereof, for survivors of all types of cancer.”

Drug resistance in multiple myeloma

“Multiple myeloma (MM, plasma cell myeloma) is a malignant hematologic disease characterized by the clonal proliferation of malignant plasma cells. The treatment of MM has changed dramatically in recent years, with the introduction of new drugs into therapeutic strategies, both in the front line setting and in relapsed refractory disease.

However, most patients eventually relapse and often demonstrate multiple drug resistance.

Therefore there is still an urgent and unmet need to define the molecular mechanisms of resistance for available drugs in order to enhance the use of existing treatments and design more effective therapies. Genetic abnormalities are well known to play a central role in MM resistance to available drugs, and epigenetic aberrations mainly affecting the patterns of DNA methylation and histone modifications of genes, especially tumor suppressors, can be involved in the resistance mechanism.

Moreover, defects in the mechanisms of apoptosis, senescence and DNA repair could also contribute to drug resistance. In addition, mutations or alterations in the expression of the drug target can influence response to therapy. Achieving a better understanding of the pathways and protein expression involved in MM drug resistance and the development of novel therapeutic strategies are important goals for further progress in the treatment of MM…”


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