Old is the New New

Treating Multiple Myeloma is somewhat simplistic. While there is tremendous complexity in the tailoring and performance of therapy, the idea is pretty simple: put something in the body that kills the bad cells.  The things is, we haven’t really been able to find a drug that targets the cancer only. Our therapies all affect healthy cells as well as the cancerous ones, and that’s pretty much what makes chemotherapy a rough road. The general idea of targeting is to aim at the more productive areas of cells because cancer is a form of cellular over-activity. So many people have digestive issues because the digestive system is one of high activity under normal circumstances, and so becomes a magnet for the toxic action of therapeutic chemistry. I dislike using the word “drug” to describe chemo, simply because the medications are so toxic and unable to be accurately targeted to problem cells only. The use of these therapies, depending on the people consuming them, can affect all of the body’s systems, including the nervous system. That’s why chemotherapy produces peripheral neuropathy.

The chemistry applied to Multiple Myeloma has sen no huge breakthroughs, although the press might give an alternate perspective. For the last decade or so, the chemical landscape has not significantly changed. While new drugs appear on the horizon or draw near, they are merely analogs of the existing chemistry used on the front lines of therapy. We are learning to refine these drugs, and so each of the successive candidate therapies have become easier on the body. The greatest surge for the better seems to be subcutaneous injection rather than injection into a vein. It might be said that pretty much all we have learned amounts to how deep to press the needle when treating a patient.

But even as I summarize with a semi-flip attitude, the improvements are significant in the therapies in use and coming along in trials. Anything that enhances patient comfort during chemotherapy is a welcome change indeed; the greatest issues of my own therapy were the side effects manifested by the chemistry in use, in my case Velcade and Revlimid. Atop it all was the grand disappointment of the therapy having no effect, save revitalizing the cancer and speeding its progress. This pointing out the saddest fact of all the treatments: they are only effective for about a third of the people they’re used on. Still today, treatment results can be put in three categories which are success, failure, and no effect positive or negative.  For all of the news we read about the advancements, each and all use terminology like “on the horizon” or “poised to find on the horizon.” So far, no one has been able to say cure with a straight face save a few sprightly effluent writers sensationalizing press releases from drug companies.  However, those who do see improvement through therapy are seeing a greater level of success than they did previously. Perhaps 16% better in some cases.

But the fact is that there is no one medical response to Multiple Myeloma because not only does the cancer come in an assortment of manifestations, but the individual difference from patient to patient prevent it. For instance, my reaction to Doxorubicin was a nearly fatal pair of syndromes, anaphylactic and toxic shock. The way that my body greeted the threapy was as an all out Defcon One response that came very close to killing me. Yet others take the same dosages in the same ways and don’t feel a thing. My reaction to Velcade and Revlimid were similar, but at least tolerated enough to be able to go through  months worth of cycles before the side effects became intolerable and life threatening.  When that happened, we had to stop and take stock, and this is when we saw that the illness had progressed significantly and my oncologists recommended that I abandon treatment. I simply could not handle the therapies that science had to offer. I notice that the Mayo Clinic doesn’t include Doxorubicin in their list of current Multiple Myeloma therapies, in spite of the new offerings like pomalidomide are recommended to be used in combination with Doxorubicin as one of the first combinations suggested, followed by Revlimid and Velcade..

This is the big fly in the ointment. People are different and they react with different sensitivities or tolerances. We have yet to learn enough about the body’s physical systems to be able to accurately predict which treatment methodology is most appropriate to each individual patient. As such, it can be and often is said that oncologists and hemotologists are shooting in the dark when they design a treatment regimen. As the old joke goes, that’s why they call it practicing medicine. Effecting medicine is not something we can do yet because of the mysteries of individual sensitivity and tolerance.

Stem cell transplants make up a now common part of fighting Multiple Myeloma. However, the process is a very strenuous one and frought with risk. And like some chemical treatments, some people, again like myself, are not candidates for the procedure. In my case I cannot handle steroids; this is one reason that the side effects to chemotherapy were so traumatic for me. The addition or prednisone or dexamethasone can go a long way towards helping the body attain full benefit from chemo drugs. But steroid use is critical with stem cell transplants. Like chemotherapy, there are three catagories of reaction to transplants: it worked, It worked partially, or, it didn’t work. Radiation can also be a prt of treatment, but it is a lst ditch weapon because the way it works is to kill the affected bone. When tumors (plasmacytomas) appear or deterioration of bone masses becomes critical, radiation is employed and works because it takes its ball and bat home, stopping the game. But also, bone is a necessary part of the hematological system and you can only kill so much before the ramifications becomes problematic and detrimental in its own right.

There is cause for some sense of relief though. Medical research continues and as it does we continue to learn about the way that our physical systems are similar and different, and it continues to make forays into the darkness of the unknown through experimentation. This motion inevitably takes us closer to a final, once and for all solution to the cancer that plagues us. My personal favorite of future solutions are the ones involving viruses to carry cancer killing chemistry directly to and only to cancer cells. But the real breakthrough will occur when we discover exactly what triggers cancer in the body. Then, like polio or swine flu, we can inoculate ourselves against it, or perhaps even manipulate the genes to disallow even the notion of a cellular disruption like cancer. In other words, my hopes rest in what is now science fiction. But that’s in no way a slam; In my lifetime I have seen the growth of technologies which were the total domain of science fiction turn into turn into such reality we have no patience for malfunction. Science marches on, and as it does, the ideas of reality versus fantasy wane tragically. The future holds tremendous promise, but it isn’t here yet, contrary to the assertions of some writers. However, the future always was and always will be coming. It’s on the way. And as we have learned, people have a tendency to master the problems they encounter, and in my heart I blieve that some day the writers which so irresponsibly use words like ‘cure’ and ‘around the corner’ today, will be making those as understatements eventually.

In the end I guess I’m saying that for about a third of the people with Multiple Myeloma have what appears to be a fairly bright future with the present tools we have to combat it. The other two-thirds of us, well, not so much and will react in a range from worked a little to didn’t work at all. But on the whole, we have learned a few good things. Like learning that low dose can be just as effective as large dose chemo, that subcutaneous injection is better than intravenous infusion –at least appears to reduce side effects. We have learned to combine a few different therapy chemicals and in these ways have made things a bit better. And that’s just okay by me.  But we need to be informed honestly about the situations we find ourselves in, if we are to make good choices about how we will face our individual challenges. Sometimes therapy is not the proper course, sometimes it is. We know that the treatments available have the same efficacy no matter when they’re begun.

For around a third of us, there’s great news. For the rest of us, we must put our faith in the future.  But for all of us, the treatments we take will still make us uncomfortable but not so uncomfortable as those in the past.  Our old chemical friends are the new new treatments by virtue of combination. More improvement. But lets not overstate anything to instill false hope. That does as much damage as trying to defeat all hope because in order for us to make informed decisions, our information has to be true.