Cycly 6 Day 1

Dr. Paba Prada and me

Yesterday was a very good day at DFCI.  For starters, I had been planning for an annual golfing trip in February, but I found out a couple of weeks ago that they had scheduled me for a stem cell collection appointment during that week.  I was pretty bummed, but I emailed Cathy Colson last week to see if the appointment could be rescheduled.  She forward the email to my new transplant nurse, Muriel, who then spoke to Dr. Richardson.  Bottom line:  they have moved my whole schedule around to accommodate the golfing trip.  They all felt it was important for me to have my vacation.  Wow, what a great team this is!  I am psyched!

Brian and Gretchen both came in for the team meeting yesterday.  As you might expect, I had several questions and issues to discuss with Dr. Richardson.  Our meeting went better than I could have expected.  He fully answered all my questions and gave me some additional insights that have really helped my decision process.

One issue that was really bothering me was a view graph that Dr. Anderson presentated at the recent patient symposium. It had the comment that Revlimid doesn't work well as maintenance therapy for patients with my t(4;14) abnormality.  Since the ASCT clinical trial I am deciding on involves Revlimid as a maintenance therapy, I was obviously concerned.  It didn't make sense to me, as Richardson had previously told me that Rev was good for t(4;14).  When I showed him the offending statement, he was visibly taken back.  As good a friend, mentor, and colleague as Dr. Anderson is to him, he had to admit that this is just a mistake.  He probably meant to say thalidomide, not Revlimid. Whew, that's a relief.  I think he plans to have that corrected, as Celgene would not be too pleased to hear about that.

So, since Revlimid is so good for maintenance, could I get it without volunteering for the ASCT trial?  The answer is yes, but it will be provided free as part of the trial.  Under other circumstances, I would have to pay for it.  So that becomes a financial rather than a medical consideration.

We also discussed the issue of continuing the current protocol until I achieve maximum response, rather than rushing into the ASCT clinical trial at the earliest opportunity.  He agreed with that, although he also confirmed the conclusions presented in the MLN9708 trial paper at ASH that all patients so far achieved maximum response after 4 cycles.  This has tempered my expectations that my Cycle 5 results will show that I have moved from nCR to CR.  I will get those results next week.

Because of the schedule change to accommodate my vacation, they have decided to keep me on the MLN trial for an another month and collect my stem cells after Cycle 7 rather than Cycle 6, which will push it to near the end of March.  Assuming I elect to go with the new ASCT trial, I would probably elect to do the transplant immediately, given the likely event that my MLN protocol will have maxed out by then.

I then asked Richardson about the tradeoff between doing early ASCT vs. waiting until first relapse after front-line treatment with the new effective drug protocols.  He said that recent research is favoring the early transplant option and mentioned the results of a poster session presented at the recent ASH meeting.  I somehow missed this in my so-called "extensive research" of the meeting, mainly because I didn't focus on the poster sessions.  However, this is extremely relevant.  Here is a link to the abstract (No. 3069):

http://ash.confex.com/ash/2011/webprogram/Paper36073.html

In this session, Dr. Antonio Palumbo presented final data from a phase 3 study on the Progression Free Survival (PFS) of melphalan, prednisone, and Revlimid (MPR) versus high-dose melphalan (MEL200) and autologous stem cell transplant in newly diagnosed MM patients.  Here is the conclusion:

PFS was significantly prolonged in the MEL200 group compared to MPR. This benefit was maintained in the subgroup of patients with standard- or high-risk cytogenetic features...This is the first report showing a PFS advantage for ASCT in comparison  with conventional therapies including novel agents.

Note that this study also addresses my high-risk cytogenic situation, and it seems to definitely tilt the scales in favor of the early transplant option.  As of now, this seems to be the best path for me to follow.

By the end of our meeting, Dr. Richardson and I were definitely on the same page.  I feel that I am fully onboard with the treatment options and the various important factors that have to be considered.   He expressed his appreciation for my taking an active interest in my treatment and feels that we have become a good doctor-patient team, which he much prefers to a patient who just asks him what to do.  I continue to be tremendously impressed with Dr. Richardson, and I know how lucky I am to have him as my doctor.  I still have a couple of months before I have to decide on participating in the ASCT clinical trial, but I am clearly leaning in that direction.