Tuesday, July 14, 2015

Dr. Barlogie's new digs

Hello friends.  Sorry to be radio silent for a bit -- have been fighting other fires.

I will be posting my thoughts on my own decisions and next steps in a couple of days; I wanted to keep the focus on this post on Dr. Barlogie's upcoming move.

It has been rumored and discussed elsewhere, and I mentioned it here last month, but now I have been asked to formally note that Dr. Barlogie will be joining the staff of Dr. Jagannath at Mt. Sinai in New York, where he will start to see patients in September.

Bart will be bringing along a fair number of his patients with him.  He is excited to be reunited with Dr. J, with whom he worked at both MD Anderson and UAMS.  However, this is Dr. J's show -- Dr. B will be taking a less central role than the one he has had at MIRT.  He seems comfortable with this, which is important -- he has very little if anything to prove clinically at this point; his motivation to continue practicing is based primarily on his commitment to his patients and his desire to eradicate this disease, but is of course influenced by his comfort with a new role, environment and culture.

He and I discussed how Mt. Sinai, which already has an impressive team, is dedicated to building a world-leading research capability in Myeloma.  It sounds like a good place for Bart to be heading for that reason alone, leaving aside his long relationship and mutual respect with Dr. Jagannath.

As his friend, I am happy to see him land someplace where he can continue his work.  As his patient, the two key questions remain for me: (1) how much institutional support will he have from Mt. Sinai -- not just for research but for clinical activity (e.g., if I need a PET scan on a few hours' notice, will that happen?); and (2) will Bart have access to trial data including not just his current patients but all work done in the TT program.  The answers to these questions will help inform my future treatment decisions; I'm not sure the answers can be had prior to Bart's arrival in New York.

More to come on my own situation in the next few days, but in the meantime, I awake every day, conscious that I'd be in pretty dire straits -- assuming I was even still alive -- had I not been treated by Bart.  Eight years ago I had no idea, but MM was already hard at work, damaging my bones.  Seven years and 9 months ago, I was diagnosed.  Today, I'm in stringent complete remission and am MRD negative -- as good as I could possibly have hoped for.  So here's to Bart, basically -- to a new chapter and a continued record of clinical and personal success!

Thursday, June 18, 2015

A frustrating, painful and expensive waste of time

Well, the good news, I suppose, is that with the help of that lidocaine creme and a very skilled nurse my port was accessed this morning.

The long and the short of it is the bone marrow biopsy hurts a lot more than usual, and the FNAs didn't get scheduled.  It's maddening.  It's not like I didn't tell the schedulers for weeks in advance that this needed to happen.  I sent meticulous email after meticulous email.

I had dinner with Dr. Barlogie and his right arm BJ last night and she tried valiantly to move things around last minute but to no avail.  Everything is booked.

The MRI is completely unchanged from before.  No resolution of remaining lesions.  And now, no way to get at what's inside them.

I came out here for absolutely nothing other than a conversation I could have had on the phone with Drs. Barlogie and Morgan (both occurring tomorrow).

It's infuriating, actually.  And the fact that I'm in pain and the damn MRI is unchanged isn't improving my mood any.

It's not a well kept secret at this point but as I didn't want to blog about it until I had been given approval to do so, Dr. Barlogie is indeed moving to Mt. Sinai Medical Center in Manhattan in the next couple of months, where he will join the staff of Dr. Sundar Jagannath, with whom he worked thirty years ago at MD Anderson before Dr. Barlogie left there to start MIRT here at UAMS, with Dr. Jagannath joining him.  I'll post more about this when I'm not so tired, in pain and angry.

Wednesday, June 17, 2015

Frustrations continue -- a partially wasted trip

So I never was able to get the port accessed today.  I did meet with a great guy who I'm going to call out here (sorta) -- one of the physicians assistants, JA, who has been a fixture here over the last several years and is an extremely kind and attentive man.  He oversees my case so today I explained the port access issue and he managed to prescribe a numbing cream and we'll try again in the morning.

Meanwhile, though, ALL the work I did to line up a very meticulous series of tests was evidently ignored.  We know we are looking for the lesions in my spine to resolve.  The last time I was here we determined that if they hadn't resolved yet, they would stick needles in my spine to pull bone marrow out of the spots and assess what's inside them.  This, as well as meeting with Drs. Barlogie and Morgan to help determine where I show up in a few months, was the point of my visit at this time.

I explained this to two scheduling nurses plus other people in the administration along the way as we scheduled my visit many weeks ago.  I probably communicated this to five people.

Instead, we have MRI only.  No time to get any other imaging required, no time to assess the MRI before acting, no bone marrow work besides the standard biopsy.

In other words, a wasted trip.  If the lesions are healed, great -- I'll celebrate.  Got some very good wine that I've been saving for such an event.  If the lesions are not, however, then all we've done is kicked the can down the road, and these tests (and the trips themselves, by the way -- airfare and hotels are not free) are not cheap.  I could have gotten an MRI on the spine around the block from my house (metaphorically speaking).  I didn't need to fly across the country for it.

GRRRRR!!!!!

When I sat back down in the clinic this afternoon, the blood pressure was even higher than it was this morning.  JA kindly offered me something for it.  I declined, but if things don't go more smoothly tomorrow I may accept.  I don't want to die of a conniption fit whilst trying to beat cancer.

Nicolas and the No Good Very Bad Day

Well, after a long day of travel yesterday I'm in Little Rock.  It's been a pretty lousy morning.

For a number of reasons I'm under a lot of stress right now.  So the hit parade began with a blood pressure reading of 148/110.  That's a new personal best.  Not in the right direction.

On the other hand, I was on time for my appointments -- always important but particularly important today as there is a lot back-to-back.

I got to the infusion clinic, my smiling and cheery self.  A nice nurse introduced herself.  I had requested some additional tests be run (immunization titres, the full cholesterol panel, etc.) and this had to be double-checked but we got that under control after a little investigation.

The lady tried to access my port, twice.  The first time was vey painful.  The second time was even more very painful.  She couldn't draw blood.  She capitulated and found a second nurse.

The second nursed confidently jabbed me.  The needle went in.  It hurt a lot.  They were unable to draw blood.  They put heparin in, and it went in, but nothing came out.  They tried again, nothing.  They then ordered another drug (Activase? could that have been it?) and I waited while that arrived.  It got there.  They adminsitered it.  We waited the requisite 20 minutes.  They tried to draw blood.  Nothing.

I'm getting pretty irritated by this point.  I went to go to my next appointment and told the nurses I would have to come back later. 

I got to the next appointment and they couldn't find me.  It's just as well, because I'd been kept so long that I was over an hour late.  In fact, I was late for the appointment AFTER the appointment.  So I went to that appointment.  The line to check in was enormous.  And the MRI was looming in 30 minutes.  So I left.  I don't need a pulmonary test right now.  I am mindful, dear readers, that I'm only here now (versus September) because Dr. Barlogie is departing and I wanted to see him one more time and also talk with his successor as the head of the instititue here, Dr. Morgan, to determine where I would be treated.

With 30 minutes remaning before the MRI and nothing to do, I went back to the infusion clinic.  A new nurse determined (based on redness and swelling) that the needle had been inserted incorrectly and the heparin and whatever else had been pushed into the surrounding tissue rather than the blood.  That would explain the pain and swelling.

I am at this point pissed off.  I hurt, my blood pressure is through the bloody roof, I've missed two appointments and I'm no closer to having any labs done than I was before I showed up.  Well I peed in a cup so maybe they can get some value out of that but otherwise this whole morning has been a waste of time.  Worse, because a simple waste of time doesn't involve the pain I'm in.

I'm not going to allow them to access the point again unless they numb the area.  There's a simple freezing spray that everybody else in the world can figure out how to get a hold of, they can damn well get a hold of it here.  I see a physician's assistant at 1PM on the other side of the MRI tests, and he can damn well prescribe this freezing spray for me or I am cancelling the whole battery of tests and getting on a flight tomorrow wihtout doing anything more than the MRI.

Screw this.  I don't need it in my life right now.

