This week Dr. Brian G.M. Durie answers the question "Should I Be On Maintenance Therapy?" This week submitted by a member of the Waterbury, CT Support Group, Michael Tuohy!

Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.

Should I Be on Maintenance Therapy?

TRANSCRIPT:

“Hi I'm Michael Tuohy from the Waterbury, Connecticut support group I'd like to ask dr. Drury to please explain the risk versus the benefit of staying on maintenance therapy.”

“The question for this week is a very common question. "Should I be on maintenance therapy?" 

Myeloma Maintenance Therapy

Obviously, maintenance therapy is a treatment that you would take for an extended period of time after you've gone through the major treatment for myeloma to achieve a response. Should you stay on some type of a drug treatment for a year or two years or possibly indefinitely as long as the myeloma is staying in remission. The answer to this is "maybe yes, maybe no".

The first thing is to discuss it with your doctor because there are some pros and cons to the ongoing use of a maintenance drug. Maintenance therapy, things like Revlimid or Velcade sub-q, these days can definitely prolong remission, so there's no doubt about that. The open question is to what extent this type of maintenance can provide longer-term overall survival benefit.

What are some of the benefits of maintenance therapy?

We do have this type of benefit demonstrated in a couple of studies with Revlimid especially after high-dose therapy and Transplant. Also one study with Velocade, it shows some survival benefits so there is an overall benefit possibility with maintenance. It seems that this benefit is especially for some patients versus others. There's a particular benefit for patients who have not achieved a full remission with their frontline therapy or with their recent therapy. That is patients who have achieved what is called "less than a very good partial response", so the myeloma has dropped less than ninety percent. In this situation, the maintenance actually is providing some added benefit. It's reducing the amount of the myeloma and then holding it at a lower level; so this is especially helpful. This is also important in patients who have what are called "high-risk chromosome abnormalities by fish", so patients who have something called "(t 4;14)", involving four and 14 on the bone marrow chromosome tests. In this case, there's a possibility of shorter remissions and again it can be helpful to maintain any response that is achieved and so there may be a particular benefit with maintenance.

What are a few of the pros and cons of maintenance therapy?

One question that comes up is "what are the pros and cons of maintenance?" What are the possible downsides to taking maintenance and there are obvious downsides.

Obviously there's some costs and toxic side effects possibly. Some patients tolerate maintenance better than others. If you happen to tolerate maintenance well, it may be that you can stay on even indefinite maintenance. If you don't tolerate it, then maybe maintenance is not ideal for you.

Is there an increased risk of second primary cancers?

One question that has come up, "Is there an increased risk of second primary cancers?" Things like possibly breast cancer or lung cancer or other kinds of cancers; and there is an increased risk, a few percentage points up to maybe three four five six percent versus maybe a to three percent background level. So there is an increased percentage chance of developing some of these second cancers; however, you can see that risk is relatively low and is mostly way counterbalanced by the benefit of staying in remission often twice as long. A remission could last four years instead of two years. This is an important benefit and so there is an increased risk. This is the sort of thing that you need to talk to your doctor about in detail. So the answer is "maybe yes, maybe no". Talk to your doctor. See if you're one of the patients where maintenance is really recommended and could provide you with long-term benefit you.