Clinical Insights Education Program – The Multiple Myeloma Research Foundation (MMRF) is sponsoring an education program about multiple myeloma clinical insights. The event will be held on September 8 in St. Louis. Myeloma experts Drs. Ravi Vij, Todd Zimmerman, Keith Stockerl-Goldstein, Shaji Kumar, and David Vesole will speak about the latest advances in frontline therapy, stem cell transplants, relapsed and refractory myeloma, supportive care, and clinical trials. There will also be a question and answer session. Registration will begin at 10 a.m., and the program will conclude at 3 p.m. A similar program will be held in Houston on October 15. For more information about the St. Louis program or to register, please see the MMRF website.

For a more detailed listing of myeloma-related events, please check the Myeloma Beacon Events Calendar.

First, the good news: More drugs are being developed now for myeloma than for any other cancer. And, for the most part, they are working! These drugs—pomalidomide (Actimid), carfilzomib, perifosine, Zolinza (vorinostat), etc.—most often work best when combined with other approved novel therapy agents thalidomide (Thalomid), Revlimid (lenalidomide), and/or Velcade (bortezomib).

Maintenance therapy after a stem cell transplant is proving to be helpful in delaying the return of the disease.

Fine tuning of therapies given to newly diagnosed patients prior to undergoing transplantation, called induction therapy, is helping extend the length of time that transplants work.

That is, if a patient decides to undergo a stem cell transplant at all! Novel therapy agents are working so well in some patients that they are able to postpone getting a transplant indefinitely.

Evidence is growing that bone strengthening agents, known as bisphosphonates, also help slow myeloma’s harmful effects. One of these drugs, Zometa (zoledronic acid), may also contain some additional anti-myeloma properties.

Clinical studies are more numerous and accessible than ever. Many patients now have access to promising, new anti-myeloma therapies, even before they are approved by the Food and Drug Administration.

Next, here is some good and bad news: Life expectancies are rising impressively for some multiple myeloma patients, but not for others.

Younger, healthier patients with slower moving myeloma and fewer genetic abnormalities are really doing well. But others are not so lucky. Those with chromosomal abnormalities (conditions that help predict a type of myeloma which is more difficult to treat), some elderly patients, those with drug-resistant disease, or patients with other serious health problems continue to struggle.

The end result: Overall median life expectancies of all multiple myeloma patients, taken together as a group, are not rising as fast as one would hope.

Now the bad news: I just don’t see a “wonder cure” waiting around the next corner. Our economic system rewards research that produces fast, positive results. Although multiple myeloma is proving to be responsive to several different types of drugs, working to find a cure is expensive and takes a long, long time. So instead, researchers are focusing on the small battles they think they can win such as modest improvements on the current treatments, instead of the tougher, far more illusive war to find a cure.

The bottom line: Considering the fact that we all deal with having incurable cancer every day, the future looks very bright!

These days, when a person is diagnosed with multiple myeloma, they are often told something like this:

“I’m sorry to report you have a type of bone marrow cancer called multiple myeloma. There is no cure—but there is hope. We have five or six different ways to treat your disease. Until recently, the average multiple myeloma patients would die in four or five years. Now, many are living twice that long—some even longer.”

I know a few multiple myeloma patients who take little solace in knowing researchers are making progress—the specter of having an incurable cancer overwhelms them. I understand.

But I take great hope and comfort from the ongoing progress that multiple myeloma researchers are making. If scientists can continue to make progress at the current rate, most of us won’t need a cure! Like prostate cancer or diabetes, myeloma patients may soon be more likely to die from other causes than their cancer. Considering the circumstances, it doesn’t get much better than that!

Feel good and keep smiling! Pat

Taking nutritional supplements is common among multiple myeloma patients and other cancer patients. These supplements, including vitamins, minerals, and various plant compounds, may be important to keep the body healthy, aid in the treatment of myeloma, or to reduce negative side effects of treatment.

However, supplements, even those found naturally in foods, have the potential to interact poorly with chemotherapy or other treatments. Physicians typically agree that eating a balanced and nutritional diet is important, but they are often hesitant to recommend the use of certain supplements, since there may be little to no research to show that they are effective and safe in myeloma patients (see a related Beacon forum discussion). So, please discuss all supplements with your doctor before taking any.

If you and your doctor decide that certain supplements may be right for you, there are several important things to keep in mind. In general, supplements should be taken with food, unless otherwise indicated. If you are being treated with Velcade (bortezomib), avoid taking supplements on the days you receive Velcade, as they can diminish the efficacy of Velcade. If your doctor approves a supplement regimen, ask your doctor to provide specific instructions on when and how to take the supplements.