Friday, May 29, 2015

Relapses in Total Therapy give me the willies

With my return trip to Little Rock coming up in three weeks, I've been thinking a lot about what to do and upon the continued need for follow-up.  And I've heard this week from two people in my cohort (Total Therapy 4 Lite with standard/low risk disease) who had sustained remissions of several years and recently lost them.

This is not good news, obviously.

In both cases, the patients had unresolved formerly active lesions in their spines which were the only things that troubled Barlogie.  Both had tested negative for MRD in bone marrow, which speaks to the fallibility of that test.  MM is patchy in the marrow -- what's clean in one place isn't clean in another.

So I want those lesions to go away, basically.  I'm trying to work the logistics so that my lesions (if they are still there) can be punctured with needles to assess the marrow in those particular spots.  Not sure if they are accessible or not.

Continued resolution would be a good sign, but I'm afraid until they are all gone I won't be able to rest easy.  One of the patients who just lost remission had only a single remaining non-active lesion, clean blood and marrow for five years...and is now being treated with Carfilzomib.

The projected cure fraction from Total Therapy 3 -- which is essentially the *heavy* version of Total Therapy 4 -- has been adjusted down to 50%.  That probably means about 60% of low risk patients.  I will be a lower figure than that for Total Therapy 4.  50 percent?  40 percent?  30 percent?

I have to hope I'm one of the lucky ones.

This means that ongoing imaging studies are of vital importance to this disease.  As a patient, demand them.

Tuesday, May 12, 2015

A quick update from MIRT/UAMS

I received a letter today co-authored by Drs. Morgan and Barlogie that affirmed Bart is going to continue practicing elsewhere.  This is notable only insofar as it reframes the previous communique from Arkansas.

As I said, there are politics involved here that I want no part of.  All the complexities of my upcoming decision remain relevant.  More to come as events merit!

Tuesday, May 5, 2015

Decisions, decisions!

I've heard from a growing number of people asking for my thoughts on the changing of the guard in Arkansas, and how to think about treatment.  So even though it's too early to call, I wanted to at least explain some of the thoughts I'm having on the subject.

It's pretty clear there are three options: (1) continue being seen by Dr. Barlogie wherever he ends up, (2) continue being seen at UAMS / MIRT, or (3) change to a new doctor.

Beyond that clarity, the issues become a lot more complicated.

As we parse through them, remember that in my case, I've been through Total Therapy and consequently I am best served if I am seen by somebody who understands the purpose of Total Therapy and agrees with its intent (that is, cure) and, further, I am best served if I am seen by somebody who has seen many patients that have gone through Total Therapy as the long-term follow-up for patients like myself is very different from the long-term follow-up for patients that have gone through different therapeutic regiments and/or with different intent.

As an example: recurrence in somebody treated less aggressively means the disease has popped its head back up and needs to be whacked down again with something else; recurrence in me means that I have a type of myeloma that is resistant to the entire arsenal that was used on me.  Another example: maintenance for a typical patient would likely be a relatively low-dose of Revlimid for a long period of time (some trials have it continuing indefinitely).  Maintenance for me, however, would likely not include Revlimid (as I have had three years of it and it has probably done whatever it is able to do against my disease) but might include some kind of immunotherapy -- which would be tough to start in most trials right now because I don't have any level of detectable disease so how could they monitor its progress?  A final example: at some point in the next couple of years, I will reach the point where I am at a higher risk of dying from secondary cancers brought on by the chemotherapy (e.g., leukemia) than I will be from the myeloma itself.  Somebody who has not gone through my therapy might not be monitored as aggressively for Myelodysplastic Syndrome (as an example) if the treating physician was not as familiar with this issue.

Now, I could of course be the one demanding that my doctor does X, Y and Z -- but that's an odd dynamic and one that is unlikely to be welcomed by many doctors, or by insurance companies.

With this in mind, some considerations regarding my three options, as I see them:

Staying with Dr. Barlogie.  It's easy to see why I would want to do this -- Bart has saved my life and given me a reasonable chance at being cured and dying in 35 years of something else versus already being dead.  He understand Total Therapy better than anyone (having invented it, after all) and has treated more people this way by far than anybody else in the world (hundreds of patients).

Some considerations, though:

1.  Part of what makes Dr. Barlogie so effective is that he has been a big fish in the UAMS pond.  He has the full resources of the facility behind him.  If the PET scan machines are booked for a week, he can make a call and get one opened up in a day.  If a bone marrow biopsy needs to be reviewed in less than a day, he can get that done.  Will Bart have these resources behind him where he goes next?  Will the center invest themselves in him as UAMS/MIRT has done?  Dr. Barlogie is not 45 years old...they are investing in a doctor who is in the last quarter of his working life.  Moreover, the center has to be large enough to have the infrastructure required to support what Dr. Barlogie would want to do.  And yet the center cannot already have a big Myeloma fish, so to speak -- at least not one that is counter to the Total Therapy philosophy (which means anyplace, really, other than Iowa).  Mayo, as an example, would not displace its program to embrace all that Dr. Barlogie would bring.

2.  Is Dr. Barlogie going to be able to take his patient data with him?  There is TREMENDOUS value in being able to see the sixteen (for sake of argument) people treated with Total Therapy 4 Lite who had the same genetic abnormalities that I did, and look at see how they are doing.  Without this data, Bart is still Bart -- but the data permits him to do some remarkable things both in terms of research for the future and in terms of longitudinal analysis of patient outcomes.  How many patients still have unresolved formerly active focal lesions?  How long does resolution take?  Have they lost remission? Good luck answering any of those questions without the patient data.  So can Dr. Barlogie take this data with him?  Have access to it?  Or neither?

Staying at UAMS without Dr. Barlogie.  Dr. Morgan is certainly a world-class Myeloma physician, so that's not the issue.  The biggest issue with this alternative -- assuming that UAMS will maintain some kind of access to the patient data I mentioned above, and assuming (which seems likely) that MIRT will still have significant influence in the overall UAMS ecosystem -- is that there may or may not be doctors remaining who have significant experience in treating people with Total Therapy.  If Dr. Barlogie leaves on his own and the other doctors stay, I could be seen by (as one example) Dr. Van Rhee -- he's a brilliant researcher and certainly has seen his share of Total Therapy patients.  But what if he and/or other doctors leave, either to join Bart or simply on their own -- whether its their decision or whether Dr. Morgan wants to change things over more comprehensively?  This is an open question.  As I mentioned, I'll hopefully have the opportunity to chat with Dr. Morgan during my upcoming visit to Arkansas next month and will get his full perspective on my case and, more generally, his approach to follow-up with Total Therapy patients.

Moving to another Total Therapy Doctor.  There aren't many.  But Dr. Tricot in Iowa was a senior member of Bart's team before setting out on his own first at Huntsman in Salt Lake and now in Iowa City.  He likely has similar institutional backing as Dr. Barlogie enjoyed at MIRT, and he's probably treated as many or more people with Total Therapy-like regimens as anybody practicing, other than Bart himself.  He's been very kind to lend his perspective to my case over the years at a couple of critical junctures, I have fellow patients who speak very highly of him, and I've observed in him the same kind of passion that I see in Bart.  This is a great third option -- although Iowa City is the answer to the Jeopardy question: "What location is even less convenient to get to from Los Angeles than Little Rock?"

And there's of course the issue of insurance -- none of this is free, and my insurance company needs to either already cover the center where I might choose to go, or accept that it is a center of excellence...which could be hard to do if it is not established (as could be the case, for example, if Bart went someplace without a Myeloma program).  So this is another wrinkle that will need to be navigated, if I may be permitted a mixed metaphor.

So as you can see, dear readers, there's a lot upon which to ruminate.  Fortunately, I don't need to make an opinion right now.  I've got some stressors in my life that I need to try to manage so that this stupid beast stays good and dead (I think stress is what helped bring it on in the first place, along with Aspartame from too many Diet Cokes) so making a final determination on the matter of where to be seen can wait for a couple of months.  I will make it to UAMS one more time next month, as noted, before Bart stops seeing patients there.  I've no doubt I will learn a lot more about the options above, and while I will of course be honor-bound to respect confidentiality, professionalism and apolitical neutrality, I'll post what I can here as it becomes available and relevant.

