Tuesday, April 8, 2014

And yet more evidence of plateau (cure) from another unrelated source...

A friend a fellow MM patient DH alerted me to an interesting article just published in an alternative means of testing for Minimal Residual Disease called Deep Gene Sequencing.  Evidently it is more sensitive than MFC tests for MRD.  The MFC test reports that I have "<.01%" (which means it cannot detect MRD with greater accuracy than 1 in 10,000 cells).  Evidently Deep Gene Sequencing is accurate to 1 in 1,000,000.   Not sure how I sign up for this!

It's not perfect, though, for the same reasons other MRD tests that rely on bone marrow are not.  MM cells are not evenly distributed throughout the bone marrow -- one could have negative bone marrow in one spot and find residual disease elsewhere.  A test needs to rely on circulating cells (i.e., in the blood).  This is still being worked on.

Since the test is imperfect, there were relapses among patients who were MRD negative -- though not among all of them.  And here is where it gets interesting:

No matter whether patients were MRD negative or not, after approximately 80 months, NOBODY EXPERIENCED RECURRENCE.   That's right, another plateau.


The full article, from the Myeloma Beacon, is here.

So in the last week, we've seen two studies -- one in Italy and this one in Spain -- demonstrate that after 8-10 years, the disease rarely if ever comes back.



Monday, April 7, 2014

More on that NIH article -- cure is out there!

A kindly if mysterious email from an address ending in .fi (Finland?) attached the NIH article for me, which I reproduce here minus the tables.

There are a few big points here.   The first is that a plateau was observed after 10 years of continuous complete remission.   The second is that MEDIAN progression free survival for someone who reached complete remission through a simply induction of VAD and one or two transplants without no novel agents was over ten years.  That means more than half of the people that reached complete remission were still in remission 10 years later -- and in that group NOT ONE relapse after 10 years.

The issue is that with VAD and Melphalan (the transplant chemo) only, the CR rate was only 19%.  That's clearly not good enough.  But in Total Therapy, the CR rate of standard risk patients is 60% -- higher if one considers trace levels of M protein to be a return to a "cure with MGUS" state (although it must be said that the study I'm about to quote did not group such persons into the CR group, and so they did not have this same outcome -- albeit they also didn't have the novel agents that Total Therapy uses).

At any rate, a plateau exists in this study.  That's great news, and certainly corroborates the claim that Arkansas has made about the disease being curable.

The study itself, with apologies for ugly formatting but I do have a day job after all.  :)




Long-Term Results in Multiple Myeloma After High-Dose Melphalan and Autologous Transplantation According to Response Categories in the Era of Old Drugs
Massimo Martino,1 Maurizio Postorino,2 Giuseppe Alberto Gallo,1 Giuseppe Messina,1 Santo Neri,6 Eugenio Piro,4 Massimo Gentile,7 Tiziana Moscato,1 Renza Monteleone,1 Roberta Fedele,1 Carla Mazzone,7 Giuseppe Console,1 Giuseppa Penna,5 Caterina Alati,3 Iolanda Donatella Vincelli,3 Giuseppe Irrera,1 Caterina Musolino,5 Francesca Ronco,3 Stefano Molica,4 Fortunato Morabito7

Abstract

We investigate the prognosis of multiple myeloma in 173 patients treated with high-dose melphalan and autologous transplantation in the era of old drugs. The relapse rate is low for patients in complete remission after 10 years of follow-up with a PFS and OS values of 58% and 70%. The achievement of depth response represents the most important prognostic factor.

Background: The aim of this study was to investigate the correlation between the long-term prognosis of multiple myeloma (MM) and the quality of response to therapy in a cohort of 173 patients treated with high-dose melphalan (HDM) and autologous transplantation in the era of old drugs. 

Patients and Methods: A total of 173 patients with de novo MM who received a transplant between 1994 and 2010 were analyzed. VAD (vincristine, doxorubicin [Adria- mycin], dexamethasone) was used as front-line regimen before auto-HPCT. The conditioning was HDM 200 mg/m2. Patients were evaluated for clinical response using the criteria from the European Group for Blood and Marrow Transplantation, modified to include near complete remission (nCR) and very good partial remission (VGPR). 

