He suggests first stratifying a patient's disease according to risk as determined by cytogenetic testing (wacky chromosomes) or by unusual espressions of disease:
- The highest-risk patients typically live only two to three years after diagnosis, and not much has been done to improve that. His description of treatments for these patients is beyond the scope of this blog post.
- Medium-risk patients are those with a specific genetic translocation (t4;14), which he says can be converted to standard-risk by the use of Velcade. Not some other novel drug, but Velcade.
- Standard-risk patients have a wide array of available treatments before them, and the real question for the doctor is, which should s/he recommend.
- Use Revlimid/dexamethasone (Rd) or Velcade/cyclophosphamide/dex (VCd) as an induction regimen for four cycles. To reduce the risk of treatment- limiting neuropathy, Velcade should be given once weekly, not twice weekly, or given subcutaneously.
- If the patient achieves a good response after four cycles, then stem cells can be harvested and stored.
- After stem cell harvest the patient may be offered the choice of an immediate autologous stem cell transplant (ASCT) or continued treatment with the induction regimen.
- A transplant is an aggressive treatment approach by any measure, aiming for a complete response but carrying significant risks, while the continuing induction regimen can be thought of as the beginning of a "sequential disease control approach that emphasizes quality of life as well as survival." In this second approach, another regimen will be tried when the original one fails. At present there are no data showing clear superiority of one approach over the other.
- Rev/dex (Rd) is commonly used in the USA. The optimum duration is not clear, but dexamethasone is usually lowered to a minimal amount or discontinued after a year.
- Thalidomide/dex is inferior to melphalan/prednisone and should not be used for these patients.
- Melphalan/prednisone/Revlimid (MPR) is not more effective than MP without Revlimid, he says. However, melphalan/prednisone/thalidomide (MPT) is superior to MP alone. An improvement is also likely if Velcade is added to the MP combination, although neuropathy is a risk. Cyclophosphamide can be substituted for the melphalan to reduce side effects.
- Having said all of that, he believes that Rev/dex (Rd) or Velcade/cyclophosphamide/dex (VCD) may be the best choices for this group, just as they are for the transplant-eligible patients. VCD is preferred for patients with kidney issues.
McCormick Place in Chicago is the largest convention center in the USA, and the ASCO convention brings to it over 30,000 clinical oncologists from all over the world.