Meanwhile, hopefully those of you emailing me for my thoughts can find the above to be helpful!


Wednesday, April 8, 2015

...and another update about the transition.

I received a very nice note from Dr. Morgan yesterday, affirming that he will continue Total Therapy and does believe Total Therapy cures standard-risk patients.  That's good news for me, for the hundreds of patients treated with Total Therapy, and for newly diagnosed and yet-to-be-diagnosed low-risk patients everywhere.

I am in the process of scheduling what will be my last follow-up with Dr. Barlogie in Little Rock, and will hopefully have the opportunity to also visit with Dr. Morgan while I am there to get his perspective on my case.  Obviously, I have no interest in getting involved in any politics -- Bart is my friend, and I'm mindful that I owe him my life...and I am also mindful that I have to do whatever best serves its longevity at this juncture.  :)

It's said there are no atheists in a foxhole -- I suspect nobody who finds him or herself in such a place is terribly concerned with office politics, either.

Separately, I also had the opportunity to look online at the specifics of my MRI.  It seems there are *seven* unresolved lesions in my thoracic spine.  Specifically, here's what the MRI says, and what we're hoping will resolve.

2. MULTIPLE SCATTERED FOCAL LESIONS WHICH ARE NOT EXPANSILE INVOLVINGTHE THORACIC VERTEBRAL BODIES AT T2-T5, T9, T10 AND T12. THESE LESIONSMEASURE BETWEEN 1-2 CM WITHOUT CANAL OR CORD COMPRESSION. NO EXTRASPINAL LOCATION OF THESE LESIONS ARE SEEN. THESE FINDINGS REMAINUNCHANGED WHEN COMPARED TO THE PREVIOUS STUDY.

Importantly, few doctors (including Total Therapy disciples) believe this necessarily means anything. Dr. Tricot and Dr. Zangari (both of whom worked with Bart, the latter of whom still does) stopped doing FNAs (fine needle aspirations) of these sites after they learned that in most cases the lesion was simply filled with blood. We'll see...I do know that another seven or so lesions, most of which were significantly larger, did fill in with healthy new bone so I'm continuing to give Bart the benefit of the doubt on this and look for that resolution.

Onward!

Monday, April 6, 2015

...and a quick update

Normally I would spread this out as my last post is a lot to cover, but two important additional tidbits.

Bart is "not retiring" but will be setting up shop elsewhere.  That settles that.  More news to come as it becomes available.

Also, I will be going to see him before he departs.  That settles that.

Now to schedule it all...


A transition in Little Rock

So I received a letter in the mail on the letterhead of Dr. Gareth Morgan, whom Dr. Bart Barlogie had hand-picked as his successor at UAMS.  Bart's intent was to continue treating his existing patients and to focus on research, but to stop taking new patients (except in very rare cases like referrals from his favorite people!) and to cease work on administrative responsibilities related to running the center (which I can imagine included fundraising, hiring, firing, dealing with the local and state and federal government, etc.)

Per the letter, Bart is "retiring from Little Rock."  The letter goes on to speak of the commitment to continued excellence in patient care.

I won't beat around the bush -- I was going to write that I suspect there is more to this than meets the eye, but in fact I *know* there is more to this than meets the eye.  I'll try to limit my commentary at the moment to what impacts me directly as a patient.

I will posit, however, two factors that I believe have gone on behind the scenes.  The first is that I'm sure it was of paramount important to Bart that the treatment philosophy of UAMS -- to wit, the belief that low-risk disease can frequently be cured through Total Therapy -- continue uninterrupted.  I was on a patient panel with the esteemed Dr. Morgan a few months back and unabashedly asked, out of my own self-interest, whether or not he would continue this philosophy.  He gave an answer that was a little more equivocal than I would have liked, focusing on individualized medicine, however this is both a very legitimate perspective and one that doesn't preclude the use of Total Therapy for those whose biology indicates likely success from that treatment approach.  So I was mollified.  I suspect, however, there is a divergence of opinion.  After all, Bart is an iconoclast.  If he weren't, I'd likely be blogging from the big Myeloma Center in the Sky at this point.  But if Total Therapy, which is part of his legacy, was going to be pushed aside in favor of the same type of treatment offered at other top centers (e.g., Mayo, Dana Farber, etc.) I suspect that would be the cause of some internecine challenges.

The other factor is something that I noted in a blog post some time ago -- or perhaps it was correspondence with another patient -- that Dr. Morgan may be running the center, but it's Bart's name on the wall in the clinic and as long as his motorcycle is parked outside, his shadow looms large.  If everybody saw eye-to-eye, it would be one thing -- but if there were differences in approach, I can imagine that additional challenges would arise.  A senior lab technician receives calls from the two doctors with conflicting instructions -- who does this technician respond to first?  A patient develops a complication -- the two doctors disagree on how to treat the patient.  A clinician might be presented with two conflicting instructions...who prevails?   I'm sure things are resolved before they reach the "instruction stage" so to speak, but I can imagine tension could be created.

Importantly, all of that is supposition on my part, but I do know that Bart isn't necessarily riding off into the sunset.  But there are many questions that arise for me, personally.

If Bart *does* set up shop someplace else, will he be able to replicate the capabilities of UAMS (insofar as the things I need, most importantly MRD testing and the full battery of follow-on tests)?  Will it be covered by insurance?  How long will this take?  It seems unlikely that it will be in place by September, since his last date at UAMS is August 28th (his last day to see patients in June 30).  Should I try to be seen one more time before he leaves?  Would this even be possible?

If he sets up shop someplace else but it doesn't have the capabilities of UAMS, do I go to him?  Do I stay at UAMS?  Do I go someplace else, like Dr. Tricot?  The first and foremost interview question for any doctor for me would have to be "do you believe Total Therapy can cure standard risk Myeloma?" and if the doctor says "no" or "maybe in a few cases" I have to find a different doctor.  This is before I even get to whether or not the doctor has seen enough cases to know what he or she is doing -- and by cases, I mean people that have been treated with Total Therapy.  My complications, side-effects, and expectations in follow-up are different than patients not treated with Total Therapy (in fact, more specifically, Total Therapy 4 Lite) and require that I be seen by somebody with significant experience with those types of patients.  How many doctors would be keenly looking at residual non-avid focal lesions under MRI to see if they resolve?  (answer: not many)   I need a continuity in approach.

If he doesn't set up shop elsewhere, will any of his coterie of doctors remain at UAMS and continue to pursue the "Total Therapy can Cure" philosophy?  I've been on a panel with Dr. van Rhee before -- he is more a researcher than a clinician but he would be philosophically consistent.  Dr. Zangari has been in both Little Rock and at Huntsman with Tricot and presumably has the same philosophy, although I've not met him.  But would either of them stay at UAMS if the philosophy changes?

And then there are the logistical questions.  I can get my medical records (presumably) without any issue, but what happens to the 6 or 7 bags of stem cells I have on ice there?  Most centers don't care for stem cells the way UAMS does -- I was told my Dr. Lill at Cedars Sinai that they "didn't have room" to store bags of cells post transplant.  If I need another transplant in the future, I need those cells -- it will be hard to harvest now after all the meds I've got.  So hanging on to them is pretty damn important.  Would a new center be able to store them and care for them?  Could I keep them at UAMS if I decide to be treated elsewhere?

Then there's the issue of Bart's research -- the twenty five years of data tracking Total Therapy patients, and most specifically the 8 years of data tracking Total Therapy 4 patients.  I could sit with Bart and say "I want to see how many people had an over expressed MYC gene at presentation and were hyper diploid with 3 or more cytogenetic abnormalities under FISH and a low-risk gene array...how are they doing" and he could pull up these people and show me how many remain in remission at a given point in time, and whether or not the curve for these patients appears to plateau (meaning no remission loss after a certain point).  If Bart moves, will he have access to that data?  If he doesn't, will UAMS still use it?

As you can see, this is not a simple situation.  I'm going to have to dedicate some serious consideration to what to do in the coming weeks.