Results: The response distribution after transplantation in our series was complete remission (CR) in 33 cases (19%), nearly complete remission (nCR) in 38 cases (22%), VGPR in 30 cases (17%), partial remission (PR) in 65 cases (38%), and stable disease (SD) in 7 cases (4%). Patients were followed for 48 ` 36 months. Median overall survival (OS) was not reached for the CR group. Progression-free survival (PFS) was 122 months for CR, 55 months for nCR, 56 months for VGPR, 32 months for PR, and 22 months for SD. Significant differences in PFS and OS were found between the CR and nCR groups (P 1⁄4 .003 and P 1⁄4 .001, respectively), between the CR and VGPR groups (P 1⁄4 .002 and P 1⁄4 .001, respectively), and between the CR and PR groups (P 1⁄4 .000 and P 1⁄4 .001, respectively). Responses were clustered in 3 main categories, ie, CR, nCR þ VGPR þ PR, and SD. The respective 10-year PFS and OS values were 58% and 70% for CR, 15% and 18% for nCR þ VGPR þ PR, and 0% and 0% for SD. 

Conclusion: The achievement of depth and prolonged response represents the most important prognostic factor. The relapse rate is low for patients in CR after 10 years of follow-up, possibly signifying a cure. [emphasis mine]

Introduction


The treatment of multiple myeloma (MM) is in continuous and rapid evolution. Drugs currently used for the treatment of this disease include alkylating agents, corticosteroids, proteasome in- hibitors, immunomodulatory drugs, and anthracyclines.1 Patients who are considered potential candidates for autologous hemato- poietic progenitor cell transplantation (AHPCT) receive 2 to 4 cycles of a nonmelphalan-containing regimen and then proceed to stem cell harvest.2 For many years, VAD or pulsed high-dose dexamethasone (HDD)3 were used as frontline induction therapy, but now the strategy has changed with new agents such as immu- nomodulatory drugs and proteasome inhibitors, bortezomib in particular. Before the advent of new drugs, the complete remission (CR) rate after induction therapy was < 10%, and several trials have shown an association between depth of response to therapy and long-term outcome.4 New induction regimens offer high overall response rates, approaching levels previously noted only with AHPCT.5 Combined treatment based on novel-agent induction regimens and high-dose chemotherapy (HDC) provide further improvement in the depth of response,6,7 and for this reason, MM remains the leading indication for AHPCT worldwide,8,9 and the International Myeloma Working Group recommends that AHPCT be offered at some point during the course of treatment to a medically fit patient.10

As a contribution to the field of HDC and AHPCT in MM, we report the results of this therapeutic approach in patients coming from a regional network and treated during the era of the old drugs. We analyzed correlations between prognosis and different response categories after long-term follow-up.

Patients and Methods

A total of 173 patients with de novo MM who received AHPCT between 1994 and 2010 were analyzed. Main patient characteristics at diagnosis are summarized in Table 1. The induction chemo- therapy was performed in 6 different institutions in southern Italy. One hundred forty-six patients underwent a single transplantation and 46 patients had a tandem transplantation.
Table 1 Main Patient Characteristics at Diagnosis
VAD was used as a frontline regimen before AHPCT. The source of stem cells was peripheral blood stem cells in all cases. Stem cells were collected after cyclophosphamide mobilization at doses ranging from 3 to 4 g/m2 in association with granulocyte colony-stimulating factor 5 mg/kg. The conditioning HDC was high-dose melphalan (HDM) 200 mg/m2.

Information about response status after transplantation, evaluated simultaneously by electrophoresis (EP) and immunofixation (IF) for serum and urinary M-protein, was available for all cases. Patients were evaluated for clinical response using the criteria from the European Group for Blood and Marrow Transplantation,11 which was modified to include nearly complete remission (nCR) and very good partial remission (VGPR). Patients were divided into different groups: CR, defined as absence of a detectable M-component in serum and urine by IF in 2 measurements over 6 weeks and < 5% plasma cells in the bone marrow; nCR, defined by a negative EP result but positive detection of an M-component by IF; VGPR, defined by detection of an M-component at EP e/o IF and reduc- tion in M-component levels between 90% and 99%; partial remission (PR), defined by an M-component reduced to between 50% and 90%. The remaining patients were considered non- responders, both with progressive disease (PD) or stable disease (SD). Patients with progressive disease were excluded from analysis.

Patients were followed until death or the end of the study, and all participants were monitored by both EP and IF in serum and urine throughout follow-up. In this period, a relapse was considered a major event and it was defined as follows: in patients with CR, by recurrence of a detectable M-component on IF, even with negative EP results; in those with nCR, by a positive EP; in those with VGPR, PR, or SD by an increase of > 25% compared with the lowest M-component level previously achieved.

The evaluation of response was performed after a median time of 3.6 months (range, 3.0-6.7 months) from transplantation, and the follow-up was started at the time of response assessment and included all patients.12 Progression-free survival (PFS) was measured from the start of follow-up to the date of progression, relapse, or death; patients alive and event free were censored at the date of the last clinical control. OS was calculated from the start of follow-up to date of death or last follow-up visit.

