JOHN (OC): We were given several medication options to begin the treatment and then told that I would be referred for a stem cell transplant in the next three or four months.

DR MIKHAEL: John’s case is something that we see every day in the clinic. We often see that patients get very good chemo up front, they get a stem cell transplant, they’re placed on lenalidomide maintenance, and then their disease starts to grow.¹

JOHN (OC): My medications have varied throughout the course of my treatment. Following my first transplant, I was on Revlimid^®- supported maintenance for just a little bit over four years. The plasma cells started increasing in number. It makes me nervous to see those numbers change. You begin thinking, you know, what’s happening? What’s changing in my body? And then, if there are important changes going on, what will the next steps be?

DR. MIKHAEL: When myeloma relapses, we detect it by different tests and different signs. The classic way that myeloma relapses is one of three ways. Number one, we see their light chains or their M-spike climbing up, what we sometimes call biochemical relapse.²

Number two, the patient presents with more bony involvement. Sometimes we just pick it up on x-rays, but often they come in because they’re having more bony pain or have experienced some kind of fracture.²

And thirdly, sometimes we see, because of certain chemistries in the blood, the calcium can go up, the creatinine or the kidney function can be altered, and that indicates to us that unfortunately the myeloma is growing.²

JOHN (OC): So the oncologist did or ordered another bone marrow biopsy, did a 24-hour urine collection, and lab tests to help us identify what changes had taken place within the disease itself.

DR MIKHAEL: Unfortunately, literally every myeloma patient is going to relapse at some point. Despite our great advances with new treatments and new drugs, unfortunately the disease ultimately finds a way to break through that. And so a treatment plan has to change at time of relapse.^1,3

The factors that I consider, when a patient is relapsing, I put in three categories: patient factors, disease factors, and treatment factors.

JOHN (OC): There were discussions with the oncologist and the transplant team, and my medication was changed from the Revlimid^® that I was taking to Velcade^®.

DR. MIKHAEL: One of the things we’ve learned about myeloma over time is that unfortunately the pace of the disease seems to increase with subsequent relapses.¹

What I mean by that is very often the time that people remain in remission after each subsequent therapy gets a little short, and a little bit shorter, and the disease, if you will, becomes more aggressive and hard to control.¹

One of the great advances in multiple myeloma have been novel drugs for relapse disease.¹

And for someone like John who has now been treated with standard drugs like lenalidomide and bortezomib and two stem cell transplants, unfortunately his disease will relapse again, but when it does we have a lot of new options.

JOHN (OC): Treatment processes have changed so dramatically in the last nine years that people are beginning to consider multiple myeloma as a controllable disease.

You don’t let the disease control you. You control the disease.

References:

1. Rajkumar SV. Multiple myeloma: 2016 update on diagnosis, risk-stratification, and management. Am J Hematol. 2016;91(7):719-734.
2. Referenced with permission from the NCCN Clinical Practice Guidelines In Oncology (NCCN Guidelines^®) for Multiple Myeloma. V.3.2017. © National Comprehensive Cancer Network, Inc 2017. All rights reserved. Accessed January 18, 2017. To view the most recent and complete version of the guideline, go online to www.NCCN.org.
3. Cook G, Williams C, Brown JM, et al. High-dose chemotherapy plus autologous stem-cell transplantation as consolidation therapy in patients with relapsed multiple myeloma after previous autologous stem-cell transplantation (NCRI Myeloma X Relapse [Intensive trial]): a randomized, open-label, phase 3 trial. Lancet Oncol. 2014;15(8):874-885.

Note: The NCCN Guidelines are a work in progress that may be refined as often as new significant data becomes available. The NCCN Guidelines are a statement of consensus of its authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN Guidelines is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network makes no warranties of any kind whatsoever regarding their content, use or application and disclaims any responsibility for their application or use in any way.

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