In order to help you decide which supplements you may want to discuss with your doctor, this article will provide for each nutrient: information on its potential purpose in multiple myeloma treatment, where to find it in your normal diet, and the suggested doses for myeloma patients.

Acetyl-L Carnitine

Some small studies suggest supplementing with acetyl-L carnitine, a nutrient normally made in sufficient amounts by the body, can help reduce the symptoms of peripheral neuropathy (nerve damage to arms and legs that is a common side effect of myeloma treatment). Acetyl-L carnitine may also protect heart cells from damage from Doxil (doxorubicin liposomal) treatment.

Acetyl-L carnitine is found in beef, pork, and milk. As a supplement for peripheral neuropathy, patients can try 500 milligrams twice a day with food. Up to 2 grams a day is safe, but over 5 grams a day can cause diarrhea, appetite changes, body odor, and rash.

Alpha Lipoic Acid

Alpha lipoic acid is an antioxidant that is commonly used in supportive therapy for peripheral neuropathy in people treated for multiple myeloma. It is an antioxidant that is normally made in the body, but people can also take extra alpha lipoic acid through supplements. Myeloma patients with peripheral neuropathy can take 300 milligrams to 1 gram daily, with 600 milligrams often recommended for up to four weeks.

Patients should be aware that one study done in myeloma cells in a lab found that alpha lipoic acid may reduce the effectiveness of Velcade treatment.

Calcium

People with multiple myeloma may take calcium along with vitamin D to help support their bones. However, bone breakdown during multiple myeloma also releases unhealthy amounts of calcium in the blood, so patients should consult their doctors before considering calcium supplements.

Curcumin

Curcumin, a compound found in the spice turmeric, may work to kill myeloma cells and prevent them from multiplying. For those who have the pre-cancer conditions monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma, curcumin may slow progression to active multiple myeloma, but this has not yet been supported by clinical research.

At the same time, patients should beware that curcumin can also suppress the immune system, which can be dangerous for people with multiple myeloma, smoldering multiple myeloma, or MGUS. For more information, please see the related Beacon news and discussion.

There is no standard established dose for curcumin in multiple myeloma. In the few small studies available on curcumin as a myeloma therapy, patients usually take about 4 grams daily spread out over many doses throughout the day. In India, where turmeric is popular in cooking, the average daily consumption is much less—60 milligrams to 200 milligrams through diet.

Enzymes

A mixture of the enzymes papain, trypsin, and chymotrypsin may weaken myeloma cells and increase the likelihood of responding to conventional chemotherapy. Anecdotal evidence suggests drinking papaya juice, which is rich in papain, may also be helpful in cancer therapy (see related Beacon news).

Eating papaya or drinking papaya juice generally poses little risk, though people who are pregnant, are allergic to kiwi fruits or figs, or have problems with blood clotting should avoid papain. Also, raw papain can irritate the skin.

There is little data on the effectiveness of this type of therapy or how much enzyme supplement to take for multiple myeloma. An ongoing Phase 3 trial is studying three daily doses of a product called Wobe Mugos E, which contains 100 milligrams of papain, 40 milligrams of trypsin, and 40 milligrams of chymotrypsin. Side effects of papain supplements, such as Wobe Mugos E, include throat and stomach irritation.

Fish Oils

Fish oils commonly contain plenty of omega-3 fatty acids, which may boost peripheral nerve health. For this reason doctors sometimes recommend them for peripheral neuropathy. Omega-3 fatty acids may also work against cancers by reducing inflammation.

Omega-3 fatty acids perform many important functions in the body and are an essential part of a healthy diet. Healthy patients are recommended to take 1.1 grams of omega-3 fatty acids a day for women and 1.6 grams a day for men. No recommendations specifically for myeloma patients were found. Patients should be careful not to take more than 3 grams a day without medical supervision because of an increased risk of bleeding.

The science on the effects of omega-3 fatty acids on multiple myeloma is still preliminary—two studies from the 1990s showed certain omega-3s kill myeloma cells in mice. For those interested in trying fish oils in a clinical trial, a trial is recruiting volunteers who have MGUS or smoldering multiple myeloma for a study on whether omega-3 supplements will delay or prevent the progression of these diseases to symptomatic multiple myeloma. The trial is starting patients on 1.25 milligrams three times a day, and the dosage will be increased for patients who can tolerate it.

