Supportive Care
imf hotLine coorDinators answer your Questions
The IMF Hotline 800-452-CURE (2873) is staffed by Debbie Birns, Paul Hewitt, Nancy Baxter, Missy Klepetar.
The phone lines are open Monday through Friday, 8am to 4pm (Pacific Time).
To submit your question online, please email TheIMF@myeloma.org.
I had a stem cell transplant about four
and were followed for four years. The
months ago and just got word that my
authors' two major conclusions were:
myeloma is in remission. My bone marrow
"Thalidomide is an effective mainte-
biopsy was normal and the doctor can't
nance therapy in patients with mul-
find the myeloma protein in my blood.
tiple myeloma," and "Maintenance
I had hoped to enjoy my remission, but
treatment with pamidronate does
my doctor wants me to consider taking
not decrease the incidence of bone
thalidomide as an "insurance policy" to
events."
keep the myeloma from coming back. What
is your take on maintenance therapy?
However, examining more closely the
conclusion that thalidomide is an effec-
Two caveats are in order. First, we are defin-
tive maintenance therapy, one must
ing "maintenance therapy" narrowly to signify
look at the subset of patients for whom
treatment given following stem cell transplant
Debbie Birns, Paul Hewitt, Nancy Baxter, and Missy Klepetar
this statement was true. The authors
to "maintain" the gains made with high-dose
summarized their findings as follows:
therapy. The issue of maintenance therapy
"...because responses may occur with doses of 50 to
It was true for patients who failed
following induction or "frontline" therapy is
100 mg/day, maintenance therapy with these low doses
to achieve at least a VGPR. In other
a thorny and unresolved one, and there is
should be proposed... thalidomide could benefit patients
words, thalidomide was beneficial for
simply not enough clinical trial data available
the active treatment of residual disease
to establish guidelines. Second, it is important
who do not have a very good partial response (VGPR)
( 10% residual) after transplant.
to note that even in the context of ongoing
at time of randomization, but has a limited effect among
therapy after autologous stem cell transplant,
patients already in VGPR at time of randomization.
The authors, thus, do not recommend
maintenance therapy is a controversial and
Thus, thalidomide may improve the survival by reducing
ongoing thalidomide treatment for
much-discussed topic in myeloma, and we are
patients who are already in complete
the tumor mass after high-dose therapy rather than
far from having a definitive answer.
remission (i.e. those in whom no
by a pure maintenance effect. This result also suggests
monoclonal protein can be measured).
The first and simplest statement that can be
that stopping thalidomide as soon as VGPR has been
Much more research needs to be done
made concerning maintenance therapy post
reached could be an effective strategy to reduce the
on the issue of maintenance therapy
transplant is: for patients who are in com-
side effects and to avoid thalidomide resistance at time
both post transplant and in the non-
plete remission (CR) or very good partial
of relapse."
transplant setting. Below are some of
response ( VGPR, or 90% reduction in
the areas that are under investigation:
monoclonal protein) after an autologous transplant, there are no
data to indicate that further therapy is necessary and/or beneficial.
· the role of corticosteroids added to thalidomide maintenance;
· the role of maintenance therapy in patients with high-risk myeloma;
If the response to auto transplant is less than VGPR, then we must turn
to the results of a significant clinical trial conducted by the Intergroupe
· the role of Velcade® (bortezomib), Revlimid® (lenalidomide), and
Francophone du Myelome (IFM), a large clinical trials consortium in
experimental agents that target cell-signaling cascades or surface recep-
France with a long history of expertise in autologous stem cell trans-
tors as maintenance therapy.
plantation. The trial results were published in Blood in November 2006,
We encourage all myeloma patients to discuss the pros and cons of
with Dr. Michel Attal as chief author. The article is entitled "Maintenance
maintenance therapy in their own particular case with their oncologists
therapy with thalidomide improves survival in patients with myeloma."
and to consider participating in clinical trials that will help answer these
Patients were randomized two months after stem cell transplant to receive
important questions. mt
no maintenance, pamidronate only, or thalidomide plus pamidronate,
NLB UPDATE -- continued from page 12
GASTROINTESTINAL SIDE EFFECTS -- continued from page 13
Is there one simple recommendation you can make that would
healthcare team. We understand that some patients feel embarrassed to
help patients better tend to their overall health?
talk about constipation and diarrhea. We understand that nausea and vom-
If you wouldn't want your internist treating your myeloma, why would
iting are sometimes not reported immediately because patients believe
you want your myeloma specialist treating your hypertension or diabe-
this is part of the treatment and they try to cope on their own. "I did
tes? Doctors who keep up-to-date in their area of specialty may not be
not want to bother you," they say. But we are here to help our patients,
as current in new drugs or guidelines in other areas of medicine. Many
and adequate management of side effects ensures a better outcome
patients travel long distances to see myeloma specialists but, to improve
for them. mt
or maintain coordination of their overall health, they should also have a
local internist looking after them. mt
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