The statistical analysis according to the different response categories was performed using SPSS software (SPSS Inc, Chicago, IL). Data are expressed as mean ` SD, survival curves were calculated according to the Kaplan-Meier method, and differences between curves were evaluated with the log-rank test. P values < .05 were considered to reflect statistical significance. Death and event rate were calculated as number of deaths (or events) per 100 patients per year.

Results

The response distribution after AHPCT in the series was 33 cases of CR (19%), 38 cases of nCR (22%), 30 cases of VGPR (17%), 65 cases of PR (38%), and 7 cases of SD (4%) (Table 2).

Patients were followed for 48 +/- 36 months. Median survival was not reached for the CR group [emphasis mine]; PFS and OS curves are reported in Figures 1 and 2, respectively. The median PFS was 122 months for patients who achieved CR [emphasis mine], 55 months for patients who achieved nCR, 56 months for patients who achieved VGPR, 32 months for patients who achieved PR,and 22 months for patients who achieved SD. The median OS decreased in parallel with PFS in the 5 response categories: 166 months (with 9% of patients deceased) for CR, 72 months (34% deceased) for nCR, 69 months (47% deceased) for VGPR, 49 months (71% deceased) for PR, and 29 months for SD.


Significant differences in PFS and OS were found between the CR and nCR groups (P 1⁄4 .003 and P 1⁄4 .001, respectively), between the CR and VGPR groups (P 1⁄4 .002 and P 1⁄4 .001, respectively), between the CR and PR groups (P 1⁄4 .000 and P 1⁄4 .001, respectively), between the CR and SD groups (P 1⁄4 .000 and P 1⁄4 .001, respectively), between the nCR and PR groups (P 1⁄4 .009 and P 1⁄4 .012, respectively), and between the VGPR and PR groups (P 1⁄4 .002 and P 1⁄4 .001, respectively). A statistically significant difference in OS was found between the nCR and VGPR groups (P 1⁄4 .04), whereas no difference was demonstrated in terms
of PFS. The median survival of both PFS (Fig. 1) and OS (Fig. 2) in patients with SD was significantly shorter compared with the other response groups (Figs. 1 and 2).

Based on these results, the responses were regrouped into 3 categories (CR, nCR þ VGPR þ PR, and SD) and an additional survival analysis was performed. As expected, a statistically signifi- cant difference was found among the 3 groups in terms of both PFS and OS. We found a plateau phase in OS after 10 years [BIG emphasis mine!]; the 10-year probability of PFS and OS values were, respectively, 58% and 70% forCR,15%and18%fornCRþVGPRþPR,and0%and0% for SD (Fig. 3).

Because a different median follow-up was revealed among groups, we normalized data calculating the event and death rate, ie, the number of events or deaths per 100 patients per year. Notably, both event (5.5% cases per year) and death (1.5% cases per year) rates of patients with CR were lower compared with patients achieving less profound responses up to roughly 1 log increase in patients with SD (Table 3); however, a 3-fold increase was demonstrated in patients with nCR or VGPR, and a one-third increase was seen in patients with PR. In particular, the death rate was 1.5% for CR cases and increased up to 10-fold in patients with nCR and in those with VGPR, up to 21% and 39% in the PR and SD groups, respectively.


The HDM approach was effective in shifting in CR 23 of 163 patients (14.1%) for whom conventional chemotherapy (CC) failed to produce CR obtained this clinical result after HDM. The clinical outcome for those patients achieving CR before or after HDM did not differ significantly.

Discussion

We report in this study the long-term results in 173 patients with MM who were treated with an induction regimen containing the older drugs and HDM with AHPCT. We found a plateau phase in OS after 10 years, with 70% in the CR group alive at 10 years. The relapse rate is low for patients in CR with > 10 years of follow-up, possibly signifying a cure [again, BIG emphasis mine]. Because this is a retrospective study, many parameters are lacking and making conclusions is difficult, and the favorable results after HDM in patients who achieved CR should be considered with caution considering the potential inclusion criteria biases of a retrospective study. Despite these limitations, our data are useful for providing insight into the selection of patients who might derive maximum benefit from intensive chemotherapy.


Unfortunately, we do not have information available on the posttransplantation therapy after relapse or disease progression, which clearly has a substantial impact on OS; however, most of these patients likely received new drugs. This information would be helpful in understanding the extent to which newer agents contributed to prolonged survival. This is a limitation of the study, but it also has to be considered that at the time HDM was proposed, the new drugs were not available for induction therapy.

