The single most important
question is: Is the treatment working as expected?
Appropriate expectations are
ASH 2011 presentations that address STEP 6
- The treating physician will have explained the benefits and side effects
of treatment including the normal timeline such as when will symptoms improve,
blood counts get better and myeloma protein levels drop. If not, ask, because
mutual understanding of what is expected is the key information required.
- Many times there will be some immediate or almost immediate benefit when
treatment is started. For example, steroids such as dexamethasone and prednisone
immediately reduce inflammation and have an anti-myeloma effect, which can
reduce pain and swelling and start to reduce the myeloma tumour burden right
- In general, additional treatment benefit occurs over a period of weeks
to a few months (2-3 months).
- With the use of new novel agents, such as thalidomide, Revlimid, and
Velcade, especially as part of 2-4 drug combinations (or greater) major
response (>50-70% reduction) with reduction in myeloma levels, occurs within
- Thus, careful monitoring after the first cycle of treatment (3-4 weeks)
and/or second cycle of treatment (6-8 weeks) gives an excellent indication of
if the treatment is working or not.
- Also, in general, it is agreed that 4-6 cycles of a particular therapy
represents both an adequate trial and is sufficient to achieve initial response
and disease control.
- Further therapy can be considered if there is an adequate level of
ongoing but slower response and side effects are manageable/tolerable.
- However, 4 cycles is a typical preparation if there is intent to move
ahead with stem cell harvesting and autologous stem cell transplant. Often the
transplant will be recommended and conducted even if the response level has
been less than hoped for (for example, <50% reduction in myeloma levels).
- If transplant is not planned, then continued therapy of some sort for a
total of 12-18 months is typically considered. This would represent what is
called consolidation and/or maintenance as discussed in STEP 7.
- If there is <50% reduction in the myeloma protein levels, careful
review and discussion with the treating physician is required. Options
- Stop at that point: watch and wait if clinical improvement has
- Switch to an enhanced or different combination to achieve better
- Maintenance at reduced doses in an effort to achieve additional
response over time.
- A crucial question is dependent upon the philosophy of the physician.
Is it essential to push to achieve a certain level of response, such as
complete remission (myeloma protein gone: reduced by 100%) or is some lesser
- Accurate response assessment is crucial and the IMWG criteria can be used to
document the exact status of the patient.
- A major focus of attention in recent years has been to evaluate the
potential benefit of higher levels of response. For example, as already noted,
is it crucial to achieve CR? How much worse is VGPR (if at all)? Is VGPR
better than PR?
©2011 International Myeloma Foundation
||Suzanne Trudel, MD
Princess Margaret Hospital
May 3-6, 2011