Ginger

Ginger is a well-known home therapy for nausea. The latest science supports using ginger alongside prescribed nausea medication to reduce nausea from chemotherapy (see related Beacon news). The study showed that 0.5 gram to 1 gram of ginger daily for three days before chemotherapy and the first three days of chemotherapy significantly reduced nausea.

Glutamine

Supplements of the amino acid glutamine may help with several major side effects of high dose-chemotherapy and bone marrow transplantation. Small studies have shown it may reduce peripheral neuropathy, mouth sores and mouth ulcers, and infections.

Patients can take 15 grams of a pure L-glutamine powder twice daily for a total of 30 grams.

Green Tea

A compound found in green tea, called epigallocatechin-3-gallate (EGCG), may aid in killing myeloma cells and prevent myeloma cells from multiplying. However, it may also block the anti-cancer activity of Velcade, leading researchers to advise people with multiple myeloma undergoing Velcade therapy to avoid green tea products and EGCG supplements (see related Beacon news).

For people with MGUS or smoldering multiple myeloma, the compounds in green tea may slow down or prevent their pre-cancer conditions from progressing to multiple myeloma. Since most MGUS and smoldering myeloma patients are not actively treated, there is no worry of interference with chemotherapy. One Phase 2 clinical trial is studying the effects of a daily green tea extract on people with MGUS and smoldering myeloma. The trial is recruiting participants in Detroit.

Iron

Anemia (low red blood cell counts) is a symptom of multiple myeloma and is also a common side effect of many myeloma treatments. Iron supplements may help certain people with their anemia. Anemia is often treated with a prescription hormone called erythropoietin that stimulates red blood cell production. In severe cases, blood transfusions may be necessary.

For those whose anemia therapy would get a boost from iron, doctors may recommend an oral iron supplement or, if that is not enough, intravenous iron. In addition, patients can try including iron-rich foods in their diet such as dried beans, fortified cereal, beef, and eggs.

At the same time, people with multiple myeloma who get blood transfusions are at risk for having too much iron in their bodies, so iron supplements are not right for all myeloma patients. Doctors can tell patients how much iron is needed, depending on their condition.

Magnesium

Magnesium may help with peripheral neuropathy. It also helps regulate calcium levels and can help strengthen bone. Green leafy vegetables, almonds, cashews, and halibut are all good sources of this essential mineral.

People with multiple myeloma can also take 250 milligrams of magnesium twice daily through an over-the-counter supplement, or they might get a prescription for a daily 400-milligram supplement, depending on how much magnesium their doctors find in blood tests. Patients should beware that too much magnesium can cause diarrhea.

Potassium

Doctors may recommend potassium for people getting treated for multiple myeloma to help with peripheral neuropathy. Patients can get potassium from food sources such as sweet potatoes, bananas, citrus fruits, peas, red meat, and chicken, or their doctor may recommend potassium supplements.

There are no documented cases of people getting too much potassium from food, but supplements can cause hyperkalemia, a dangerous condition than can lead to sudden cardiac arrest. Since the kidneys work to remove extra potassium from the body, people with multiple myeloma, which often reduces kidney function, might be especially vulnerable. Multiple myeloma patients should be especially careful to take potassium supplements only under direction from their doctors.

Resveratrol

Resveratrol, a compound abundant in grape skins, may kill myeloma cells, prevent myeloma cells from multiplying, and enhance the effects of some common chemotherapy drugs (see related Beacon news).

Those interested in including more resveratrol in their diet can enjoy grapes, purple grape juice, red wine, peanuts, blueberries, and cranberries.

There are also many resveratrol supplements available on the market. However, because there have not been any completed clinical trials on resveratrol in multiple myeloma therapy, there is no established dosage. A Phase 2 clinical trial was studying the effects of 5 grams daily of a formulation of resveratrol in multiple myeloma patients. However, the trial was suspended earlier this year after several patients developed kidney failure (see related Beacon news).

Vitamin B

B vitamins, including vitamin B-1 (thiamine), vitamin B-2 (riboflavin), vitamin B-6, vitamin B-12, and folic acid, are important for the formation of red blood cells, enhance the immune and nervous systems, and more. People with multiple myeloma often have low red blood cells counts and can suffer from peripheral neuropathy, so getting enough B vitamins may be especially important for those with multiple myeloma.

Good food sources of B vitamins include fortified breakfast cereal; other fortified grain products; animal products such as fish, poultry, meat, and dairy; vegetables such as carrots, peas, and leafy greens; fruits such as avocadoes, grapes, and dates; and beans.

Vitamin B-1 and vitamin B-12 are so common in foods, people rarely need to take supplements for them. For the other B vitamins, supplements commonly come in a B-vitamin complex formula that includes many or all of the B vitamins in one pill.