The rationale to proceed to HDC with AHPCT was to increase the depth of response,13 and over the past decade this approach has been considered the standard of care for younger patients with newly diagnosed MM14-16 based on an increased rate of CR, prolonged disease-free survival,17-22 and OS17,19 compared with CC in several randomized studies. However, not all the published studies have demonstrated the superiority of AHPCT,20-22 and a systematic review and meta-analysis has shown a significant benefit with single AHPCT in terms of prolonged PFS but not of OS23 In the following years, different studies evaluated the efficacy of additional therapies after AHPCT based on a second autograft with the rationale of reducing residual disease.24-26 The tandem AHPCT approach achieved improvement in OS [ANOTHER BIG EMPHASIS mine],25 even though a survival benefit was seen mainly in those patients in whom at least a VGPR was not achieved after the first transplantation.26 Recently, a Cochrane Review compared tandem AHPCT with single AHPCT as first-line treatment in patients with symptomatic MM with respect to OS, PFS, quality of life, and treatment- or transplantation-related mortality.27 They did not consider any study to be sufficiently informative for contemporary treatment decisions concerning the question of single versus tandem AHPCT in view of inherent biases. In addition, none of the trials integrated the so-called novel agents that are now considered standard treatment for MM.28 Interest in optimizing initial therapy and conditioning regimens before AHPCT remains strong. Numerous new doublet, triplet, quadruplet, and multidrug combinations are available for initial therapy in MM,1 and it is probable that incorporation of novel agents into transplantation programs results in increased rates of immunophenotypic or molecular remissions, or both,10 compared with those reported in the recent past. Moreover, we do not have data about switching induction regimens in patients who achieve only a nCR or PR before transplantation. An appropriate HDC conditioning regimen contributes to the efficacy of AHPCT mainly through the cytoreduction effect, and the development of a more effective approach may help in improving the outcome.29

However, attainment of CR after both induction therapy and AHPCT is 1 of the strongest predictors of long-term outcomes30,31 and represents a major end point of current treatment strategies.32 Moreover, sustained CR is predictive of favorable long-term out- comes,33 and continuous efforts are being made to improve the sensitivity of methods used for CR assessment, including molecular techniques34 and immunophenotyping assays.35,36 In our series HDM was effective at producing a CR in 14.1% of patients for whom CC failed to produce a CR; these patients had an outcome similar to that of patients who underwent transplantation and achieved CR.

The results from our study demonstrate a correlation between depth of posttransplantation response and outcome in the era of the old drugs, confirming previous reports. Moreover, our analysis clearly differentiated patients achieving CR (negative on IF) from those achieving nCR (positive on IF). These data are in line with a Spanish study32 in which results from a large series of uniformly treated patients demonstrated an association between quality of response after transplantation and both event-free survival (EFS) and OS. Patients achieving CR had significantly longer EFS (median, 61 vs. 40 months) and OS (medians not reached) versus patients achieving nCR, who likewise had somewhat better outcomes compared with patients achieving PR (median EFS, 34 months vs. nCR; median OS, 61 months).

In a recent study, Martinez-Lopez et al showed that achieving CR after HDC and AHPCT is the most important prognostic factor in MM, even after long-term follow-up.37 The relapse rate was low in patients who maintained a CR after > 11 years of follow-up. [My emphasis -- another corroborating study!] In this study, the median OS for the CR category was 7.6 years.

A recent meta-analysis, including 10 prospective trials38 in MM, showed that the depth of the response to treatment in this disease, particularly CR defined by an absence of the M-component and absence of plasma cells in the bone marrow, is clearly related to a better OS and PFS, but in some trials CR and nCR and VGPR were analyzed together,17,25,39 whereas our and other authorsdata33 indicate that these posttransplantation response categories are different regarding their impact on long-term disease outcome.

The prevailing opinion is still that myeloma is an incurable disease. Nevertheless, in our cohorts, none of the patients main- taining a CR 10 years after HDC and AHPCT experienced a relapse of disease, thus suggesting that a small fraction of patients with a long-term CR can be cured. [HUGE EMPHASIS MINE].  This emphasizes the importance of response stability over time in MM33,40,41 and reinforces the idea of using maintenance treatments to avoid recurrence of the disease and to increase the response rate. However, this does not mean that additional treatment that drives more patients into CR also gives them a better prognosis. Neither is the correlation of CR-longer survival an argument for maintenance therapy. The benefit of these additional approaches has to be proved by randomized trials.
Another concern is that IF, used to assess response status after transplantation, has well-known limitations, and it is a subjective and sometimes difficult to interpret method. The introduction of more objective and sensitive methods,34,36 including imaging techniques42 to assay response, will not replace IF but could lead to a deeper evaluation of the response to treatment.

