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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 1 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 4 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 5