Recommended amounts for multiple myeloma patients with peripheral neuropathy include 50 milligrams of vitamin B-6 daily (but not more than 100 milligrams a day) and 1 gram of folic acid daily.

Vitamin C

As an antioxidant, vitamin C helps protect cells from environmental damage that may lead to cancer. It also functions in protecting the immune system. The best protective benefits seem to result from obtaining vitamin C through fruits and vegetables, but the vitamin is still one of the most popular supplements for people with cancer.

Myeloma patients who are interested in vitamin C supplements should be aware that taking antioxidants on the same day as Velcade treatment reduces Velcade’s therapeutic effects (see related Beacon news). However, patients can still enjoy fruits and vegetables that are naturally high in vitamin C, such as red peppers, citrus fruits, kiwi, and broccoli.

Vitamin D

Vitamin D works with calcium to build bone, and recent research suggests it might be important in reducing some signs and symptoms of multiple myeloma. Supplements may help people with multiple myeloma deal with chronic bone pain, weakness, fatigue, and peripheral neuropathy. Meanwhile, vitamin D deficiency may be associated with poorer multiple myeloma prognoses (see related Beacon news).

Patients should aim to get 800 international units (IU) to 1,200 IU of vitamin D daily. Getting out in the sun every day for 15 minutes can go a long way toward keeping vitamin D levels up. Including fortified cereal and fortified milk, cheese, and other milk products in the diet can also prove beneficial. For those who cannot eat or drink dairy products, most alternatives, such as soy milk, rice milk, and almond milk, are fortified as much as cow’s milk. Vitamin D is also present naturally in fatty fish, such as salmon or tuna.

Many people do not get enough vitamin D through sun exposure and their diet, however. A daily supplement with 400 IU to 800 IU of vitamin D2 (ergocalciferol) or D3 (cholecalciferol) can help.

Vitamin E

For those suffering from peripheral neuropathy, vitamin E supplements may help. This antioxidant vitamin may protect nerves during therapy, especially with Velcade or thalidomide.

Additionally, Vitamin E may help heal mouth sores caused by chemotherapy. In a 2003 entry, multiple myeloma blogger Jon Siegel wrote about applying the contents of a vitamin E capsule to his mouth sores. He found he had “a relatively easy time of it compared to other folks” who had gone through chemotherapy.

For food sources of vitamin E, look to almonds, sunflower seeds and oil, peanut butter, and safflower oil. If taking a supplement, 400 IU daily is recommended.

For more information about nutrition for myeloma patients, see Part 1 in the series.  Feel free to post as a comment any recommendations your physicians made about these or additional supplements, and please remember to always consult with your doctors before taking any new supplements.

The current standard of care for multiple myeloma patients under the age of 65 is treatment with high dose chemotherapy followed by stem cell transplant.  High dose chemotherapy prior to stem cell transplant, often called a conditioning regimen, is administered with the intention of eliminating cancerous cells from the patient’s bone marrow.

Melphalan (Alkeran), administered as a single dose of 200 mg/m² (MEL200), is currently the most widely accepted conditioning regimen for multiple myeloma.

However, little research has focused on improving the efficacy of the conditioning regimen, which may result in better responses following stem cell transplant.

“I think this study will stimulate the investigation of more efficient conditioning regimens for multiple myeloma, since very little has been done in this field in the past,” said Dr. Juan Jose Lahuerta, principal investigator of the study, in an email to The Myeloma Beacon.

The goal of this study was to compare a conditioning regimen that included busulfan (Myleran) to the standard MEL200 regimen.

Of the 767 newly diagnosed multiple myeloma patients under the age of 70 enrolled in the study, 225 received oral busulfan (12 mg/kg) followed by a single dose of melphalan 140 mg/m² (BUMEL). The remaining 542 patients received a MEL200 conditioning regimen.

At the time of the transplant, no statistical differences were seen between the BUMEL and MEL200 conditioned groups.  The average time to stem cell collection and platelet engraftment, meaning that the stem cells began producing platelets again, was similar.  Furthermore, the hospitalization time averaged 20 days for both groups.

Responses to treatment were similar between both groups.  Partial response or better after the stem cell transplant was seen in 90 percent of BUMEL-conditioned patients compared to 92 percent of MEL200 patients.

Time to disease progression was significantly improved in the BUMEL conditioned group. Five years after the transplant, 39 percent of patients in the BUMEL-conditioned group remained progression free compared to 21 percent of MEL200 conditioned patients.