In conclusion, the achievement of depth and prolonged response after AHPCT represents the most important prognostic factor, supporting the concept that a small cure rate could also be achieved in patients treated with old drug combinations as induction and consolidated with an AHPCT. 


Author Contributions
Study concepts: MM, MP, and FM
Study design: MM, MP, and FM
Data acquisition: MM, MP, GAG, GM, SN, EP, TM, RF, GC,
GI, CA, IDV, CM, FR, SM, and FM
Quality control of data and algorithms: MM, MP, GAG,
and FM
Data analysis and interpretation: MM, MP, and FM Statistical analysis: MM and MP
Manuscript preparation: MM, MP, and FM Manuscript editing: MM, MP, and FM
Manuscript review: MM, MP, GAG, and FM

Acknowledgments
We wish to thank all the centers in southern Italy that gathered all relevant information to locate eligible patients and performed data management: Hematology and Bone Marrow Transplant Unit, Reggio Calabria (Pasquale Iacopino, Elisabetta Massara); Hema- tology Unit, Reggio Calabria (Francesco Nobile, Vincenzo Callea, Caterina Stelitano); Hematology Unit, Caserta (Antonio Abba- dessa); Hematology Unit, Papardo, Messina (Maura Brugiatelli); Hematology and Oncology Unit, Catanzaro (Maria Grazia Kropp, Rosanna Mirabelli); Hematology Unit, Catanzaro University (Francesco Tassone, Marco Rossi); Hematology Unit, Cosenza (Ernesto Vigna); and Oncology Unit, Rossano Calabro (Francesco Iuliano).

Disclosure
The authors have stated that they have no conflicts of interest. 


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Friday, April 4, 2014

New article from the NIH -- very interesting indeed! Cure?!?!?

Okay, another update quicker than I had envisioned.

The NIH published an article with long-term follow-up on patients treated with a single autologous transplant during the era of "old drugs."   This means before velcade, revlimid, thalidomide, etc.  This also means before maintenance.

The abstract of the article is here.

The last line of the article speaks volumes.

The achievement of depth and prolonged response represents the most important prognostic factor. The relapse rate is low for patients in CR after 10 years of follow-up, possibly signifying a cure.

This fully corroborates the concept of the plateau that Arkansas has spoken of and which others have denied or been skeptical about.   Now I don't have NIH access so I haven't read the full article.  I'm sure  there's more to it than just that one line.  But there is more and more evidence, and more and more doctors are admitting, that aggressive therapy can cure the disease.

Onward!

Remembering my diagnosis

Hello friends.

In an effort to (1) alert interested parties that I am still alive and kicking, (2) have a (slightly) more uplifting comment sit atop my blog, and (3) push that photo of the "madam" puppet farther down the queue so it doesn't pop up every time I reference this blog online…I thought I would cross-post something that I posted in a comment on Pat Killingsworth's blog.

Pat had discussed the moment of his diagnosis.  It's certainly a life-changing moment.  I started this blog to at least part put the lie to the idea that one replaced one's birthday with the date of one's transplant.  I hoped that would be rubbish and indeed it has been.  My life two months before my transplants wasn't very different from my life right now.

But my life is undeniably very different from how it was before transplant.  In some ways, horribly so (complications, awareness of one's mortality, the impact on career and other aspects of one's "normal life") but in some ways beautifully (a resolve to be more positive, to not be bothered by trivialities, a perspective on helping others).  Don't get me wrong, I'm not Pollyanna-ish enough to suggest I'm glad I got cancer.  But I do take what learning from it that I can.

In any case, the date of my diagnosis was a bigger life-changer than the date of my transplant, and I recall it pretty clearly.   Pat had asked for people to discuss the moment of their diagnosis.  Mine can be found elsewhere in my blog in the first pages, but I reproduce a version of it here.

Have a good weekend, all!

I had turned 40 a few months before, and I noticed a pain in my shoulder. I had always viewed — pardon me for those in the profession — chiropractors as somewhere just above witch doctors on the medical ladder. But I considered that I might need to see one and I thought the pain was simply age related.  I had no idea that it was what it turned out to be…a tumor.

