The Resistance Problem

I thought maybe I should attempt to clarify the resistance problem I mentioned in the previous post.

Unlike most of the more familiar types of cancer, multiple myeloma does not arise in a specific organ, but is systemic in nature. Even if, as in my case, there are tumors, there is no hope of chopping them out and then testing to see if you can convince yourself that you "got all the cancer". You can think of myeloma as being metastatic right out of the starting gate. The cancerous cells are white blood (plasma) cells, which are everywhere in the body. Furthermore, no known chemotherapy can be guaranteed to get all the cancerous plasma cells either; a few are bound to survive the encounter with the chemotherapeutic agent, and if they take it into their heads to begin multiplying, the patient is back where he began -- except that the previous "successful" therapy is no longer a viable option. At that point, the patient and his oncologist must shop for another therapeutic regimen to try.

Some myeloma patients experience this cycle of treatment, remission, and relapse many times. A good illustration of this is a recent Phase 2 clinical trial of Onyx Pharmaceuticals' carfilzomib, which is designed to add yet another option for this type of patient. The trial involved 266 "heavily pretreated advanced multiple myeloma patients". These patients had undergone a median 5 prior therapeutic regimens, involving a median 13 chemotherapeutic agents.

This isn't necessarily my fate. There are myeloma patients who survive many years on the same maintenance therapy, without disease progression. I'm keeping my fingers crossed.

Bone Marrow Biopsy Results

I was finally able to obtain the results of the biopsy done at Johns Hopkins on July 1: "No evidence of myeloma... There is no evidence of an increase in plasma cells."

So, even though it's never wise to claim that one has "beaten" myeloma -- the fact remains that, for most patients, the eventual development of resistance, followed by disease progression, is more or less inevitable -- this is probably as close as I can get to overcoming this disease, and should celebrate it as such. I'll breathe that much easier, though, if I get the same results for the 12-month evaluation, which will happen around the beginning of next year.

July 2010 Tests

On Thursday July 1 we traveled to Johns Hopkins for the six-month stem cell transplant evaluation. The battery of tests done was identical, I think, to that of the sixty-day evaluation done in February: blood and urine tests, and a bone marrow biopsy.

I have experienced the biopsy procedure several times by now, but I don't believe I have ever described it in detail. There is really not very much to it. I am ushered into a small room containing a padded table, and instructed to unfasten my trousers and lie face-down on the table. The biopsy technician pulls my clothing down far enough to expose the right hip. Before each step, he gives brief announcements warning what is about to happen. First comes the application of a lubricant to the area where the needles will go in. Then a shallow local anesthetic is administered: "A little stick, and some burning." Next comes another local, but closer to the bone: "Another stick, deeper this time." The crucial part is of course to get a larger needle into the soft marrow of the hip bone: "You'll feel some pushing back here... More pushing..." Which is exactly the sensation, just as if some blunt object were being pushed at the hip. And then finally: "Pulling now.... Another pull..." This is the marrow being siphoned out through the hollow needle. But I would not describe the sensation exactly as "pulling". I'm not quite sure how to characterize it. I wouldn't describe it as "painful" either, although it is sufficiently unpleasant as to make a glad ending. The closest comparison I can draw, although not really a good one, is with the drilling of an anesthetized tooth. The impression is not as vivid, and yet somehow seems more invasive, as if the center of one's physical being had been penetrated, which in a sense it indeed has been; it's hard to get "deeper" than the marrow of one's bones. A very sensitive person might have the feeling of having been violated in a way, which again is not completely unfounded. In any case, the needle is immediately withdrawn, a patch is affixed to the point of entry, and the patient is instructed to button up and be on his way.

More than two weeks later, the results of this procedure remain unavailable. By contrast, the results of the blood and urine tests were available within a couple of hours. They appear as numbers in a spreadsheet-like report, each "cell" having a colored background, or not, indicating its relationship to the "normal" range of values for that number. A number comfortably in the normal range does not have a colored background; a number in the normal range, but close enough to one or the other end of the range, is "flagged" by having a yellow background; a number outside the normal range is flagged by having a red background. "I am not used to seeing chemistries without any flags," said the Hopkins oncologist, on reviewing my results. Some of the cell count numbers were flagged, but that is to be expected, as my bone marrow is still recovering its normal function of making blood cells (and Revlimid has the side effect of suppressing white blood cell counts as well). But, pending the results of the biopsy, the oncologist is as pleased as can be with my progress so far. He granted me permission to terminate the antibiotic I have been taking all year so far (a good thing, since I was about to run out of that one). He instructed me to consult with the Christiana oncologist on the subject of possibly dropping the antiviral as well. When I return for the 12-month evaluation, assuming all is still going well, I will begin the process of reacquiring my childhood immunizations, all lost in the course of the stem cell transplant.