All that said...I feel fine.  I believe that Bart's protocol worked on me.  And I want to see it through until even the most skeptical doctor has to admit that I don't need to fear a recurrence.  It was six years ago right now that I was going through my first transplant.  I achieved complete remission in September, 2009.  After ten years of continuous complete remission, most doctors would admit that I'm cured.  So that's 55 months and counting down...

I had hoped Bart would keep the wheels on the cart in Little Rock until after that point in time.  But we patients don't exist in a vacuum.  Doctors move on.  And in a disease as complex as this where there is no unified position on treatment, it can pose unique challenges for the patient community.

Regardless, only one way to go: onward!

Thursday, January 15, 2015

Update from Little Rock

A mostly good-to-very-good checkup.

Highlights:

* It is FREEZING in Little Rock in January.  I never remember that and always pack as though it's going to be in the 60s.  Well it was 19 degrees last week and got as low as 30 last night.  Chilly!

* I remain in stringent complete remission.  No M protein, all markers normal except for IgM which remains low and is recovering post-transplant.  More on this below.   Most importantly, bone marrow is negative for any minimal residual disease -- the most sensitive test, of course.  I believe (though I'll need to check) that makes four random marrow sites over the past 18 months that have tested MRD negative.  A good sign, to be sure.

* The pits in my spine have not resolved -- they are unchanged from my previous scan, and number five, all sub 1cm and in the thoracic vertebrae.  I am going back on Zometa every other month to see if we can spur resolution.  Should that fail, I can likely look forward to fine needle aspirations of as many of them as can be reached with the needle (this was an issue before -- they have to go deep, evidently), and those aspirates subjected to MRD assessment.  We shall see.

* Insurance has, for the first time, been a real issue.  They rejected all scans.  I paid out of pocket for the MRI of the T-spine (ouch, to the tune of $1500).  I would have liked to see a PET and other MRIs but for now, no dice.

* I have experienced an uptick in Lambda free light chains -- they are still well within normal ranges but have increased steadily over the past year.  BB confirmed that this is likely just a sign of my immune system recovering.  Still, as FLCs increase before M protein does, it was one of those "this is probably nothing...BUT..." moments.  All that said, negative MRD trumps everything.

* I asked BB a number of questions.  Among them:  (1) Confirm that I did have cytogenetic abnormalities so that I can read the data to parse for my biology (yes, I did); (2) has my gene array returned to what looks like a patient without any MM whatsoever (work in progress); (3) is there a plateau among TT4 lite (too early to say but numbers do not appear to be plummeting, which I was worried about initially -- and in fact among those with my "subtype" (proliferation) there does appear to be a plateau; (4) should I get any other tests, like a heavy lite assay, to assess my condition or the depth of my remission (no); (5) are the rising LLCs cause for concern (likely just recovering immune system); (6) what should we make of the persistent former lesions in my spine ("why are those f*ckers still here?" he said as he looked at the MRI results...put me back on Zometa every other month, probably fins needle aspiration of remaining lesions in September to test specific marrow from those sites for MRD; (7) what is the plan for recurrence? ("I do not plan on recurrence."  me: "That's great, Bart, but I want to plan for recurrence."  BB:  "We would need to assess your biology at that time and look at whole genome sequencing and other analysis to inform our strategy at that time."

The upshot: steady as she goes, watchful and hopeful waiting, let's see if the Zometa makes those lesions disappear.

Wednesday, January 7, 2015

Does Do No Harm do harm? Food for thought.

Happy New year.  I recently joined an interesting call hosted by the MMRF for a few interested parties, where Dr. Lonial from Emory along with Dr. Daniel Auclairre of the MMRF spoke about the highlights from the ASH conference and took a few questions (some of which were from me).

One thing that struck me in hearing all these trials -- and in the philosophy of Dr. Lonial, who is quite an excellent doctor -- is that our entire medical system remains rooted in the concept of "First do no harm."  Incidentally, I was going to make a wisecrack about Hippocrates but it turns out this phrase originated not with the Hippocratic oath but with 19th century surgeon Thomas Inman.  Thank you, Wikipedia!

Anyhow, back to Myeloma.

A significant result of the "first do no harm" approach is that if you know treatment X is going to have more side effects than treatment Y, and you don't yet know if treatment X is going to be better than treatment Y, one is disinclined to pursue treatment X.  If you consider that the life-expectancy of a newly diagnosed patient is now 5+ years, that means that if we started today with a test of a lower side-effect therapy versus a higher side-effect therapy (Total Therapy qualifies, certainly) it would take much longer than 5 years before we knew enough to decide between the two types of treatments.  Conservatism will err on the the side of the treatment with fewer side effects.

This explains a lot, including the approach that Mayo and other conservative centers take with respect to treating the disease.

Interesting, at UAMS, this is turned somewhat on its head.  BB and Dr. GT, formerly at UAMS and then Huntsman and now in Iowa, have both told me on separate occasions that because they fervently believe that they approach cures a meaningful portion of patients while less aggressive approaches (to "standard risk" newly diagnosed disease) to not, that it would be a violation of medical ethics to put people into a trial that didn't offer then the same chance at a cure.  That "doing no harm" (in terms of not introducing side effects or any treatment related mortality whatsoever) in fact *does* do harm in the long run.

When you combine these two issues -- conservative centers that don't want to risk greater side effects with aggressive centers that believe it would be unethical to randomize into less effective trials -- it points out how challenging it will be to ever get a head-to-head trial to compare Total Therapy with something less aggressive.  And even if such a trial could be put together, it would take many years before results were known.

In other words: there will probably be a clear and definitive cure before there is a clear and definitive universal point of view on Total Therapy.   And until that time, patients will be required to do their own research, form their own opinion, and select a doctor whose philosophy and approach is compatible with their own belief set, comfort level, risk/reward preferences and other decision-making factors.

Some food for thought.

Sunday, December 7, 2014

Everything you Wanted to know about Transplants (new and improved!)

Hello folks.

I published the bulk of this in a post a couple of days ago.  I didn't like the screwy way it was appearing here (I wrote the original in Word and pasted it in here and the formatting made it very difficult to read despite attempts to edit it) so I'm retyping it.  At the same time, my post engendered a couple of follow-up questions which I am trying to address.  Lastly, as ever, I'm never satisfied with my work so there are a couple of little improvements in language and phrasing, including one area where my friend Suzierose encouraged me to be a bit more precise.

I do a fair amount of outreach to Myeloma patients in both the online and the "real" world, and I've noticed that time and time again the same questions are being asked about transplants.  These questions were prevalent five years ago, and they remain prevalent today.  Should I have a transplant?  Should I have it as part of initial therapy or save it for later?  Should I have one or two transplants?

It also occurs to me that doctors -- even the most brilliant ones -- may or may not be excellent at making decision the way they are made in business, or even explaining concepts.  Oftentimes research is at odds with simple, didactic explanations and clear, precise, strategic thinking.

So I'm going to try with this post to approach these transplant questions using the reasoning that I've learned and applied outside the medical field in order to provide a different perspective.  I'm not a doctor -- so please take all this with the knowledge that I'm just trying to make sense of something from a layman's point of view.  I'd like to acknowledge the help of my good friend and fellow MM warrior Suzierose, aka Myeloma Cinderella, who is no fan of transplants (for reasons that in the case of her biology are well-founded) but who has vetted the substance of what I write below.  If it made it past her, you know it's gotta at least be even-handed!  :)

I'm referring in this post to autologous transplants, not allogeneic transplants, for reasons which will be made clear.


What a Transplant Is, and What a Transplant is Not.

A transplant, first of all, is not a transplant.

It can be helpful to think of a transplant as high-dose Melphalan instead.  I'm excluding from this the rare transplant done with a different type of chemo).

Melphalan is a type of chemotherapy that has been around for quite some time.  And that's all there is, really, to a transplant: it's just a lot of chemo.  After getting high-dose Melphalan, you get your own blood back to help you recover.  That's it.  There is no "transplantation" and getting the blood back serves no purpose in killing the myeloma.  The purpose of an auto transplant is to kill Myeloma with Melphalan.  This is in contrast to an allo transplant, the purpose of which is to kill Myeloma by introducing a donor's immune system to the patient.  That is an entirely different ball of wax.