I have genetically high cholesterol, and had been on Lipitor for some time. Lipitor can irritate the liver, so one generally needs bloodwork done every three months to ensure things are okay and maintain one’s prescription. I had avoided this for a year because I didn’t like needles (editor's note: did I pick the wrong disease OR WHAT?!?!?!?). When I tried to renew my prescription, my doctor told me I needed to man up and get the bloodwork done or he wouldn’t fill it.
I got my bloodwork done sometime in early October, 2008. Two days later he called me and said he wanted to do one more test. I went back in and gave more blood. The next day he called me and said that I had elevated protein in my blood and he wanted me to see a hematologist.  I remember clearly sitting at my desk (directly to my left as I type this), with a white note pad, looking out the window as I took notes on what seemed to be a very strange conversation that wasn't even threatening at the time.  
At that time, I was very naive about hematology (really, though, isn’t everybody unless they have a need to be learned about it)? I thought the protein might be a reflection of my diet, which emphasized lean protein. He gently told me he didn’t think so, and that it was most likely a condition called MGUS. He told me that there was a small chance it could also be something called Multiple Myeloma (I can see myself writing it down in my mind's eye right now -- blue ink on that white notepad).   I still wasn’t that nervous, but jokingly said “anything that ends in ‘oma is bad.” He said it was a “malignancy of the blood” and that it wasn’t as bad as leukemia or anything like that. He’s a very non-alarmist sort of guy, my primary care physician.
So I made the appointment with the recommended hematologist, and that night I spoke with my childhood best friend, who himself is a primary care physician.  My childhood best friend, unlikely my own primary care physician, is a bit more of a stress case. He told me that MGUS was “terrible” and that Myeloma was “fatal in three to five years” and that I needed to rest more, quit my job, consume 10X my daily Vitamin D, give up wine, etc. I was depressed. Possibly more about the over-the-top lifestyle changes than the diagnosis, which I still had trouble understanding could be real.
I saw the kindly Beverly Hills hematologist, who explained that my bloodwork looked fine except for the protein, and he thought it was very unlikely to be anything other than MGUS. He said they rarely saw Myeloma in someone my age, that 2% of the general population have MGUS, etc. He wanted to do a bone marrow biopsy to confirm that’s what it was. I wasn’t prepared to do that the same day, and I wanted to be given conscious sedation for it, so I scheduled it for the next day. Along with many X-rays.
The next day I went in, had the BMB and X-rays and left. I still wasn’t that concerned, buoyed by the doctor’s opinion that all the other tests looked normal. I had good amount of the “good protein” (albumin), normal B2M (which would be high in cancer), good kidney function, normal red and white and platelet counts, etc.  "Everything is pointing towards MGUS," he said.  The hematologist flat out laughed when I told him my friend said I could have 3-5 years to live. He said that was ridiculous, and I should be more concerned about crossing the street as I left the office.
Now, as it happens, my daughter (5 at the time) had recently been diagnosed with a pretty serious retinal defect that would render her with seriously impaired vision and with no current means to correct to treat it. I was hoping to join the board of the Jules Stein Eye Institute at UCLA so as to be up to date on treatment options and possibly even influence the direction of research, etc.   On the day after my bone marrow biopsy, I had a meeting with their director, a forgettable man whose first name, now that I think about it, was Bart. I never made that connection before just now — funny how the mind works.
Anyhow, *this* Bart and I had a bit of a disconnect. Here I was, a senior executive at Disney, involved in strategic planning and feeling as though I could have a material impact on the Eye Institute's future direction — and this guy’s idea of my ability to help was to drive around bad parts of LA in the “Vision Wagon” handing out pamphlets about the importance of having your eyes checked every two years.
Frankly, I was a little perturbed as I was driving home.
I was on a call with my office in my car at around 2:30PM -- on Mulholland drive as it happens, I remember that clearly as well -- speaking with a newly-minted graduate of a top business school to whom we had extended an employment offer, and I was convincing him of the merits of joining Disney, when I saw call waiting coming from the hematologist. I politely excused myself, leaving my colleague to finish the sell job.
I said a quick prayer and picked up the other call. I pulled over to the side of the road because I was concerned that traveling through the canyon road might lose coverage.  The hematologist said “I’ve received the results of your bone marrow, and it looks like you have multiple myeloma.”
I was stunned. I paused a moment and said “Does this mean I’m going to be around in five years?”
The doctor said, soberly, “that’s a very difficult question to answer.”
In my mind, I was pretty ticked off. Wasn’t this the guy who three days ago was LAUGHING at the assertion that I only had 3-5 years to live?
I was going to voice some incredulity at that flip-flop, but determined a better question was simply “is it curable?”
He said “it is TREATABLE. I’ve cleared my calendar tomorrow afternoon, you will be my only patient. Come in at 3PM and we’ll take as long as you need to discuss the options.”
And that was "the moment" of my diagnosis.
So as to make sense of the Bart coincidence to those that don’t already know, let me add a brief epilogue.
In the 3PM session the next day, I told my doctor I wanted to beat the disease and would travel anywhere in the world as needed. He told me I didn’t need to leave the US, but that there were a number of different approaches to treatment. He said that he recommended the use of dex and thalidomide, followed by one transplant. He said that there was another doctor in town named JB, who he said was opposed to transplants, because “he doesn’t think they extend life expectancy…and he’s right…but I like them because you then aren’t on any drugs and you aren’t tethered to monthly doctor visits” (I didn’t question him about maintenance at that particular visit, but he told me at my next visit that he didn’t believe in it). He told me that Mayo agreed with his approach, and that when it came back, other drugs like Revlimid and Velcade could be used.   How amazing this approach is to me now…so many things about my chosen doctor's protocol that was deemed "crazy" at the time is now the standard of care.  Maintenance.  Revlimid in newly-diagnosed disease.  Velcade in newly-diagnosed disease.  Anyhow, I continue.
My diagnosing hematologist was open-minded enough to say that there was a guy in Arkansas named Bartalogie [sic] who did two and sometimes three transplants. I said “why would somebody do more than one if it doesn’t extend life expectancy.” The doctor said “he believes it does. And it is a factory there, they only treat this disease, and he sees more of it than any other center in the world…but the results have never been duplicated outside Arkansas so there are a lot of skeptics.” He suggested I go.
I consulted with several other specialists over the next few weeks at very prominent centers across the country, before ultimately being treated by Bart Barlogie. And the rest can be found in the pages of this blog.  Suffice to say, I'm very glad to be here over five years later with no evidence of MRD at this time.
Have a good weekend, all!

