Step 6: Is treatment working?
Timeline for improvement
Be sure to have a discussion with your treating physician about the benefits and side effects of treatment, including the normal timeline for symptoms to improve, blood counts to climb, and myeloma protein levels to drop. With the use of novel agents, especially as part of 2- to 3-drug combinations, responses of 50-70% reduction in myeloma levels usually occurs within 6-8 weeks. Many times, there is an almost immediate benefit after 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 tumor burden.
Additional cycles of therapy
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 whether the treatment is working or not. It is generally agreed that 4-6 cycles of a therapy are sufficient to achieve initial response and disease control. Further therapy can be considered if there is a slower response and side effects are manageable.
Four cycles of therapy are the typical preparation for stem cell harvesting and autologous transplant. If transplant is not planned, then continued therapy 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.
Accurate response assessment is crucial. The 2016 IMWG response criteria can be used to document the exact status of the patient. If there is less than 50% reduction in the myeloma protein levels, the patient and the treating physician should carefully review and discuss the following options:
- Stop at that point: watch and wait if clinical improvement has occurred.
- Switch to an enhanced or different combination to achieve better response.
- Maintenance therapy 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? Is it crucial to achieve complete remission or is a lesser response acceptable?