To bring you up to speed, yesterday I wrote this:
So as you can see, the answer to the question, “How long do I need to stay on maintenance therapy?” is a complicated one. A majority of hem/oncs would answer, “Indefinitely.” At least that’s what one needs to do in order to gain the significant time to disease progression benefit outlined in studies like the one above.
At this point, readers often ask: “How can using maintenance therapy keep my myeloma away for almost two extra years, yet in the end not help me live much longer?”
Great question! I will attempt to answer it tomorrow…
Justin’s comments from last night echoed my “million dollar question”:
That statistic (increased time to disease progression but NOT overall survival) is the thing that constantly haunts me on a daily basis. It just SHOULDN’T BE! One should follow the other, and it’s possible it is (on a patient by patient standpoint rather than the whole), but the trend does tend towards the “you’re damned if you do and damned if you don’t”….
Great point, Justin! It doesn’t make any sense. Depending on the study, maintenance therapy, using Revlimid, slows time to disease progression–also often referred to as progression free survival (PFS)–on average between 19 and 22 months. That’s an almost two year advantage over doing nothing!
So what gives? I have a theory.
While I was visiting two Minnesota support groups last month, something jumped-out at me. A majority of patients were in the midst of taking extended drug free holidays, including several patients that had recently relapsed.
What makes this so unusual is that the standard of care these days is to keep relapsed patients on meds continually. The theory is allowing advanced myeloma to gain momentum risks facing the beginning of the end; a runaway freight train that can’t be stopped once therapy is resumed.
Well, apparently Mayo Clinic and University of Minnesota docs don’t necessarily agree! One of the patients I spoke with was on a drug free holiday following his third relapse, despite not having any medical issues that might force him to stay off chemo.
This regional anomaly highlights my theory. Sue (Patient One), stays on maintenance and her myeloma is held-down for an extended period of time. But when it busts-out, it has become resistant to one of the two main drugs that could be used to knock-it-back.
Randy (Patient Two), stops using Revlimid as soon as they achieve a complete response (CR), or their myeloma becomes stable and they achieve a very good partial response (VGPR).
Randy’s myeloma returns a full year earlier than Sue’s. BUT Randy’s myeloma isn’t as drug resistant as Sue’s. So the Revlimid works for Randy, knocking his myeloma back and keeping it stable for 18 months.
In the end, both patients ends-up in the same place!
Each approach has advantages and disadvantages. While taking an extended drug free holiday might be great short-term for the body and soul, data in yesterday’s study summary pointed-out how more patients died when they weren’t on maintenance. And many patients (and docs!) aren’t confident enough to give-up the security blanket of ongoing therapy and quit cold turkey–especially in the face of such overwhelming PFS data.
Following yesterday’s post, Purdue University researcher, Gary Blau, wrote this:
Pat: I am looking to answers to this question not only for those following a transplant but for us elderly and frail types who jump right to maintenance following consolidation. I hope you will also address the issue of becoming refractory to maintenance agents. Shouldn’t we be saving their use until needed?
How about dosage regimen. It seems to me that in the past you decried the three year maintenance period at UAMS. Have you changed your perspective?
Insightful questions, Gary! I will try and answer them tomorrow.
Feel good and keep smiling! Pat