At the time of follow up, the median progression-free survival for BUMEL-conditioned patients was 41 months, compared to 31 months for those who received MEL200.

Despite the improved progression-free survival of BUMEL-treated patients, the overall survival between the two groups was similar.

The median time of survival was 79 months for BUMEL-conditioned patients and 71 months for those who received MEL200. The five-year overall survival rates for BUMEL and MEL200 patients were 55 percent and 57 percent, respectively.

Patients who received the BUMEL conditioning regimen were at a significantly increased risk of developing veno-occlusive disease compared to those who received MEL200.

Veno-occlusive disease is a complication of high-dose chemotherapy in which some of the small veins of the liver are blocked. Patients with veno-occlusive disease often experience weight gain due to fluid retention and increased liver size.  The condition is also associated with kidney failure.

Of those patients who received BUMEL conditioning, 8 percent were diagnosed with veno-occlusive disease, compared to less than 1 percent of patients who received MEL200.  In 3 percent of BUMEL patients, death was directly attributed to veno-occlusive disease, compared to less than 1 percent of patients in the MEL200 group.

Furthermore, a higher percentage of patients in the BUMEL group died within 100 days of transplant from causes other than multiple myeloma, including stroke and infection in the blood stream.  Of those treated with BUMEL, 5 percent died from such complications, compared to 3 percent treated with MEL200.

The researchers concluded, “Our analysis suggests that BUMEL may have greater anti-myeloma activity than MEL200; however, this should be balanced against its higher toxicity profile and treatment related mortality.”

They suggested that the study be extended using the intravenous formulation of busulfan, which other studies have demonstrated to reduce or eliminate the risk of veno-occlusive disease.

For more information, please see the full article in Haematologica.

This draft guidance follows a previous draft published by the National Institute for Health and Clinical Excellence (NICE) on June 2, which recommended both thalidomide (Thalomid) and Velcade (bortezomib) as first line treatments for multiple myeloma patients ineligible for stem cell transplant or high-dose chemotherapy.

NICE’s most recent draft states that the clinical effectiveness of Velcade and thalidomide are comparable, yet designated Velcade as a backup treatment to thalidomide after analyzing the costs of the two treatments.

These recommendations followed consultations with a number of government, patient, and professional multiple myeloma organizations. Determinations of cost effectiveness were made based on reports submitted by Janssen-Cilag, the distributor of Velcade in the U.K., and Celgene, the manufacturer of thalidomide.

The statements presented in the draft have raised concerns at Janssen-Cilag about the accessibility of Velcade as first-line treatment for multiple myeloma patients in the U.K. The company said in a statement that it will appeal against NICE’s recommendations.

The appeal period for this draft will close on September 10, and a final guidance is expected to be published by NICE later that month.

Both drugs are currently recommended as second-line treatments for the treatment of multiple myeloma.

More information about the draft can be found at the NICE website.

Healthy eating can help people with multiple myeloma heal faster, feel more energetic, respond better to treatment, and protect a vulnerable immune system. But treatments like chemotherapy and stem cell transplants can sap appetites, leading to malnutrition and vitamin deficiencies.

However, as a multiple myeloma patient, you can manage your nutrition by following the principles of a balanced diet that you are probably already familiar with, such as eating plenty of colorful fruits and vegetables, getting enough protein, avoiding fried foods, and getting unsaturated fats from sources like fish, nuts, and seeds. You can also meet with a registered dietician during treatment, who will work with you to choose a diet that will help you feel the best you can.

Eating well and getting regular exercise are good ways to prepare for treatment. Once treatment starts, there are many strategies you can use to make up for nutritional deficiencies and to overcome side effects that reduce your appetite.

Strategies For Eating Well During Treatment

“The biggest problem I encounter with myeloma patients is poor intake of protein and calories due to effects of disease progression and treatment,” wrote a University of Arkansas cancer center dietician on the university’s Myeloma Institute website.

Eating snacks and frequent small meals every two or three hours can help increase calorie and protein intake. If you find that you need to gain weight, try adding grated cheese on top of meals, adding powdered milk to cream soups and casseroles, choosing the full-fat versions of dairy products and dressings, or supplementing your diet with nutritional drinks and shakes.

Nausea and vomiting are common side effects of chemotherapy. If you are feeling nauseous, try eating small meals, avoiding strong smells, and eating cold instead of hot foods. Bland, dry foods like crackers and toast and clear liquids like broths, juices, and water may be appealing.

