Question: Dr. Chiragbhai, thank you for guiding us on how to suspect and make diagnosis of myeloma? What about treatment options? This is a bad disease, right?
Answer: Well, Multiple Myeloma is one of the diseases in Hemato-Oncology which has seen major improvements in survival, increase in treatment options, increase in convenience of therapy, in last decade. So, yes it used to be a “bad disease” and most doctors would remember very few myeloma survivors beyond 3-4 years.
However, with addition of Stem Cell Transplant, and newer medicines, now it is common to have patients surviving beyond 5 years, and many of them over 8-10 years. If you read NEJM review article in 2011, these are the two reasons given for major improvements in survival.
Que: This is really good to know, since most of my colleagues also think that myeloma patients rarely survive long and that treatments are also very difficult.
Ans: Yes, you are right, as the old treatment options were either VAD or MP. VAD was a combination of chemotherapy and steroids requiring four days of continuous infusion through a central line. This was repeated every 3 weeks. For older or weaker patients, oral melphalan and steroids was given, which rarely led to a complete response.
A lot has changed however now. Almost all patients are treated without any hospitalization now, mostly with oral medicines like lenalidomide/thalidomide or with subcutaneous injection of Bortezomib or uncommonly intravenous medicines like liposomal doxorubicin. So, the treatment is much more convenient, better tolerated, and much more effective, leads to complete response in about 30-50% patients (about 5% with old treatments).
When you add Stem Cell Transplant, the complete response increases by additional 20%, helping to clear more resistant disease. That is, about 70% of patients can now achieve complete remission (CR) compared to about 5-10% earlier. Transplant is helpful in patients with more resistant disease forms as well, such as patients with renal insufficiency/failure, patients with Amyloidosis, and others.
There is a significant improvement in supportive care as well, leading to better survival of patients who present with serious complications of myeloma such as renal failure, hypercalcemia, infections, spinal cord compression and others. Radiotherapy to spine is a very useful adjunct treatment for patients with severe pain not controlled by medical measures.
Improvements in supportive care has also allowed treatment of older patients, and patients with comorbidities e.g. we have done Transplant for patients up to age 66, and those with coronary stent, diabetes, hypertension, renal insufficiency etc. Such patients were not subjected to active treatments in past.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com