Dr. S. Vincent Rajkumar, of Mayo Clinic in Rochester, MN, outlined what
seems to be Mayo Clinic’s current standard of care for newly-diagnosed
patients. Title: Upfront Therapy for Myeloma –
Tailoring Therapy Across the Disease Spectrum. This is a very
significant talk. With it, he presented a flow chart for determining the
best initial treatment for a newly-diagnosed patient.
He suggests first stratifying a patient’s disease according to risk as
determined by cytogenetic testing (wacky chromosomes) or by unusual
espressions of disease:
- The highest-risk patients typically live only two to three years after
diagnosis, and not much has been done to improve that. His description of
treatments for these patients is beyond the scope of this blog post.
- Medium-risk patients are those with a specific genetic translocation
(t4;14), which he says can be converted to standard-risk by the use of
Velcade. Not some other novel drug, but Velcade.
- Standard-risk patients have a wide array of available treatments
before them, and the real question for the doctor is, which should s/he
He then suggests classifying the standard risk patient once more, according
to eligibility for transplant, determined not so much by age as by health
factors such as diabetes, kidney disease, heart disease, and other
“comorbidities.” For those eligible for transplant:
- Use Revlimid/dexamethasone (Rd) or Velcade/cyclophosphamide/dex (VCd)
as an induction regimen for four cycles. To reduce the risk of treatment-
limiting neuropathy, Velcade should be given once weekly, not twice weekly,
or given subcutaneously.
- If the patient achieves a good response after four cycles, then stem
cells can be harvested and stored.
- After stem cell harvest the patient may be offered the choice of an
immediate autologous stem cell transplant (ASCT) or continued treatment
with the induction regimen.
- A transplant is an aggressive treatment approach by any measure, aiming
for a complete response but carrying significant risks, while the
continuing induction regimen can be thought of as the beginning of a
“sequential disease control approach that emphasizes quality of life as
well as survival.” In this second approach, another regimen will be tried
when the original one fails. At present there are no data showing clear
superiority of one approach over the other.
Transplant ineligible patients are usually elderly and have medical
complications. Some points:
- Rev/dex (Rd) is commonly used in the USA. The optimum duration is not
clear, but dexamethasone is usually lowered to a minimal amount or
discontinued after a year.
- Thalidomide/dex is inferior to melphalan/prednisone and should not be
used for these patients.
- Melphalan/prednisone/Revlimid (MPR) is not more effective than MP
without Revlimid, he says. However, melphalan/prednisone/thalidomide (MPT)
is superior to MP alone. An improvement is also likely if Velcade is added
to the MP combination, although neuropathy is a risk. Cyclophosphamide can
be substituted for the melphalan to reduce side effects.
- Having said all of that, he believes that Rev/dex (Rd) or
Velcade/cyclophosphamide/dex (VCD) may be the best choices for this group,
just as they are for the transplant-eligible patients. VCD is preferred
for patients with kidney issues.
Final thought: The two endpoints that matter to the patient are length of survival and quality of life.
McCormick Place in Chicago is the largest convention center in the USA, and the ASCO convention brings to it over 30,000 clinical oncologists from all over the world.