Some treatments can cause sore throats or mouths, or reduced saliva and a dry mouth. Soft, bland foods can help. Soups, milk, pudding, and ice cream are good examples. Avoiding spicy, salty, or tart foods like citrus fruits and avoiding alcohol can also help. Dry and sore mouths are prone to cavities and infections, your doctor may recommend a rinse or brushing after meals to keep your mouth clean.

Another common side effect after stem cell transplantation is an altered sense of taste or smell. Try rinsing your mouth before eating, using different herbs and spices, or adding more salt or sugar to your food. If you do not have a sore throat or mouth, you can try tart, citrus flavors. If you are bothered by a metallic taste in your mouth, try sucking on sugar-free lemon drops or mints and using plastic utensils at meals (see a related Beacon forum discussion for more tips).

Even side effects such as diarrhea, constipation, and fatigue can be managed in part by diet.

Avoiding Infections

In addition to getting enough nutrition, people undergoing multiple myeloma treatment will also need to eat well to help protect their weakened immune systems.

“Decreased red blood cell and white blood cell counts are common side effects of chemotherapy. While patients are aware of this, they often overlook the fact that poor nutrition can also play a role,” wrote the University of Arkansas dietician.

If you have low white blood cell counts, avoid raw foods such as raw seafood, salads, and soft cheeses like Brie or Camembert. Wash your hands often and keep your kitchen especially clean. Doctors or nurses can provide advice on how to keep the home safe while you are vulnerable to infection.

Vitamin Supplements

You may become interested in taking supplements during your myeloma treatment, especially as more studies emerge showing the importance of different vitamins to cancer healing. A few recent studies have suggested that fixing vitamin D deficiency in people with multiple myeloma may lead to better prognoses, and that vitamin D supplementation can reduce bone complications and correct hypercalcemia.

However, excesses of vitamins may interfere with cancer therapies. In particular, vitamin C, green tea, and other antioxidants may interfere with Velcade (bortezomib). In addition, taking more than 100 percent of the recommended daily value of any given vitamin may increase cancer risk. Patients should always consult their doctors before making any changes to their diet, including taking supplements.

Eating well during multiple myeloma and its treatment takes care and planning, but provides patients with an effective, actionable way to feel healthier and respond better to therapy.

For more information, see articles on nutrition by the Leukaemia Foundation (pdf) and the American Cancer Society. Also check out Part 2 of the Beacon nutrition series.

Keeping a positive attitude in the face of a cancer diagnosis and treatment isn’t easy. But a positive attitude is the cornerstone of improving any patient’s quality of life during treatment.

Enough with the general, philosophical stuff! Here are a few practical suggestions to help multiple myeloma patients and caregivers make it through their day:

Keep moving. Go for a walk. Stretch for ten minutes. Swim. Roll your wheel chair up and down the block. Do some type of resistance training. Exercising can help lower your blood pressure, reduce the risk of blood clots, protect and strengthen bones, burns calories, and improve appetite. It can also help improve your mood and ability to concentrate. Best of all, it costs little or nothing to get started.

Do something for someone else. When you aren’t feeling well, it is easy to fall into the “It’s all about me!” trap. Reach out to another patient or person in need. Your efforts will be appreciated, and I guarantee you will feel better about yourself. It’s a win-win!

Speak with your physician about your medications. If you are experiencing adverse side effects, ask why you are taking each drug. Is it really necessary? Adjusting your dose up or down, or substituting a different drug, might help you feel better.

Now that you understand why you need to take your meds—and you agree with your doctor that they are necessary and dosed correctly—embrace them! Sure, side effects like constipation, nausea, or peripheral neuropathy are inconvenient—even painful. But try and keep your eye on the prize: completing treatment, feeling better, and staying alive!

Change your routine. Feeling safe and knowing what to expect is comforting. It can be tempting to stay at home where you feel safe when you aren’t feeling well. But becoming dependent on an ever shrinking world should concern you. Try not to become too scheduled and rigid. It will only make it harder to adjust as your medical condition changes.

Resist the temptation to sit at home and do nothing. Get out and eat lunch with friends. Shop a little. Take a walk in the park or on the beach. Visit with someone in the next room if you are staying in the hospital or nursing home. Visit with the staff at the nurses’ station.

Don’t skip breakfast. Eating breakfast will help regulate your blood sugar and keep your mood up.

Eat more raw fruits and vegetables. Then eat some more! Vitamins and antioxidants are always better in fresh, uncooked foods.

Make sure you get enough protein. Many multiple myeloma drugs make it difficult to maintain muscle mass.

Be hopeful! Researchers are making more progress in multiple myeloma therapies than any other cancer. Life expectancies are doubling every two or three years. This isn’t “pie in the sky” hope. This is real, “science is making progress and it will probably help me live longer” hope!