So the first concept to help you sort through this is that an auto transplant is not a transplant of anything.  I suppose you could call it a replant.  But it's best to think of it as high-dose Melphalan.


What a Tandem Transplant Is.

A tandem transplant, which is used in some aggressive protocols such as Total Therapy at UAMS/MIRT in Little Rock and at the University of Iowa under Dr. Guido Tricot, is nothing mystical or mysterious: it's just double the amount of Melphalan.  If you are doing two transplants a year apart, that's not a tandem transplant.  That would be two single transplants.  The purpose -- and value -- of a tandem transplant is just to give you twice as much of the chemo at a time when the disease hasn't yet become resistant to it.


Do Transplants Work?

Often, but not always.  It depends on what type of disease characteristics that one has.  Very simply, if one has disease that is susceptible to Melphalan, a transplant will very likely be effective.  Conversely, if one has disease that is not susceptible to Melphalan, a transplant will probably not be very effective.

Melphalan's "mechanism of action" (i.e. how it works) is changing the DNA of cells in the bone marrow and getting in the way of certain processes that cells need to survive.  This mechanism is called alkylation, and Melphalan is in a class of drugs called alkylators or alkylating agents.   Alkylation is the process of adding something disruptive to the DNA of cells in order to kill them.  Very specifically in the case of Melphalan, the drug adds an alkyl group to the guanine base of DNA at the number 7 nitrogen atom of the imizadole ring.  Aren't you glad that you don't need to know that for it to benefit you, or to understand what the role of a transplant is?  Me too!  :)

Melphalan is nasty stuff.  In fact, it's very similar to mustard gas.  So getting a high dose of Melphalan will kill a lot of cells.  It may not kill all of them, because some cells can be corrupted by the cancer into lacking certain pieces of DNA that are needed for the Melphalan to work.  And because it may not kill all the cells, it may not kill enough of them to cure the patient, or even to put the patient into a long-term remission.  Additionally, if the cells are resistant to dying, but the Melphalan tries to monkey with the DNA anyway, cells could be pushed to mutate in other directions, creating what is called "genomic chaos" which ultimately means the Myeloma could become pissed off and quite nasty.

How do we determine if one's MM is of a type that is susceptible to Melphalan?  You'll need a bone marrow biopsy for that.  A more comprehensive test is the Gene Array test performed either at UAMS/MIRT or through Signal Genetics.  This requires bone marrow.  It also translates to a "risk score" that reflects the overall risk of the Myeloma.  This can be used as a proxy for "will my MM respond to Melphalan" but it is really tailored for Total Therapy, so it's more like "will my MM respond to a combination of all the agents used in Total Therapy, including Melphalan."

Most patients (80-85%) have Myeloma of a type that will be sufficiently killed by Melphalan to have at least some response, and the response can be profound.  Within this group, perhaps half of them require a LOT of Melphalan to kill all the cells (which is why tandems can be more effective than a single transplant).  Melphalan used all by its lonesome used to get remission rates on the order of 30% (we're talking before the advent of combination therapy, discussed below).  In combination therapy, it is more effective.  Total Therapy throws the kitchen sink at the disease, with Melphalan being a centerpiece of that kitchen sink, and they achieve complete remission is about two-thirds of this 80-85% group, with almost all of the remainder returning to what is an "MGUS-like state" with very little disease (that might, in fact, not represent Myeloma but could be like the MGUS that is present in 2% of the general population).

From these observations, a couple of things can be explained.  First, when people talk about "high risk disease" they have traditionally been talking about disease that has characteristics in common with other patients whose MM cells haven't been sufficiently killed by Melphalan (or other medicines).  Second, this explains the philosophy of tandem transplants -- some people need more Melphalan than others to get the optimum effect from it in terms of killing as many MM cells as possible.


Do other types of therapy do the same thing?  


Other types of therapy can also be effective, but with rare exception they don't necessarily do the same thing.  This is important to the idea of combination therapy, which tries to kill MM by as many means as possible.

Here are a few alternatives based on therapy that I received in Total Therapy.

Traditional chemo used against newly-diagnosed Myeloma comes in several varieties:
  • Cisplatin (the "P" of "PACE" therapy, which stands for platinum) works in a way similar to Melphalan.  It also messes around with guanine DNA.  It interferes with cell division, which is slightly different from the DNA disruption that Melphalan causes.  When the cell finds out that it can't divide properly, it tries to repair itself.  When repair proves futile, the cell politely dies (a process call "apoptosis" or "programmed cell death").  But cells have a way of learning to bypass platinum over time.
  • Adriamycin, the trade name of Doxyrubicin, is the "A" in "PACE" (and Doxil is a modified version).  These drugs also interfere with DNA through a process called intercalation.  Intercalation disrupts DNA and the process through which cells replicate.
  • Cytoxan (the trade name of cyclocphosphamide, the "C" of "PACE" and the Cy of the CyBorD treatment) works in a way very similar to Melphalan's mechanism of action.
  • Etoposide is the "E" of "PACE" and works differently.  This chemotherapy screws up a different part of the cell replication process by messing around with an enzyme that is needed by DNA strands during cell duplication, causing those strands to break.  Cancer cells divide more rapidly than healthy cells and more reliant upon this enzyme than are healthy cells, so the cancer cells are disproportionately effected.
Then there are two classes of drugs that have come to be called "novel agents":
  • IMIDs (the class of drugs to which Thalidomide, Revlimid and Pomalidomide all belong) work by inhibiting cells in the bone marrow that support the Myeloma cells, and by inhibiting the growth of blood vessels that Myeloma relies upon.
  • Proteasome inhibitors (the class of drugs to which Velcade and Kyprolis belong) interfere with the process through which cells remove abnormal proteins.  When a cell has abnormal protein, it tries to remove them in order to remain healthy.  When this process is interfered with, the cell eventually realizes that it has too many abnormalities and gives up the ghost.  
Lastly, there are steroids.  Steroids suppress the immune system and kill plasma cells.  There's predinose, and Dexamethasone (trade name Decadron), aka "demon dex" which is it's 5X-stronger-brother.  If you are killing plasma cells, you are killing MM cells (which are aberrant plasma cells).  The immune system suppression helps with the side effects that would be caused by some immune reaction to other drugs (for example, the rashes that are commonly experienced with Thalidomide and Revlimid) as well as keeping the immune system from producing too much immunoglobulin, which is where the MM sits.  You don't want those cells trying to reproduce even more aggressively while we are trying to kill them off, after all.

It goes without saying that none of this is healthy.  The purpose of all this medicine, obviously, is to kill cells.  Killing cells through disrupting DNA is nastier and more chaotic than killing cells through other means.  Consequently, there are more side effects -- both near-term and long-term -- from chemotherapy that messes with DNA.  Patients must judge for themselves whether or not the additional side effects are worth the additional killing power.


Do transplants work as well as other types of therapy?  Do other types of therapy work just as well as transplants?

The answer is: we don't know yet.  We do know they work differently, and that different cells are susceptible to different things, depending on the individual characteristics of one's disease.


Consider the above diagram.  Group A, above, represents types of cells that are only sensitive to alkylators like Melphalan.  Dr. Roger Tiedemann at Princess Margaret Hospital in Toronto has shown that in vitro (that is, in a lab outside the human body) the precursor cells of Myeloma do not exhibit the cell structure required to be susceptible to novel therapies.  Dr. Tiedemann's research shows that alkylators are essential to kill these precursor cells -- they can't be touched by Velcade or Revlimid or their cousins.  Velcade and Revlimid are the equivalent of mowing a lawn full of weeds: you are getting rid of the parts of the dandelions that you can see, but the roots are still there and no amount of lawn-mowing will stop the weeds from eventually growing back.  Not everybody agrees with this research...but it is an idea to consider.