On July 13, the Christiana oncologist joined the party congratulating me on my progress, and told me to stop taking the antiviral, once I have run out of what I have. As a result, in terms of medications, that leaves me with only Revlimid, allopurinol, omeprazole, and the monthly Aredia IV (plus non-prescription stuff like calcium and low-does aspirin).

One Year After

June's blood test results were similar to May's: Normal chemistries and proteins, somewhat low but acceptable blood cell counts and immunoglobulins. In addition to the blood tests, this month I also got a skeletal X-ray survey, and an ultrasound on my legs.

The comparison of the current skeletal survey with the last one, done in October of last year, indicates that, if lytic lesions can be taken as evidence of the presence of the myeloma, then the disease has more or less been stopped in its tracks. There is no evidence of spreading, for example, to the arms, legs, or pelvis. Although the skull and spine are unchanged and seemingly stable, the ribs show improvement, which comports with the (ever so) gradual reduction of the pain that I have endured in that area.

The ultrasound, taken as a precaution against the threat of blood clots introduced by the Revlimid that I have resumed taking, revealed no such clots.

The oncologist expressed great satisfaction with these results; he appeared as jocular as such a very reserved individual gets. As of this month, in my case he can give himself credit for one year of survival. Survival, where cancer is concerned, is measured from the date of positive diagnosis. This seems somewhat arbitrary, since the patient has clearly already "survived" having the disease for some period of time already by then; but there is really no other way to objectively measure it, since there is no way to determine exactly when the onset of the disease occurred. By June of 2009, I may have had multiple myeloma for six months or six years. In any case, survival, thus defined, is nearly the sole measure of success or failure in the oncological world. The survivor's quality of life, as important as that might be, is too subjective in nature to serve as a scoring mechanism. Moreover, cancer is such a rapacious adversary that the oncologist must be resigned to burying most of his patients sooner or later. He counts a success if he manages to cheat the statistics by some span of time. If he is very good or very lucky, he somehow pushes the patient out onto the long right-hand tail of the life expectancy distribution. In the case of multiple myeloma, the long tail begins around five or six years. So I still have a long road to travel to reach it.

Frankly, I am avoiding using the occasion of this anniversary to indulge in any extensive reexaminations of the road traveled thus far. This strategy for maintaining some kind of emotional equilibrium in the face of -- dare I use what seems an overused term -- horror, has some disadvantages. The worst of it is that I can seem ungrateful for the truly herculean efforts that have been made by many other people (my wife in particular) to keep me from sliding into the abyss. I can only offer a simple apology, and the excuse that dwelling on the events of the past year will do nothing to help me get through the next one. Also, doing so creates a certain feeling, that I would prefer to avoid. It reminds me of the feeling I experienced on emerging from the Holocaust Museum in Washington, when I visited it years ago -- a feeling of inescapable involvement in an enormity that roams the world, devouring souls without justification and without mercy.

Provenge, And Mylovenge

Several weeks ago, the FDA approved for certain types of refractory (i.e. unresponsive to standard treatment) cases of prostate cancer a new "vaccine", brand name Provenge. The reason I'm using the scare quotes here is that Provenge is not a vaccine in the conventional sense; no one who does not already have prostate cancer will be taking Provenge to avoid getting it. The mass media is using the term "vaccine" to characterize Provenge because it's a term that is much more familiar to the general public (not to mention more concise) than is "autologous cellular immunotherapy", and because it serves to convey an important fact about the drug: like an ordinary vaccine, it enables the patient's immune system to combat the cancer. A patient's white blood cells are extracted, are treated with the drug, and are then returned to the patient, having now been "taught" to recognize the cancer cells as things that should be attacked and destroyed. Provenge is the first therapy of this type approved by the FDA for the treatment of any type of cancer.

Therapeutically speaking, Provenge isn't notably impressive. It extends survival by only four or five months, and it doesn't seem to affect tumor progression at all, which is apparently one of the reasons why the FDA had such trouble granting approval for it, finally doing so about ten years after it was first presented. And it will of course be appallingly expensive, thus giving rise to yet another of those "health care rationing" conundrums that we seem to specialize in creating.

But in conceptual terms, one can visualize Provenge as being the prototype for an extremely effective class of future cancer therapies. The immune system's job is to attack and destroy bad guys; cancer cells are bad guys that diabolically pretend not to be; the obvious answer is to somehow make the immune system see through the cancer cells' disguises for what they are, and go git em. That's what Provenge, and its presumed successors, would seek to accomplish.

