Download Initial treatment for myeloma

Some definitions
Natural course of myeloma
Initial treatment for myeloma
Dr Kerri Davidson
Remission: Absence of paraprotein in blood and myeloma
cells in bone marrow following treatment
Symptomatic
disease requiring
treatment
Relapse
Plateau:
There is still some evidence of the myeloma but
at a stable level following good response to
treatment
Relapse:
Disease progression following a previously
successful course of treatment
Relapse
Consultant Haematologist
Victoria Hospital, NHS Fife
MGUS,
asymptomatic
myeloma
1st remission
or plateau
2nd remission
or plateau
Refractory: No response to treatment whether initial
treatment or treatment at relapse
Treatment
At presentation
• 15% patients have no symptoms
• 38% emergency presentation
- Kidney failure
- Spinal cord compression/loss of movement
- Fracture
- High calcium
• Remainder have symptoms, commonly
- Backache or bone pain
- Tiredness / anaemia / increased infections
Treatment
Treatment
When does treatment start?
Many patients do not start treatment as soon
as they are diagnosed
No evidence that treating asymptomatic
disease will increase survival
Symptoms or evidence of progression
Joint decision by doctor and patient
The patient’s role
•
•
•
•
Patients can refuse treatment
Patients cannot insist on a specific treatment
Patients have a say in choice of treatment
Factors in choice of treatment
– Extent (or burden) of myeloma
– Intensity of treatment
– Effectiveness of treatment
– Patient preference
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Asymptomatic myeloma
Aims of treatment
• Diagnosis does not automatically mean that
treatment must start
Reduce number of
myeloma cells
• Good reason to wait until symptoms develop
- regular monitoring of paraprotein, blood counts,
kidney function etc.
• No symptoms but blood tests show
progression
- judgment when to start treatment
- joint decision
Successful treatment should:
Slow progression of disease and induce longest possible
remission/plateau
Achieve maximum response with the minimum of sideeffects
Reduce symptoms
and complications
Relieve pain and address other symptoms
Prevent further damage to the body
Improve quality and
length of life
What is the best treatment?
What is the best treatment?
Adding a new drug to old is better than old drugs alone
Improve and preserve quality of life for as long as possible
Intensive and non-intensive
Diagnosis
Things to consider:
Symptomatic
myeloma
100
90
80
70
60
50
40
30
20
10
0
MPT
MP
Facon
MPV
MP
San Miguel
CTDa
MP
Morgan
MPR
MP
Palumbo
• How effective is the treatment?
• What are the side-effects?
• Is there anything else about me to consider?
• Other illnesses?
• Tablets or injections – preference?
• Nature of the myeloma?
• What is approved by NICE?
Are you a candidate for
stem cell transplant
Yes
Induction treatment,
stem cell transplant
Clinical
trial
No
Non-intensive
drug treatment
2
High-dose therapy
and stem cell transplantation
Initial treatment
Velcade
Revlimid
CTD
TD
PAD
VCD
VTD
CRD
Thalidomide
Velcade
Doublets
Non-intensive
MPT
CTD
VMP
VCD
MP
CD
TD
VD
Consolidation/maintenance
Induce
remission/plateau
Consolidation
Initial treatment to kill myeloma cells
Short period of treatment aimed at
maximising response from previous
treatment
1. Stem cell mobilisation
4. Stem cell
transplant
Fatigue
Infections
Melpalan
Thalidomide
Intensive
(induction prior
to transplant)
Stem cell transplantation
2. Stem cell collection
3. High-dose melphalan
Recovery
0
Remission – current practice
No treatment, most drugs stopped
Maintenance treatment – not standard
Bisphosphonates for at least 2 years
Minimal effective pain management
14
7
Cell infusion
21
Months
days
Maintenance
Continuing on a lower dose of treatment until the myeloma progresses
Maintenance
No
maintenance
Longer until
next treatment
More options
when myeloma
progresses
Better control of
myeloma
Fewer sideeffects
100
50
Maintenance
Longer term treatment aimed at long
term disease control
20
1st
REMISSION
3
Myeloma XI Trial
Maintenance
No
Maintenance
Maintenance
Newly
diagnosed
myeloma
No
Maintenance
Cyclophosphamide
Thalidomide
Dexamethasone
Cyclophosphamide
Revlimid
Dexamethasone
Cyclophosphamide
Kyprolis
Revlimid
Dexamethasone
No
maintenance
Supportive treatment
•
•
•
•
•
•
•
Bisphosphonate to protect bones
Blood transfusions/EPO injections
Antibiotics as needed
Pain-killers as required
Radiotherapy
Kyphoplasty occasionally indicated
Psychological support
Summary
Revlimid
maintenance
This talk has covered….
• Myeloma is an individual cancer - requires a personalised
approach
• Patients should have a role in their treatment plan important to discuss goals and perceptions
• Various treatment combinations are effective and generally
well tolerated
When treatment starts
What treatment aims to do
• But, it remains a difficult and challenging disease
• More research required to understand and develop better
treatments and better ways of using existing treatments
What affects the choice of treatment
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MUK resources
Take home messages
MUK resources
• Treatment may not start at diagnosis
Newly Diagnosed Pack
• Infopack for newly diagnosed patients
Myeloma – an introduction
• Myeloma – An introduction
Myeloma – your essential guide
• Myeloma – Your Essential Guide
Myeloma TV
• Myeloma TV
Infoline
• Medical animations (including The Origin of the
Myeloma Cell, The Effect of Myeloma on the Bone
Marrow , High-dose Therapy and Autologous Stem
Cell Transplantation)
• The aim of treatment is to prolong life,
prevent myeloma damaging the body and
achieve best quality of life
• Doctors and patients work together to decide
when treatment should start and what it
should be
** please visit the Myeloma UK Patient Information
stand in the foyer area for further information
• Infoline
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