In group C, on the other hand, are cells that are sensitive to Velcade or Revlimid but are not sensitive to Melphalan.  By definition, "high risk" MM exists either in this group, or completely outside any of these circles -- and if one has a flavor of the disease that isn't sensitive to any of the weapons we use, one is said to have refractory disease and one is then reliant upon new therapies in order to extend one's life.  Back to those in group C, though: there is concern that for patients with disease that is not killed by Melphalan, that result of screwing around with that DNA can cause mutations in the MM cell that can make it more aggressive.  This explains why Total Therapy with Melphalan doesn't have long-term success for high-risk patients, and explains why UAMS has moved away from transplants for those patients.  Dr. Sagar Lonial at Emory believes this, also, to be the case -- and does not treat these "high risk" patients with transplants.

There there are those in group B -- people with disease that could be killed by multiple means.  Here, does one just use novel agents?  Or does one use novel agents plus Melphalan?  Or does one use the kitchen sink?  This requires a perspective on the concept of combination therapy, which I attempt to explain below.


The concept of combination therapy

The last piece of the puzzle we need to put this all together is the idea of combination therapy, which is a pretty simple notion: multiple medicines with different mechanisms of action work better together than they do individually, whether because they are synergistic (medicine A kills 1,000 cells, medicine B kills 1,000 cells, but the two together kill 3,000 cells because they make each other more effective) or whether because inclusion of an additional agent helps make a medicine that has become ineffective once again effective.  This second idea is an important one, because it relates to whether or not one believes in transplanting early or late, if at all.

Here's a tortured metaphor that will nonetheless suffice to illustrate the point.

Imagine the Myeloma cells are sitting around in a room that has a single door.  The medicine is a helpful monster (I'm envisioning Sully from Monsters Inc).


So the cells are sitting in the room and the monster walks in, causing a physiological reaction represented with startling verisimilitude in the above illustration.  The monster starts eating the MM cells.  The MM cells -- notwithstanding their look of slack-jawed terror in the above photo (which may have been captured by electron microscope) -- are smart.  They see the door is blocked by the monster and they start looking for another way to get out of the room.  Some of the cells will start cutting a new door in the side of the room and leave through that new door.  The idea behind using multiple agents in combination is that every potential door the MM is likely to try to cut in the walls of the room will have another type of medicine standing behind it, and ultimately one or more of those helpful monsters will eat the cell before it can figure out how to get out of the room.

The concept of so-called "triplets" (e.g., VRD, CyBorD) and "doublets" (e.g., RevDex) working better than single agents is established and pretty much universally accepted at this point.  This also explains why transplants done before the era of novel agents didn't perform as well as transplants now do when novel agents are included in the regimen.  The enhanced efficacy of drugs achieved in combination therapy creates more durable response: deeper remissions and, in some cases, even cure.

It stands to reason that clobbering MM with VDT-PACE plus Melphalan plus more VDT-PACE in combination -- all in rapid succession, no 9 months of waiting while the MM gets smart -- and then following this with three years of VRD in maintenance is just a very aggressive version of this same combination philosophy. 

The question is whether or not there are a lot of patients in group B -- the center circle in the diagram above -- who don't need all of that medicine, whether because their disease biology is particularly susceptible to novel agents alone, or whether because the newest novel agents (Kyprolis and Pomalidomide) are so powerful that they can accomplish all this on their own.  These patients need some of what Total Therapy offers. but not the whole kitchen sink.


How do we know when enough is enough?

We have imprecise measures for that at the moment.  

Since this is an individual disease, ultimately it requires an individualized approach.  Even assuming everybody was the same age, had the same overall health, had the same opinion on side-effects impacting quality of life, etc., there would still be almost as many precise flavors of myeloma as there are individuals with the disease.  

An idea that is gaining currency is the notion of treating until such time as the patient has achieved what is called "MRD negativity" -- with MRD standing for "minimum residual disease."  If you eliminate all traces of Myeloma with one course of Velcade, per this line of thinking, why bother continuing.  And that theory would be great if we could test at a sufficiently sensitive level and with consistent and comprehensive measurement.  

The problem is we can't at this time.

MRD tests come in different stripes.  Generally speaking, the most sensitive was developed originally through the "Salamanca group" (doctors in Spain) and has been adopted at several centers in the US, for example at UAMS.  This uses a highly sensitive type of test ("multi-color flow cytometry") to identify myeloma cells and can detect one myeloma cell in one million.  Is that sensitive enough?  Well, it might be.  Maybe.  Except that it looks for 6 or 7 proteins that we know MM cells express.  But what if some cells don't express those proteins?

Then there's the problem of consistency.  I've written before that MM cells sit in bone marrow in patches and that one's bone marrow is like the coat of a dalmatian.  You could pull bone marrow from one spot and looking at that one spot only, deduce that the dog was all black or all white.  

Until such time as MRD can be tested in the blood, where MM cells circulate evenly, we won't be able to definitively say someone has no trace of the disease whatsoever.    Right now, people are telling me to be confident because over a period of 18 months I have tested negative for MRD four different times.  But even that is only four spots in my marrow.

Then there's the issue of the time it takes to do an MRD test relative to when the medication is administered.  Delivering the combination therapy in rapid succession before the MM can figure out how to cut another hole in the wall, so to speak, is part of what Total Therapy seeks to do.  You're done with the second transplant long before you see the result of the first transplant, which conventional wisdom believes takes 100 days to show up.  Heck, by the time 100 days have passed from your first transplant in Total Therapy, you've had your second transplant and at least one cycle of VDT-PACE consolidation therapy, if not two.

So we aren't there yet, unfortunately, for a number of reasons.


When should one transplant?

Given what we have discussed, the decision on when to transplant can actually be framed up more simply than one might expect.

If you have disease that is not likely to respond to (or worse, be complicated by) Melphalan, then do not transplant.  If your bone marrow studies indicate that the abnormalities exhibited by your MM cells are consistent with those of other patients that have not responded to transplants, then you are in group C of that three-circle diagram.  No transplant for you.

If you have disease that is likely to respond to Melphalan, then the question becomes one of how extensive you (and your doctor) believe the combination impact and synergy between medicines is:
  • If you believe that there are real synergies / combination benefits from using medicines at the same time, then transplant early, because you have naive disease that will be confronted by as many different types of medicines as possible.  You'll kill off most of the MM that way.
  • If you believe that combination benefits don't make that much difference, then transplant late.  You'll kill off some of the MM with the first type of medicine, and when it returns, you'll kill off some of it with the second kind of medicine (Melphalan).  Personally, I think this is a half-measure, both because I believe in the synergies and because I've seen too many friends have unsatisfactory results when they use Melphalan in this way (a "salvage" treatment after other forms of medicine have proven to be ineffective).  But when all those studies talk about overall survival being the same regardless of progression-free survival being different in those that transplant early, it's because eventually, the myeloma cells figure out how to saw a new door in the room and get out.  The early transplants block two doors up-front, while the late transplant simply waits until the MM cells have started to cut a second door before blocking it.  In both cases, the Myeloma eventually cuts a third door.  :(
  • If you believe that synergies / combination benefits make a big difference, then consider Total Therapy and try to blow the MM out of the water.  The idea here is to surround the room with a lot of different monsters so that as soon as the MM tries to cut a new exit hole in the wall, it will be confronted with one of them and then Sully the happy monster from Figure A and his friends will eat all the MM cells before they can get out of the room.

Should there be one transplant or two?

In the context outlined above, the notion of a "tandem transplant" is easily considered and assessed.  There's no mystery to it: a tandem is simply twice the Melphalan at a time when the disease has not yet learned how to outwit the medicine.  You might have disease that isn't responsive to Melphalan in the first place, in which case a tandem won't do any good.  You might have disease that is responsive to Melphalan but needs more than the usual dose, in which case it will make a difference and potentially a big one -- but again, it depends on the types of medicine and how much is done after the tandems.  I know people that have done a tandem but without the VDT-PACE before and after, and they have lost remission.  So the Melphalan alone -- even in a tandem -- is not enough to cure the disease with any consistency.


How long will remission last after a transplant?

