Step 3: Is treatment necessary?
Deciding that treatment is necessary is the most pressing initial decision post-diagnosis. Since all treatments have side effects, treatment must be medically necessary. This is the case if the patient has one or more Myeloma-Defining Events or if myeloma-related damage is assessed using the CRAB criteria. Benefits of treatment must outweigh unwanted side effects. The IMWG®’s new diagnostic criteria represent a paradigm shift in the approach to myeloma and have considerable impact on the management of the disease. It is important for patients to discuss the following with their physician:
Important baseline questions:
- Day-to-day functioning: Will treatment affect the ability to perform daily activities?
- Work: Will any changes or interruptions be required?
- Age: Is this a factor in treatment selection and expected outcomes?
- Treatment side effects: How significant will these be?
- Other medical issues: Will they affect treatment choices and tolerance to treatment?
- Transplant: Is high-dose chemotherapy with transplant recommended?
- Speed of response: How rapidly will the treatment work and how will that be assessed?
- Initial and later decisions: How much needs to be decided on Day 1?
You can find answers to these questions in such IMF publications as The Patient Handbook and The Concise Review. As always, discuss options with your provider. Decisions should be individualized and will change through the course of the disease.
Control therapies aim to achieve long-term disease control (which is a reality for many patients) and maximum quality of life.
Cure therapies aim at a cure that extends beyond the so-called "functional cure," defined as complete remission lasting more than four years. Detailed testing typically reveals that patients in complete remission have small amounts of myeloma remaining (“minimal residual disease or MRD”), which can lead to relapse. Precise testing to detect MRD, followed by targeted treatment, is the foundation of the IMF’s signature Black Swan Research Initiative®.
Patients with myeloma are treated by a team
The current consensus of the International Myeloma Working Group® (IMWG) is to store stem cells for possible future need. In general, patients who are younger than 65 years are considered candidates for transplant, and many older patients are in excellent physical health and would be considered transplant-eligible. In the United States, Medicare will cover a single autologous stem cell transplant (ASCT) for eligible patients up to the age of 77 years. If you have an autologous transplant as a Medicare patient and need another autologous transplant after relapse, Medicare will cover it. Eligibility for stem cell transplant must be evaluated on an individual basis, taking into account health status, other illnesses, and treatment history.
Frontline (first therapy after diagnosis) clinical trials are available, but be sure you understand the full scope of the protocol. Depending on the trial design, you might be randomly assigned to one treatment versus another, and might be “locked in” to future randomization and treatments.
Key point: If one treatment does not work, this does not mean that another treatment cannot work extremely well and give an excellent remission.
Initial treatment options
Initial therapy can include an ASCT. Determining factors include age, medical issues besides myeloma, myeloma cell genetics, and the aggressiveness of the disease.
- For transplant patients, the latest consensus is that three-drug combination therapies are recommended as induction prior to ASCT. Possible regimens for newly diagnosed patients include VCD, VRD, VTD, or PAD. Clinical trials are also investigating the inclusion of a monoclonal antibody as part of induction therapy.
- Treatment for non-transplant candidates is determined by a patient’s age and fitness. Those who are either fragile or over the age of 75 would have a low-dose two-drug combination therapy such as Rd or Vd, or the three-drug “RVD lite.” Rd on a continuous basis is a simple option for ongoing disease control, especially for patients in this category.
- Fit patients with no non-myeloma medical issues would be treated with IMiD-based combination therapy or proteasome inhibitor-based combination therapy. As with fit transplant candidates, triple-drug therapy provides superior outcomes for fit patients.
- Fit patients with additional medical issues, such as renal problems or a risk of venous thromboembolism (VTE), would consider subcutaneous Velcade once weekly as a platform for combination therapy. Revlimid is the preferred platform therapy if neuropathy is an issue.