Last evening I wrote an article about the IMF’s ASH kick-off event, featuring doctor Durie, Medical Director of the IMF, Dr. Rajkumar with Mayo Clinic, Dr. San Miguel from Spain, Dr. Palumbo from Italy, Dr. Moreau from France and Dr. Orlowski with M.D. Anderson in Houston.
This was a very impressive, international group. I have heard all of these myeloma experts speak before, but certainly not together on the same stage.
Dr. San-Miguel from Spain stressed Velcade often works best in high risk patients, but often isn’t enough to extend these patient’s lives. He did discuss waiting to transplant until first relapse as a new option, even in high risk patients.
There was one question from the audience: What is the current mortality rate among patients undergoing an auto stem cell transplant (ASCT). His answer: “We haven’t lost a single patient at our center over the past three years.” The audience of over 800 applauded enthusiastically.
Next, Dr. Palumbo from Italy spoke about maintenance therapy and how to best deal with relapse, with an emphasis on elderly patients.
But before he began, Dr. Palumbo shared he likes to hit “the disease” as he calls myeloma, hard at the beginning, using multiple combo therapies while “the disease is still sensitive.”
Not surprisingly, Dr. Palumbo also likes to aggressively try and get “the disease down into CR.” “Don’t stop at a very good partial response.” he stressed.
Dr. Palumbo went on to say how he believes a patient in CR is “not really in remission–it is actually just a partial response–and the disease is still there.” He said this applies even to patients who are in a stringent CR.
Again, not surprisingly, Dr. Palumbo believes strongly in continuing treatment, using constant maintenance therapy.
The only exception is in elderly patients due to toxicity risks. In this case, elderly means over 75 years.
Velcade, melphalan and prednisone (VMP) is still the standard of care for elderly patient in Europe.
Once a week Velcade has become standard during the maintenance stage of treatment.
He closed with the advice not to over treat elderly patients.
Next up, the French oncologist, Dr. Moreau, spoke about using consolidation and/or maintenance therapy in younger patients.
I don’t use the term “consolidation therapy” very often. Briefly, consolidation is when a post transplant patient (ASCT or SCT–either acronym can be used) is given a combination of drugs starting a few months after treatment.
If a post SCT patient fails to achieve CR, myeloma docs often chose to–as Dr. Palumbo would say in his slow, strong Italian accent–”hit the disease hard.”
After a number of months of consolidation, the question becomes whether to continue a lighter, one drug maintenance therapy.
Dr. Moreau’s opinion: “Yes!” Quoting a large, 2005 study, Dr. Moreau pointed out how patients with stable disease all fared better using Revlimid maintenance. In this study, this data applied to both low and high risk patients.
I want to pause here and caution you about one thing: Terms like “success” and “all fared better” are based on something called time to disease progression, not overall survival. Those numbers may be coming in the future. But for now, improvements in progression free survival does not mean patients are living longer.
This is confusing, especially to us patients! Myeloma docs don’t seem too worried about it. For one thing, they expect the overall survival numbers to start moving up soon. For another thing–they don’t have multiple meyloma!
Danny, who I introduced to you in last night’s article, felt the same way. Looking over his shoulder, I noticed he wrote on his note pad: “Why does PFS not translate to OS with maintenance?”
Good question, Danny! I told him I will ask that question later–either in the Q/A at the end of the evening or by asking myeloma docs their opinions whenever I get a chance this weekend at ASH.
I didn’t have to wait that long. Before I or other audience members had a chance to ask questions, the panel began debating this very issue.
All were in favor of aggressive maintenance therapy with the exception of Dr. Rajkumar from Mayo Clinic. Dr. Moreau stressed the time to progression free survival was so impressive when using maintenance that he expected these numbers to soon translate to overall time of survival.
However, Dr. Rajkumar was more conservative. He felt more data was needed before using maintenance therapy as a standard of care. Why? The disappointing overall survival numbers.
Dr. Rajkumar talked about how his goal is always to extend a patient‘s life. He went on to say, “We (myeloma docs) shouldn’t be moving the goal-posts until we see survival numbers improving.”
Cost, risks and quality of life issues come into play here. I was pleased to hear Dr. Rajkumar stand-up to the rest of the panel. Why take these toxic, expensive drugs if they haven’t proven to lead to a longer life?
Something to ponder as you wait to read my third and final installment from tonight’s meeting on Sunday.
I will start sharing multiple myeloma data with you from the convention floor this evening here–with news about leukemia, lymphoma and other blood cancer on http://www.blogger.com/goog_689688540
Feel good and keep smiling! Pat