There's no way to know for sure.  For some, transplants provide only a short period of remission.  For others, it could be ten years.  It depends on (1) the degree to which one's MM is sensitive to Melphalan, and (2) the other medicines used before and after transplant.  We've collectively learned that maintenance certainly prolongs remission, if not survival.  So it stands to reason that if you have a successful transplant, you will have a longer remission period if you follow it up with maintenance. Total Therapy adds "consolidation" chemotherapy after transplants as well.  Another part of the kitchen sink.

But ultimately, the duration of remission depends on many factors.  It is hard to cite statistics, in fact, both because everybody's disease is different and because a transplant in a given trial is not the same as a transplant in another trial.  A single transplant given to somebody who has relapsed from many other medicines and done without maintenance cannot be compared against a transplant done at the onset of the disease with VRD administered at the same time -- much less compared against tandem transplants in a total therapy setting.

If you have disease that is resistant to Melphalan or not sensitive to it in the first place, remission from transplant will be hard if not impossible to achieve in the first place and it it unlikely that it would be nearly as long in duration as would be the case if you have disease that is not resistant to Melphalan and is sensitive to it.  And if you believe in synergies and combination benefits, you will have a longer remission if you are treated with multiple agents before transplant plus maintenance afterwards than you will if you are treated with fewer agents.  On the other hand, if you don't believe in synergy, you would say it doesn't matter -- but there are more and more studies that prove maintenance does make a difference, not just in PFS but in OS as well.


Where does this leave us?

If you are diagnosed when older, there's no need for a transplant as novel agents are good and getting better, and they can lead to control of the disease for quite some time -- unless you have high-risk disease, which by definition doesn't respond to a transplant either.  In any case, being cured just means living long enough to die of something else, so if you have standard risk disease and are 75 (for sake of argument) at diagnosis, even if the medicine only gives you, say, 7 years, you are dying at 82 years old.  Not bad.  I'm 46 now.  You can sign me up for that, I think.

If you are young and have disease that is unlikely to respond to Melphalan, then I would try the best novel agents you can, treating the disease aggressively in the hopes of suppressing it as long as possible.  Immunotherapy is another option, and early theories indicate that the Myeloma might never learn to outsmart it -- if that is true, it's a good thing to try at any point in your therapy, ideally up-front.  But at the time of this writing, that's all just a theory.  We will need many, many years of data before we can be confident in it working in the long-term.

If you are young and have disease that responds to Melphalan, I would hit it hard, Total Therapy style.

As I have mentioned many times, this is an individual disease: everybody's biology is different.  It is paramount that the newly diagnosed patient understand the characteristics of his or her Myeloma so that he or she can make informed decisions with his or her medical team -- and this team must include a Myeloma specialist.  The average kindly corner hematologist / oncologist does not see enough of this disease to understand its twists and turns, is not involved in research, is not aware of the newest clinical trials and the best approaches, will not anticipate the range of response to therapy, etc.  If your doctor can't read what I've written here and not only understand it but point out ten areas where I have oversimplified or don't have a full grasp of what is going on, then they shouldn't be treating you.  :)


Tuesday, December 2, 2014

The Grand Unified Theory of Transplants -- or "To Transplant or Not to Transplant"

Hello folks.

I do a fair amount of outreach in the online and real world, and I've noticed that time and time again the same questions are being asked about transplants that were asked five years ago.  Should they be done at all?  Should they be done up front or later?  Should there be one or two?  It also occurs to me that doctors -- even the most brilliant ones -- may or may not be excellent at making decisions the way they are made in business, or even explaining concepts.  So I'm going to approach this using the reasoning that I've learned and applied outside the medical field and outside research to try to provide a different perspective.  I'm not a doctor -- so please take all this with the knowledge that I'm just trying to make sense of something from a layman's point of view.  I'd like to acknowledge the help of my good friend a fellow MM warrior Suzierose, aka Myeloma Cinderella, who is no fan of transplants (for well-founded reasons) but who has vetted the substance of what I write below.

We're talking about auto transplants here, by the way, not allo transplants.


What a Transplant Is, and What a Transplant Is Not.

A transplant, first of all, is not really a transplant.

Think of a transplant as high dose Melphalan[1] instead.  Melphalan is a type of chemotherapy.  That’s it to a transplant, nothing more, nothing less: a transplant really is just a lot of chemo.  After this, you get your own blood back to help you recover.  That’s it.  There’s no “transplantation” and getting the blood back serves no purpose in killing the myeloma.  The purpose of an auto transplant is to kill Myeloma with Melphalan.  This is in contrast to an allo transplant, the purpose of which is to kill Myeloma by introducing a donor’s immune system.  That is an entirely different ball of wax.

An auto transplant is not a transplant of anything.  I suppose you could call it a replant.  But it’s best thought of as high dose Melphalan.


What a Tandem Transplant is.

It follow from the above that a tandem transplant is nothing magical – it’s just double the amount of Melphalan.  If you’re doing it spaced a year apart, it’s not a tandem transplant -- it’s two single transplants.  The purpose – and value – of a tandem is simply to give you twice as much of the chemo at a time when the disease hasn’t yet become resistant to it.


Do transplants work?

Often, but not always.  It depends on what type of disease characteristics you have: very simply, if you have disease that is susceptible to Melphalan, a transplant will very likely be effective.  If you have disease that is not susceptible to Melphalan, a transplant will probably not be very effective.

Melphalan works by changing the DNA of cells in the bone marrow and getting in the way of certain processes that cells need to survive.  This process is called alkylation.  The Melphalan adds something to the DNA of cells that kills them.[2]

This kills a lot of cells.  It may not kill all of them; it may not kill enough of them; and it might also piss off the ones that survive.  It depends on whether or not the patient has myeloma that is susceptible to this precise type of treatment.  Most patients (80-85%) have cells that will be sufficiently killed by Melphalan to have some response.   Of that group, maybe half of them require a LOT of Melphalan to kill all the cells.

However…if the patient has cells that do not respond to Melphalan, not all the cells will be killed and the process of changing the DNA could result in an outcome where the remaining cells are resistant to this or other kinds of treatment, or whereby they mutate more rapidly and/or chaotically.

From this, a couple of things can be explained.  First, when people talk about “high risk disease” they have traditionally been talking about disease that has characteristics in common with other patients whose MM cells haven’t been killed sufficiently by Melphalan (or by other medicines).  Second, this explains the role of tandem transplants – some people need more Melphalan than others to kill all the cells.  Which explains when Melphalan was used by itself got 30% remission rates, but tandems do much better than that.


Do other types of therapy do the same thing?

Other types of therapy can be very effective, but don’t necessarily do the same thing.

Here are a few alternatives based on therapy I’ve received.

Traditional chemo used against newly diagnosed Myeloma comes in several flavors:

  • Cisplatin (the “P” of “PACE” therapy, which stands for platinum) works in a similar way.  It also monkeys with the guanine DNA.  It interferes with cell division, which is slightly different than the interference from Melphalan.  When the cell finds out that it can’t divide, it tries to repair itself.  When repair proves futile, the cell politely dies.  But cells have a way of learning to bypass platinum over time.
  • Adriamycin, the trade name of Doxyrubicin, is the “A” in “PACE” therapy (and Doxil is a modified version).  These drugs also interfere with DNA through a process celled intercalation (which disrupts DNA and the process through which cells replicate).
  • Cytoxan (the trade name of Cyclophosphamide, the “C” of “PACE” and the Cy of the CyBorD treatment) works in a very similar way to Melphalan.
  • Etoposide is the “E” of “PACE” and works differently.  It screws up a different part of the cell replication process by messing around with an enzyme that is needed by DNA strands during cell duplication, and causes those strands to break.  Cancer cells divide more rapidly than healthy cells and are more reliant upon this enzyme than healthy cells, so they are disproportionately effected.

Then there are two classes of drugs that have come to be called “novel agents.”

  • IMIDs (the class of drugs that includes Thalidomide, Revlimid and Pomalidomide) work by inhibiting cells in the bone marrow that support the Myeloma cells, and by inhibiting the growth of blood vessels that Myeloma relies upon.

  • Proteasome inhibitors (which include Velcade and Kyprolis) interfere with the process through which cells remove abnormal or misfolded proteins (and thus help the cell to survive).  When this process is interfered with, the cell eventually realizes it has too many abnormalities and politely dies.

