IMF Satellite Seminar Best ASH Session A new patient saw two Johns Hopkins doctors in 2008; both told her to get her affairs in order. She found the IMF, then Dr Hayman at Mayo Clinic, and she seemed strong at ASH. She’s not dying anytime soon. This session was about current standards of treatment, for practicing doctors. Dr Vincent Rajkumar, Mayo Clinic Diagnosis P With immunofixation (IFIX, IgG & IgA), serum protein electrophoresis (SPEP, M- spike), and free light chain analysis (FLC) we have the tools to detect myeloma. May need them all. P With FISH and other cytogenetic studies we can evaluate risk factors. P MGUS => 1% per year symptomatic myeloma. SMM => 10% per year. Rajkumar, continued P C.R.A.B. (Calcium, renal, anemia, bone) symptoms define active myeloma, Stage I at least. P Dr Rajkumar thinks that unexplained neuropathy can also signal active myeloma and maybe should be added to the CRAB criteria. Terms: P CR = Complete Response. No M-spike and < 5% plasma cells in bone marrow biopsy. P VGPR = Very Good Partial Response, 90% reduction in serum M-spike and < 100 mg M- protein per 24 hr urine. P PR = Partial Response, 50% reduction in serum M-spike and < 200 mg M-protein per 24 hr urine. Terms, Continued: P PD = Progressive Disease, 25% increase in M-spike over lowest value, plus worsening of at least one C.R.A.B. symptom. P SD = Stable Disease, does not meet any of the above criteria. P ASCT = Autologous Stem Cell Transplant. Dr Phillippe Moreau, Nantes France Treatment, Newly Diagnosed Patients < 65 P Audience of hematologists polled. 75% thought that ASCT is the “standard of care” for newly-diagnosed patients. P Use novel drug combos first because: < They don’t interfere with stem cell collection, < Getting CR or VGPR is important to ASCT outcome. P But if CR or VGPR achieved, proceed with ASCT anyway? Panelists were divided. Moreau, continued P Consolidation is a drug regimen after transplant or multi-drug regimen that brings patient to CR or VGPR. P Maintenance is a continuing drug regimen to maintain a good response. Dr Mario Boccadoro, Turin Italy Newly Diagnosed 65 and Older P Two thirds of all myelomiacs are 65 or older! P In USA we do not have a hard cutoff at age 65 where treatment regimen changes. P Every Boccadoro regimen contained melphalan or another alkylating agent. P In one study, the control group survived longer than the study group. !?! Dr Robert Orlowski, MD Anderson, Houston Relapsed & Refractory Patients P (1) Try something that has worked before; P (2) Then Velcade alone or with DEX; P (3) Then Velcade with Doxil; and finally P (4) Velcade & Doxil w DEX or even an alkylating agent. P He is studying carfilzomib and likes it a lot. Velcade and Peripheral Neuropathy (PN) Make the Pain Go Away P Grade 1 & 2 PN are not disabling. P Grade 3 is disabling, Grade 4 is debilitating. P Doctors are becoming more aware of quality of life issues and especially PN. P As many as 50% of patients eventually get to Grade 3 or 4 on Velcade, especially with thalidomide. Velcade & PN, continued P Three ways to reduce that, eventually: P RIGHT NOW the regimen can be reduced from twice weekly to once weekly. < Helps a LOT. < May require more cycles to get to CR or VGPR. < May be the standard of care at Mayo Rochester already. P Hopefully soon: Tanespimycin, in Phase III “clinical development,” prevents much of Velcade’s toxicity. Bristol-Myers Squibb is pushing hard - lots of hype. Velcade & PN, continued again P Hopefully sooner: Carfilzomib is claimed to be better than Velcade in every way: < Almost no PN. < May work for people whose myeloma is resistant to Velcade. < Some doctors are a little skeptical. < May be approved by end of 2010. < It is indeed named after Carla and Phil. Humanized Monoclonal Antibodies Antibodies bind to antigens to cause cell death P Antibodies are like IgG and IgA - part of the immune system. P Humanized means safe for use in humans. P Monoclonal means the antibodies are all exactly the same. P Drug names end in “-mab” Humanized MAB, continued Elotuzumab P Binds to CS1, a cell protein specific to myeloma cells. P Phase I and II trials are looking very good. P Testing with Velcade and Revlimid. P This is a very promising field, with several other MABs in the works, by several different drug companies.
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