I could go on and on and on.

You can do this! Having multiple myeloma isn’t fun or fair. But there are good, wonderful things all around you. You just need to remember to look.

Feel good and keep smiling! Pat

However, patients with the t(4;14) abnormality did not respond as well to Velcade and dexamethasone as patients without the abnormality.  Patients with del(17p) did not show the same improvements when treated with Velcade-dexamethasone.

The presence of chromosomal abnormalities in the plasma cells of multiple myeloma patients is associated with poor outcomes. Some novel drugs, such as Velcade (bortezomib), have been shown to overcome the poor prognosis associated with certain abnormalities, such as t(4;14), a translocation of a chromosomal region from chromosome 4 to chromosome 14, and del(17p), a deletion in a region of chromosome 17. However, these findings are based on a small number of patients.

To shed more light on the issue, French researchers investigated a large group of newly diagnosed multiple myeloma patients under the age of 65 years who received four cycles of Velcade and dexamethasone (Decadron) as their initial treatment, followed by high-dose melphalan (Alkeran) and stem cell transplantation.

Of the 507 patients included in the study, 106 were positive for the t(4;14) abnormality and 54 were positive for del(17p).

The researchers found that at a median follow-up of two years, more patients with t(4;14) (41 percent) relapsed than patients without this chromosomal abnormality (36 percent). In addition, patients without the chromosomal abnormality had a significantly higher 4-year overall survival rate than patients with the t(4;14) abnormality.

The researchers found similar results for patients with the chromosomal abnormality del(17p). The median event-free survival time was 14 months for patients with del(17p), compared to 36 months for patients without the chromosomal abnormality. The 4-year overall survival rate was 50 percent for patients with del(17p), compared to 79 percent for patients without del(17p).

In follow-up analyses, the researchers compared the results of their study with another set of 512 patients who received four cycles of vincristine, doxorubicin (Adriamycin), and dexamethasone (VAD) as initial therapy. Of this group, 98 were positive for t(4;14) and 119 were positive for del(17p).

They found that in comparison to VAD, Velcade-dexamethasone significantly improved outcomes for patients with t(4;14). Patients with this chromosomal abnormality who received Velcade-dexamethasone as initial therapy had a median event-free survival of 28 months and a 4-year overall survival rate of 63 percent, compared to 16 months and 32 percent for patients who were treated with VAD.

The researchers did not observe any difference between the two treatments with regard to outcomes for patients with del(17p).

The researchers concluded that based on their findings, Velcade-dexamethasone may become the standard of care as initial treatment for patients with the t(4;14) abnormality.

They added that a standard of care for patients with del(17p) has yet to be determined.

For more information about this study, please refer to the Journal of Clinical Oncology (abstract).

Stem cell mobilization is the process of increasing the number hematopoietic (blood forming) stem cells in the circulating blood to ensure that enough are available to be collected for the transplant. Hematopoietic stem cells are primarily found in the bone marrow and circulate in very low concentrations in the blood. During mobilization, the administration of growth factors, such as granulocyte colony-stimulating factor (G-CSF), causes hematopoietic cells in the bone marrow to be released into the circulating blood stream.

Although G-CSF is the most commonly used mobilization agent, one recent study reported that only 34 percent of patients treated with G-CSF alone mobilized a sufficient number of stem cells for transplant over a two day collection period.

Other studies have shown that initial treatment with Revlimid (lenalidomide) has a negative impact on stem cell mobilization when G-CSF was used as a single mobilization agent.

Supplementing G-CSF with chemotherapy such as cyclophosphamide can increase the number of stem cells harvested during collection and reduce collection failure rates compared to the administration of G-CSF alone.

While cyclophosphamide is effective in improving stem cell yields, it increases the risk of low blood cell counts and high fevers associated with low white blood cell counts. In order to avoid these side effects, researchers in this study investigated the efficacy of an etoposide (VP-16) and G-CSF combination as a stem cell mobilization regimen in multiple myeloma patients.

Etoposide is a form of chemotherapy used for the treatment of lung cancer, testicular cancer, and lymphoma.  Previous studies have shown that etoposide is highly effective in mobilizing stem cells.

The 152 multiple myeloma patients enrolled in the study received 375 mg/m² of etoposide once daily on days 1 and 2 of the stem cell mobilization process. G-CSF was administered twice daily starting on day 3 until the last day of stem cell collection. Stem cells were collected from all patients between day 7 and day 13 of treatment.

Stem cells were successfully collected from all patients after one mobilization regimen.