Oh, and we can’t forget steroids.  Steroids suppress the immune system and kill plasma cells.  There’s prednisone, which is not as powerful or as effective as Dexamethasone.  If you’re killing plasma cells, you’re killing MM cells (they sit in the plasma).

It goes without saying that none of this is healthy.  The purpose, obviously, is to kill cells.  Killing cells through disrupting DNA is nastier and more chaotic than killing cells through other means.  Consequently, there are more side effects – both near-term and long-term – from chemotherapy that messes with DNA.  Patients must judge for themselves whether or not the additional side effects are worth the additional killing power.


Do transplants work as well as other types of therapy?   Do other types of therapy work just as well as transplants?

The answer is we don’t know yet.  We do know they work differently. 
  

Think of it this way.  The cells in group A, above, are only sensitive to alkylators like Melphalan.  Dr. Roger Tiedemann at Princess Margaret Hospital in Toronto has shown that in vitro (that is, in a lab outside the human body) the precursor cells of Myeloma do not exhibit the cell structure required to be susceptible to novel therapies.  His research shows that alkyalytors are essential to kill these precursor cells.  In other words, these cells exist in group A and they can’t be touched by novel drugs like IMIDs and proteasome inhibitors.  Those other drugs are the equivalent of moving a lawn full of weeds -- you are getting rid of the parts of the dandelion that you see, but the roots are still there and no amount of lawn-mowing will stop the weeds from growing back.  Not everybody agrees with this research..but it’s an idea to consider.

In group C are cells that are sensitive to Velcade or Revlimid but are not sensitive to Melphalan.  By definition, “high risk” MM either exists in quadrant C here (since Melphalan doesn’t work for very long, if at all, on some disease biology) or it exists outside these circles completely and requires that new solutions be found.  There is concern that for patients with disease that is not killed by Melphalan, the results of screwing with that DNA can cause advanced mutations in the MM cell that can make it more aggressive.  This explains why Total Therapy with Melphalan doesn’t work long-term for high risk patients, and explains why UAMS has moved away from transplants for those patients, as has Dr. Lonial at Emory.

Then there are those in group B – people with disease that could be killed by multiple means.   Here, do you just use Melphalan?  Or do you just use novel agents?  Or do you use both?  This requires a perspective on the concept of synergy between medicines, which I attempt to explain below.


The concept of synergy

There’s one more piece of the puzzle before we can start putting this all together.   It’s a pretty simple notion: the idea that multiple medicines work better together than individually.  Myeloma is smart.  Permit me a crude analogy:

If the Myeloma cells are in a room with one door, think of the medicine as a helpful monster preventing the MM from leaving the room, and eating the MM cells in the room who are panicking, looking for a way out.  The cells will start looking around for other ways out of the room, and will essentially cut a new door in the side of the room and leave through that new door.  The idea behind using multiple agents is that every potential door the MM might cut in the room has another type of medicine standing behind it and ultimately one or more of those monsters eats the cell before it can get out of the room somehow.

The concept of so-called “triplets” (e.g., VRD) and “doublets” (e.g., Rev + Dex) working better than single agents is established and pretty much universally accepted at this point.  This also explains why transplants done before the era of novel agents didn’t perform as well as transplants in the era of novel agents.  Synergy from using the drugs in combination created more durable response: deeper remissions and, in some cases, even cure.

It stands to reason that clobbering MM with VDT-PACE plus Melphalan plus VRD in maintenance is an aggressive version of this same philosophy – the question is whether or not there are a lot of patients in group B, above, who don’t need all of that – whether because their disease biology is particularly susceptible to novel agents alone, or whether because the newest novel agents (Kyprolis and Pomalidomide) are so powerful they can do a great job all on their own.   They need some synergy, but not as much as VDT-PACE offers.


When should one transplant?

Given what is laid out above, the decision on when to transplant is actually a much simpler one.

First, if you have disease that is unlikely to respond (or worse) to Melphalan, do not transplant.  How do you find this out?  You’ll need advanced bone marrow studies – such as UAMS’ gene array – to tell you what chromosomal abnormalities you have and you’ll need to learn whether or not those chromosomal abnormalities are consistent with those of patients who have not responded well to transplants.  Because per the first part of this little essay, it’s not that they aren’t responding to the concept of a transplant – it’s that Melphalan doesn’t work on that type of myeloma.

If you do have disease that is responsive to Melphalan, then the question becomes one of how extensive you (and your doctor) believe the synergies between medicines are:

- If you believe that there are real synergies between medicines, then transplant early, because you have na├»ve disease that will be confronted by as many different types of medicines as possible.  You’ll kill off most of the MM that way.

- If you believe that synergies don’t really make a difference, then transplant late.   You’ll kill off some of the MM with the first type of medicine, and when it returns, you’ll kill off some of it with the second kind of medicine (Melphalan).  Personally, I think this is a half-measure – both because I believe in the synergy and because I’ve seen too many friends have unsatisfactory results when they use Melphalan in this way (a “salvage” treatment after other forms of medicine have proven to be ineffective).   But when all those studies talk about overall survival being the same regardless of progression-free survival being different in those that transplant early, it’s because eventually, the Myeloma figures out how to saw a new door in the room and get out.  The early transplants block two doors up front, the late transplant simply waits until later to block the second door.  In both cases, the Myeloma eventually cuts a third door.  : (

- If you believe that synergies make a BIG difference, then consider total therapy and try to blow the MM out of the water.  The idea here is to surround the room with a lot of medicine monsters so that as soon as the MM tries to cut a new exit hole in the wall, it will be confronted with something.

 
Should there be one transplant or two?

In the context outlined above, the notion of a “tandem transplant” is easily considered and assessed.  Again, there’s no mystery to it: it’s simply twice the Melphalan at a time when the disease has not learned how to outwit Melphalan yet.  You might have disease that isn’t responsive to Melphalan in the first place, in which case it won’t make a difference.  You might have disease that is responsive to Melphalan but needs more than then usual dose, in which case it will make a difference.  It is Arkansas’ contention that most people need more than the dose from a single transplant in order to kill the disease versus just control it.


How long does a remission from a transplant last?

It depends.  On a lot.

It’s very hard to cite statistics, both because everybody’s disease is different because a transplant is not a transplant is not a transplant.

One transplant given to somebody who has relapsed from a lot of other medicine and done without maintenance cannot be compared against a transplant done at the onset of the disease with VRD administered at the same time – much less compared against tandem transplants in a total therapy setting.

If you have disease that is resistant to Melphalan, remission from transplant will be hard if not impossible to achieve in the first place, and won’t last as long as would be the case if you have disease that is NOT resistant to Melphalan.  And among those who have disease that IS responsive to Melphalan, if you believe in synergy, you will have a longer remission if you are treated with multiple agents at the same time plus maintenance than you will if you are treated with fewer agents.  If you don’t believe in synergy, then you would say that it doesn’t matter – but there are studies proving that maintenance does make a difference.


Where does this leave us?

If you are diagnosed when older, no need for a transplant as novel agents are good and getting better and they can lead to control of the disease for some time – remember, being cured just means living long enough to die of something else.  J

If you are young and do NOT have disease that responds to Melphalan, then I would try the best novel agents you can, treating the disease aggressively in the hopes of suppressing it as long as possible.  Immunotherapy is another option.

If you are young and have disease that responds to Melphalan, I would hit it hard Total Therapy style.

Ultimately, this is an individual disease – everybody’s biology is different.  It is paramount that the newly diagnosed patient understand the characteristics of his or her Myeloma so that he or she can make informed decisions with his or her medical team…which MUST include an MM specialist.  If your doctor can’t read what I wrote here and not only understand it but point out ten areas where I drastically oversimplified, then they shouldn’t be treating you.   :)




[1]I am ignoring for the moment the rare transplant that uses Bendamustine or another agent.

[2] Very specifically, for those who have are playing along at home with the Johnny Neutron Nuclear Medicine Home game, Melphalan adds an an alkyl group to the guanine base of DNA at the number 7 nitrogen atom of the imidazole ring.