To SCT or not?

There are at least two schools of thought, and depending on the institution you are attending for treatment, you might be being unwittingly steered in one direction or the other. Some centres specialise in what used to be called Bone Marrow Transplants, now called Peripheral Blood Stem Cell Transplants (or SCTs for short),. others prefer to take a more ‘softly softly’ approach. Which one is right? Can I change my mind/centre/
doctor/ can I have more time to think? Yes, yes, yes, and in most cases, yes. Lets look at the two types of treatment (and this is a generalisation) on offer:

STEM CELL TRANSPLANT.
In the bad old days, they used to withdraw bone marrow from your bones, after some hefty doses of chemo, and then re-infuse it after an even bigger chemo dose, or give you somebody else’s Nowadays the prodedure is much less risky (risk of infection, discomfort, long recovery period) and quite painless. The principal is this: when the tumour burden is as low as it is going, by chemo, oral meds, sometimes a bit of radiation, you enter the ‘harvest’ phase. The idea is to get your young, relatively healthy stem cells to leave the bone marrow environment, where they are growing, and enter the circulating (or peripheral) blood. To do this, two things have to happen:

1. The oldest and least healthy stem cells are killed off with a medium sized shot of a chemo drug like Cyclophosphamide or Etoposide; this forces the system to go into overdrive and produce more stem cells. Often there are more than can be accomodated in the bone marrow and they start spilling out into the bloodstream.

2. A white blood cell stimulant, called G-CSF is self injected by the patient for somewhere between 8 and 14 days. G-CSF stands for Granulocyte Colony  Stimulating Factor and what it does is stimulate the white blood cells into maturing quicker than normal.

When you have a successful mobilisation there will be pain in the bones, as the new stem cells are forced out of the marrow into the bloodstrem. Sometimes this pain can be very strong; it stops as soon as the G-CSF shots are stopped. The presence of bone pain is a very good thing. It means you have mobilisation.

The final stage of harvest is to be connected to an apheresis machine (often in a blood transfusion centre) whilst your new stem cells are removed in the machine. That’s all there is to it. The actual amount of peripheral blood and stem cells is small in volume,
no more that 150-250mls. The rest of your blood is returned by the apheresis machine.
Once collected, many centres will store the stem cells for up to ten years; so if you are relatively healthy and don’t want a stem cell transplant yet, check whether your centre has a storage facility - the SCs are frozen.

You then move into the actual transplant process. You will be given a much larger dose of chemo, usually something like Melphalan. This is called HDT, or High Dose Therapy.
Your stem cells are re-infused, normally within 48 hours of the HDT. What happens is a carefully controlled process of life and death. The chemo kills your bone marrow. The new stem cells re-colonise the marrow and start producing new blood cells, both red and white. Some days after the HDT, usually 8-12, you will become neutropoenic, which means you have no immune system, until the new blood cells start reproducing and functioning correctly. Once you re-build your immune system you are able to carry on a normal life.

As with all treatments, some people react better, quicker, more easily than others. An
SCT can be quite a difficult procedure for some patients and some risk of infection (viral, bacterial) still exists. What we have just talked about is known as an autologous transplant, where the patient is given back his or her own stem cells. Another type of SCT is called an allogeneic, or Allograft. The procedure is the same, but instead of getting your own stem cells back, you get those of another person; usually a sibling.
Allo transplants have a complicating factor called GVHD, or Graft Versus Host Disease.
This is where the new immune system of the donor attacks the host or recipient. Some
degree of GVH is desireable - you want the non-myeloma brother or sister’s immune system to attack yours. But only a little. Too much GVH can be fatal, and not enough might not stimulate the response needed to fight the MM. The most successful Allo is from a twin brother or sister, known as a Syngeneic Transplant.

The recovery time from a Stem Cell Transplant can vary from a few weeks to a few months. The remission offered by an SCT is also variable, from a few months to two or three years. Some institutions offer tandem transplants, where the patient is given one transplant, followed by another within three to six months. The remission period for a tandem is generally thought to be better than a single. More auto tandems are done nowadays than auto/allo.

The centres that push SCTs argue that the remission period is better and longer, the high dose therapy kills more MM cells and the patient has a longer drug free time.

MAINTENANCE THERAPY.

What if you don’t want a transplant, or you are just not up to the rigours of such a process? Well, this is our second type of treatment.

As yet there is no cure for MM. It is probably the most researched cancer of all, yet we
still don’t have a cure. Some doctors take a ‘less is more’ approach to the treatment of MM, arguing that if the disease is contained for long enough, and as little damage as possible is done to the body, a cure will be found. Repeated chemo, SCTs, high dose steroids can wear the body down. In addition we are more susceptible to rogue infections like pneumonia and septicaemia because of our lowered immune response: so a train of thought has emerged that argues the less damage that is done to the body the more likely
the body is to cope with the cure when it is found. This presumes that your particular type of MM isn’t aggressive, and is well controlled with less toxic drugs. There are many types of low dose treatment available, and more coming on the market each year. They work by interrupting cell paths, preventing some cell types from reproducing, or stopping blood supplies from forming. Of course everything comes with side effects, some have more than others. There are a number of treatments available at the moment. Steroids like Dexamethasone and Prednisone taken in smaller doses are successful and widely used. drugs like Melphalan and Cyclophosphamide can be used in low dose regimens to control MM. Newer drugs like Thalidomide, Velcade and Revlimid are being used as alternatives to SCT.

This form of treatment has quite a large following. It is easy to tolerate, can be well monitored with regular blood tests and does the least damage to the patient. The treatment can be administered for years in some cases, and eventually, a cure will be found. No need to take time off work, or neglect the family. no need for wigs or anybody to know you are getting treatment. You don’t feel lousy, and to a greater extent, life can go on as usual. A few pills each day or each week. It’s opponents argue that the ‘hit it hard’ treatment takes out more MM cells and delays the relapse. They also argue that repeated use of drugs can cause resistance and also a tendency to infection.  The proponents say that lower and lower doses of drugs are found to be as effective: less
drugs, less toxicity.

WHICH ONE?

Who’s right, and who’s wrong? The answer is neither. MM is as variable as the number of patients there are in the world. No two people have the same disease characteristics, nor do they respond the same to treatment. One may make a complete recovery from SCT and stay in remission for decades. Another may have a difficult transplant and have a poor remission. The same goes for moderate treatment. One person’s MM may be well controlled for years, another’s may take off like a screaming banshee. Some types of MM are quite benign, others are extremely aggressive. Nobody knows what type you have until you start treatment. Fortunately there are many, many drug regimens availabe, from gentle to very hard. If you are fortunate enough to have the type of MM that can be controlled with minimal doses of drugs, then that is an option you should look at. If you have very aggressive MM you may not have that choice and high dose treatment with SCT may be the best for you.

At the end of the day you have to make an informed decision; you need the input of your medical team, your family and caregivers, as much outside information as you can glean
and an MM specialist who is going to listen to you. Don’t accept second best; if you are unhappy with your treatment, or the plan your doctor has for you - discuss it. If you are still unhappy, get a second opinion. You must remember, this is your health and welfare you are discussing - often your life. Make sure that whatever decision you come to, you have weighed up all the options and that the decision is comfortable with everybody;
you, your doctors, your family and caregivers.