Thursday, March 13, 2014

War correspondence and punch to the gut

In the wake of my revised thoughts on the curative potential of Total Therapy for a certain subset for patients, at the request of my friend and fellow blogger Pat Killingsworth, I let him cross-post my thoughts in his own blog to encourage a bit of healthy reflection.

"Healthy reflection" turned into a barrage of comments for and against Total Therapy, its medical creators and administrators, and (as always, surprisingly to me) its patients.   By the end of a three day back and forth, I was getting tired of taking it from all sides.  My doctor tortures patients.  My doctor runs a "house of horrors."  I have "drunk the kool aid."  Whatever.  All I know is I'm here, more than five years from diagnosis, in complete remission, and it's a good start no matter what comes next.

When I wrote my observations and adjusted them, I did so with the express intention of making the statement that "Total Therapy may cure people" LESS controversial.  After all, I qualified it very heavily.  Here's who it will NOT cure:  (1) people that have been heavily treated elsewhere, and (2) 15% or so percent of patients who have disease profile (you might call it "high risk" or if you are cynical you might call it "those who have biology that hasn't done well with Total Therapy in the past") for whom the therapy doesn't offer the promise of cure.   Then there are people that are sufficiently old that the difference in outcome between this and novel agents isn't worth the time or the financial, psychological and physical cost of the aggressive therapy.  Then there are the people who can't logistically pick stuff up and move to a center of excellence for the therapy, and those who aren't healthy enough to endure the treatments.   Who does this leave?  Young, otherwise healthy patients with standard-risk disease characteristics who haven't already been treated, and who can afford to take the time to move to Arkansas (or Iowa, etc.) for six months, give or take.   And those people have a better than 50/50 chance of being cured.

I had *thought* this would be relatively non-controversial, particularly as even those doctors who are reluctant to admit the disease is curable acknowledge that this "could" represent a cure for a meaningful portion of people thus treated, but we just don't know yet.

Boy was I wrong.

It's like mass hypnosis sets in.  I had three people tell me that Dr. Rajkumar said something during our Cure Talk panel on cure versus control about a "false plateau" in previous statistics for Total Therapy 2.  I listened back twice to be sure.  He didn't say anything of the sort.  In fact the only thing I've seen about a "false plateau" on Total Therapy was something *I WROTE* in questioning some statistics associated with Total Therapy 3, which have subsequently been updated.  So much for drinking the bloody Kool Aid.  I'm very circumspect about this stuff -- it doesn't serve me to pull the wool over my own eyes, for God's sake.  I'm trying to make analytically sound and well-reasoned decisions about my life or death!!

Ugh.