Stem cells were harvested from 94 percent of these patients in one day of collection.  The majority of patients (61 percent) were able to undergo stem cell collection 11 days after the start of their etoposide and G-CSF regimen.

Furthermore, twice the number of stem cells were collected with G-CSF and etoposide than with G-CSF alone. These numbers were comparable to those obtained with a cyclophosphamide and G-CSF regimen.

Side effects experienced by patients in the study were manageable and were mostly the result of complications caused by low blood cell counts, which required 20 percent of patients to receive blood transfusions.  Severe fevers that required hospitalization or the administration of intravenous antibiotics occurred in 17 percent of patients.

The researchers suggested further studies be conducted to determine which compound yields the best results in combination with G-CSF in patients who are predicted to be poor stem cell mobilizers and which patients may not need a second agent for successful stem cell mobilization.

For more information, please see the study in Biology of Blood and Marrow Transplantation (abstract).

High-dose melphalan (Alkeran) is the standard conditioning treatment for multiple myeloma patients who will receive an autologous stem cell transplant. Previous studies have shown that melphalan treatment elicits favorable complete response rates and overall survival. However, the possibility of achieving even better responses was investigated in this study by combining melphalan with other therapeutic agents: Hycamtin (topotecan), which inhibits the replication of DNA in cancer cells, and cyclophosphamide (Cytoxan), which works similarly to melphalan to slow or stop growth of cancer cells.

The study evaluated the safety and efficacy of the Hycamtin-cyclophosphamide-melphalan (HCM) combination in 60 patients with relapsed or refractory multiple myeloma or patients in first remission. HCM was administered intravenously over the course of six days preceding an autologous stem cell transplant.

The overall response rate for the HCM combination was 85 percent: 12 percent of participants achieved complete response, 32 percent very good partial response, and 30 percent partial response. Among the remaining participants, 13 percent had stable disease, and one patient progressed.

Very good partial response and complete response rates were higher in patients who underwent autologous stem cell transplantation within 12 months of their myeloma diagnosis; 68 percent of these patients achieved at least a very good partial response, whereas patients who received stem cell transplants more than 12 months after diagnosis achieved at least a very good partial response rate of 32 percent.

Additionally, very good partial response and complete response rates were higher in patients who achieved at least partial response to HCM therapy before stem cell transplantation. Of those who achieved this preliminary partial response, 63 percent went on to achieve very good partial response or complete response after transplantation. Of those who did not achieve an initial partial response, 31 percent achieved very good partial response or complete response after transplant.

After a median follow-up period of 32 months, the median progression-free survival time was 18.5 months. Five years after the completion of the study, 60 percent of the patients were still alive, and 33 percent were in remission.

Serious blood-related side effects were high, with all patients experiencing low white blood cell counts and low platelet counts. Most other side effects were mild and manageable; the most common were mucositis/stomatitis (inflammation and ulceration of the mouth and digestive tract, 65 percent), nausea (58 percent), and diarrhea (42 percent).

In comparison, past trials have shown that single-agent high-dose melphalan has a complete response rate of 22 to 44 percent, a progression-free survival time of 18 to 30 months, and a median overall survival time of five years, making the HCM combination comparable to, but not an improvement over, melphalan alone.

HCM yielded a lower complete response rate (12 percent) than the standard melphalan regimen, which may be due to a lower melphalan dose used in the combination treatment. Increasing the melphalan dose in HCM could raise the complete response rate, but at the risk of increasing side effects as well.

The side effects of HCM and high-dose melphalan were not directly compared in this study. Dr. Muzaffar Qazilbash of the University of Texas MD Anderson Cancer Center and an investigator of the study explained that side effects were comparable with only a small difference. “Subjectively we felt that the HCM regimen was slightly more toxic in terms of mucositis, diarrhea, and abdominal discomfort than melphalan alone,” said Dr. Qazilbash.

The HCM regimen is also administered over a course of six days, whereas the standard high-dose melphalan treatment is administered over one or two days. Therefore, the HCM treatment would likely be more costly and require longer hospital stays than the standard melphalan treatment.

Aside from complete response rates and treatment times, HCM is comparable to the standard melphalan regimen in terms of overall response rates, progression-free survival rates, and overall survival. However, researchers suggest that a Phase 3 trial directly comparing HCM to high-dose melphalan will be necessary in order to truly determine which treatment regimen is more beneficial.

“Until we can show unequivocal superiority of [HCM] or another regimen, melphalan should remain the standard of care,” suggested Dr. Qazilbash.

For more information, please see the study in Bone Marrow Transplantation (abstract).