Questioning Prevailing Theory

I was having trouble. The sewing machine in front of me just wasn’t cooperating and I was getting pretty frustrated. I’d spent the last two hours trying to remove an access panel so I could get to the adjustments inside. It was a simple matter, really. Every now and then the ancient Singer sewing machine would get out of sync with itself so that whenever the machine drove its needle down, the bobbin arm would collide with it and break the needle. All it took was realigning the little gears inside and the old machine would be good to go again. I kept rubbing the screws on the access plate with the vegetable scrubber I snagged from below the sink where my wife kept them, but no matter how hard or long I rubbed the screws, they refused to come out. After failing to remove the screws with multiple attempts with the vegetable scrubber, I sighed and resorted to the screw driver I kept in my middle desk drawer. To my great surprise, the screws came right out. “Hrmmm,” I mused. “Perhaps there’s a lesson here.”

Okay, you got me. I’m fibbing to make a point:  Using the wrong tool is a great way to fail; a vegetable scrubber is not the right tool to remove screws with. (duh) But it seems to me that some oncologists take a virtual veggie scrubber to their patients because they apply rule-of-thumb generalities to treatment strategies when they should instead use the right tools for the job. And sometimes, that means no tools at all.

Conventional wisdom says that all multiple myeloma should be treated the same way. Some oncologists even champion the idea that MGUS or smoldering myeloma should be dealt with, not through watchful waiting, but through rigorous high-dose combination chemotherapy with Dexamethasone. They fail to see a difference in undeveloped monoclonal gammopathy, non-secretor, or symptomatic mutiple myeloma. A recent interview with Dr. Ola Landgren in the Myeloma Beacon demonstrates my point. The conversation centered on recent studies in Spain, and it is not the discussion I thought was noteworthy so much as Dr. Landgren’s predispositions towards multiple myeloma generally, in each of its forms. It appeared somewhat blatantly that he drew no distinction between MGUS and high-risk symptomatic myeloma and all in between.

I have questioned the concept of using Bortezomib (or subsequent analogs) in non-secretory multiple myeloma cases because the therapies are based on protein inhibition. It never made any sense to me that a protein inhibitor be used in a situation that presented no proteins. Perhaps that’s a layman’s perspective mistake, but so far, no oncologist or hematologist I’ve discussed this with has been able to defend the policy. Yet, at the same time, they will explain that all symptomatic myeloma should be treated with the same tools because that’s the rule of thumb currently embraced. When the discrepancy is pointed out, to an individual, they all shrugged and said something along the lines of “that’s how it is.”

I became interested in this subject as a result of my own case. I was treated with Bortezomib and ended up suffering severe neuropathy as a result, yet took absolutely no benefit from the treatment. The various physician’s involved in my treatment each opined that not only did the treatments do me no good, they appeared to have increased the progression of the cancer. In the end, the neuropathy resulting from that treatment set the stage for its nearly instantaneous return with the next treatment regimen tried. In other words, it took away the option of success in following treatment attempts. When Velcade was abandoned and my neuropathy allowed to wane away, subsequent treatment with Revlimid brought the neuropathy back before even a single cycle could be completed.

A part of the problem was that I’m in the  group of patients who cannot tolerate steroids. Even small doses cause red zone high blood pressure and heart arythmia. This evokes a strong possibility of stroke or other complications. As a result, steroid-less treatments with Doxorubicin, Bortezomib and Lenalidomide all take a greater toll on me physically. Steroids are used to moderate the toxic effects of chemotherapy, and so my exposure is, ergo, unmoderated and leaves me vulnerable to the full force of their side effects. In hindsight, which always presents a clearer picture, had we moved instantly to Thalidomide or Lenalidomide when Doxorubicin proved untenable, it’s likely that I would have been able to benefit from treatment, at least to some degree.

So it would appear that my case demonstrates a rather significant flaw with the concept of treating all myeloma the same way, with the same tools. This is true on two separate fronts. The first being the absence of response to treatment while experiencing the worst of side effects. The second is the apparent acceleration of my cancer evoked in the treatment attempt. These two things indicating that watchful waiting is indeed a wise approach when it comes to MGUS or smoldering, and that treatment regimens be customized to the subtype of myeloma to be treated.

As with most things in life, the one size which fits all, often fits none. It seems to me that cancer treatment shouldn’t be an exception to this sad refrain.