Anyhow, for whatever reason, Total Therapy remains a flashpoint for some patients.  I have a friend whom I respect a great deal who is adamantly opposed to it.  She is adamantly opposed to it for very sound reasons -- particularly with respect to her own biology as she is in the group that would not be likely to benefit from it.  And she believes that continued tinkering with families of agents that are highly toxic but haven't been proven to work is tantamount to banging one's head against a brick wall…which would be fine except it's the patient's head that gets bloodied.  So I *get* her objections.  It's the denial of objective statistics, deep objections to quality of life from patients who haven't undergone any of the therapy, and ultimately the borderline Godwinism with respect to BB and his methods that don't make sense to me.

One person said that I didn't need to be BB's online advocate and that he's a big boy.  I wrote that yes, indeed, he is a big boy, having done (in the words of Rajkumar) "more for Myeloma than all other Myeloma specialists put together."  BB's legacy is secure -- he doesn't need my online advocacy for Total Therapy.  Newly diagnosed patients are the ones that need my online advocacy for Total Therapy, so that they can investigate it, determine whether or not they think it is right for them, and evaluate it relative to other treatment options that they have.

It is mind-boggling to me (sorry if I already used that phrase but I'm not going back to check at this point…I'm on a roll like D-Day in Animal House right now and the fingers are flurrying across the keyboard) that some patients have such an adamant opinion about a therapy that they didn't choose that they will not only encourage others not to do it (which is of course their right and frankly something they SHOULD be doing if they truly feel it's a bad choice) but piss on those who HAVE chosen it already.

Okay, enough.  I've vented.  : )    At some point soon, Pat is going to give me his thoughts on why some patients have formed this perspective, and I will be very interested to get his ideas on this.  If they are appropriate, perhaps they'll find their way to a post here.

And now, some truth in advertising from this non-kool-aid-drinker-objective-patient-who-went-through-Total-Therapy.

When I was first diagnosed, I looked around the Internet for other people with the disease to learn how they were doing, what treatment choices they had made, etc.  It was this experience (quite depressing, since so much seemed to be about how awful and irrevocably life-changing treatment would be) that inspired me, in part, to keep this blog going beyond the simple daily updates for friends and family during the most active portion of my treatment.

There were two positive voices that I found.  One was a man named DC with whom I still interact.  He was treated by Dr. GT in a regimen quite similar to BB's and he is doing great these days some 8 years later, I think.   The other was a woman named Lois Bertoni.  I mention her name rather than her initials out of respect for her.

Lois had been treated by BB a little more than three years before I met her.  She was in complete remission, although she had to terminate the Total Therapy protocol early (if I recall correctly, she had only one transplant and no consolidation or maintenance) because she had Lupus and had difficulty tolerating the treatment.  She'd had only two cycles of VDT-PACE and one transplant.  No Revlimid because her immune system couldn't handle it due to her Lupus.  Still, she (and even BB, truth be told) seemed confident she had licked it.   One time during a follow up visit that coincided with one of my own, I took her and her husband out to a nice dinner.  Delightful people.  I last exchanged emails with her in March of 2011 and she was doing great.

The day before yesterday I was reading a blog entry elsewhere that talked about a treatment called SUPERBEAM.  This is a nasty collection of alkalyting agents that BB and UAMS use (others as well, I'm sure) for those who have already been transplanted or heavily pre-treated (a corollary of which is that they now have disease in a state that can't be cured).  I saw somebody (possibly Pat) write that this meant four agents representing the BEAM part, but it seemed to me that UAMS uses more than just four agents.  I'm not scared by M-VDT-PACE and SUPERBEAM even worried ME.  I remember one friend who has since succumbed to the disease told me they brought one of the agents out in a glass bottle for the IV because it would eat through plastic.   Anyhow, I was researching SUPERBEAM when I found an online entry from Lois.

It was dated just a couple of months after our last email exchange.

Her disease had returned.

And as it can, both with Total Therapy and other treatments, it returned in a high risk form that didn't show up in blood, only on PET scans or in bone marrow.  She went in for aggressive treatment that included SUPERBEAM and metronomic chemo called MED-PAC.  Two years later, in the fall of 2013, she passed away.  I learned because in expanding my online search for continued updates from her, I found her obituary.

A punch to the gut.

A reminder that, as Dr. GT told me, "nobody -- not even Bart -- can tell you when you've been cured."

I have statistics.  I have exponentially more sensitive tests that thankfully have come back consistently negative.  And I have confidence in my doctor.

Confidence, but not certainty.  Never certainty.

And so the search for a definitive cure goes on.

Rest in peace, Lois.  And thank you for your guidance.