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Module 3: Post-Treatment Maintenance, Relapsed or Refractory Disease, and Other Issues Related to Multiple Myeloma

Section 2: Relapse

What is the definition of relapse?

Dr. Brian Durie: It is difficult to define relapse from the plateau orremission state because relapse can be evaluated in two different ways. Thereis a technical definition of relapse, which relies upon changes in M componentlevel. The problem with this way of defining relapse is that relapse may not requireimmediate therapy. I think that a more helpful definition of relapse includesa combination of percentage change in M component level combined with some parametersindicating clinical change that warrants initiation of further therapy.

What indicates that a patient has relapsing disease?

Dr. William Bensinger: If a patient has been in a stable plateau stage for 6 to 9 months, and suddenly his or her protein level increases for example, 25% over baseline but there is no drop in hemoglobin or any evidence of hypercalcemia or renal dysfunction, what should be done? If there are no additional clinical indications pointing to the need for treatment, a physician may be justified in not initiating treatment at that time.

Dr. Robert Kyle: I agree with that. I think that a patient should not be treated strictly on the basis of an increasing M-protein. That patient, however, should be followed more closely and watched until other evidence of progression occurs.

Dr. Brian Durie: I have been evaluating the role of whole-body position-emission tomography (PET) scanning in this setting. Whole-body PET allows the physician to assess if there is focal relapse in any particular part of the body that might warrant early intervention. [View Reference]

Dr. David Roodman: I still would stress what Dr. Kyle said: The return of symptoms is really the basis for treating a patient who has relapsed. An elevated beta2-microglobulin or an elevated monoclonal protein on its own is not sufficient, in my opinion, to warrant treatment. Development of anemia, deterioration in renal function, new lytic lesions, hypercalcemia, or other indicators that have been used to treat patients at diagnosis are the real indicators that should be used for treating patients even at relapse.

You cannot simply treat the level of the monoclonal protein or the beta2-microglobulin. You have to look at the whole patient and understand that you are not going to cure these patients when they relapse. At that point, we are really talking about palliative therapy.

Dr. Robert Kyle: Right. I think it is important to also keep in mind that the patient cannot tell whether his or her M-protein is 1 g/dL or whether it is 3 to 4 g/dL. The physician certainly feels a lot better when the M-protein is 1 g/dL, but the patient doesn t know the difference.

Dr. William Bensinger: I think it is very important to remember that when patients relapse and there is an indication for treatment, these are often very appropriate patients to enroll in clinical trials designed to evaluate new agents or trials that evaluate different modalities of therapy to compare response rates in patients who are relapsing. This is how we learn what can work in this patient population.

Maintenance Therapy | Relapse | Therapies for Relapsed or Refractory Disease | Complications of Treatment for Disease | Disease Related to Multiple Myeloma

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