So what does this have to do with multiple myeloma? Nothing, except that at one time -- ten years ago -- Dendreon, the company that developed Provenge, was working on a vaccine for multiple myeloma, called Mylovenge. Mylovenge was at some pointed granted "orphan drug" status by the FDA (thus qualifying it for certain types of research-related tax credits), and it reached Phase II clinical trials by 2002 or thereabouts. And then.... nothing. I was able to find traces of a clinical trial involving Mylovenge that completed in 2005, but not the results of the trial. There is nothing mentioning Mylovenge on Dendreon's web site, and calls to Dendreon's corporate offices proved fruitless. Intense Googling turned up a claim that Dendreon stopped working on Mylovenge when it became apparent that it would be difficult to manufacture, and that its therapeutic results compared poorly with those of other types of drugs that became available in the meantime -- drugs that didn't require the expensive and cumbersome pheresis process.

In fact, Mylovenge is the tip of a large iceberg of relative failure for cancer immunotherapies. This idea -- that the battle should be fought by the immune system -- as reasonable as it sounds, has proved difficult to implement in practice. Many types of immunotherapies have been developed and tested during the past couple of decades, to little practical effect so far. No doubt a tremendous amount has been learned in the process, but to date this knowledge has not been translated into longer lives for cancer patients. Reading the press around the Provenge approval is attended by deja vu: the potential of the immunotherapeutic approach is set forth in terms almost identical with researchers' promises made ten or fifteen years ago. That's not the researchers' fault, really; this stuff is hard, harder probably than anyone would have guessed at the beginning.

And now, suddenly, the President's Cancer Panel comes out of left field with a report declaring that the environmental causes of cancer have been "grossly underestimated", and recommending that maybe someone should look into this. So at this point, the larger problem of cancer -- where it comes from, and how to stop it -- is still generating many more questions than answers.

This Month's Tests

The monthly routine into which my medical life has settled goes something like this: A few days prior to visiting the oncologist, I have blood drawn for the battery of tests he wants to do. The office visit itself of course begins in the outermost waiting room; eventually I am called upon by a physician's assistant, who weighs me before ushering me into an examination room, where I await my audience with His Lordship. Upon entering, he gives me a glance up and down and pronounces his satisfaction with my appearance; then he jumps onto a computer, brings up my test results, mutters a bit about one number or another, but finally declares his general approval of the aggregate. He inquires about any pain I might be having, but am not. Then I'm up on the table while he listens to my lungs and heart, and gently probes my belly and squeezes my ankles. We talk about whether he needs to write any prescriptions for me. Finally, it's Q and A time, which these days usually is brief, although this month we chatted a bit about the new vaccine recently approved for prostate cancer, and whether there is anything like that being developed for multiple myeloma (but that's a subject that deserves a post of its own). Finally, on the way out, I schedule my next office visit, and a session for an Aredia IV, which ordinarily occurs a day or two later.

The blood tests that are being done fall into one of three broad categories, from my perspective. One category is that of blood cell counts: red, the various types of whites, and platelets. This month, these were all within their normal ranges, except that I am a bit low on red blood cells. This is a side effect of the Revlimid, and is a factor in my fatigue problem.

A second category of tests I think of as "levels of chemicals in the blood", stuff like calcium, sodium, potassium, creatinine, and glucose. Currently these are all in their normal ranges.

The third category is that of proteins and immunoglobulins (a.k.a. antibodies). Oversimplifying greatly, we want to see adequate numbers of the types of antibodies expected to be produced by normal plasma cells, and we don't want to see any of the junk monoclonal proteins produced by defective, cancerous plasma cells. Again, currently the tests are showing more or less the right numbers of the former, and none of the latter. I will continue to take Revlimid as long as this state of affairs continues.

Meanwhile, the monthly Aredia treatments are supposed to be strengthening my bones; this, in concert with suppression of the disease that caused them, should be making some of the lytic lesions on my spine disappear. I haven't had a skeletal survey for awhile, so I will get one sometime in the next month or so, thus giving us a reading on how well I'm doing on this front.

Revlimid In The UK

I have been wondering how I would be faring in one of the socialist paradises possessing a single-payer health care system, such as the UK. Answer: It's not clear, to me.

Here I'm considering solely the position Revlimid occupies in the National Health Service's scheme of things. The determination about whether or not the NHS will pay for a particular therapy in particular circumstances for a particular class of patients is made by the National Institute for Health and Clinical Excellence (NICE). This is what certain former governors of Alaska are referring to when they talk about "death panels": inevitably, NICE will decide that a very expensive cancer drug that, statistically, extends the life of patients by only a few months is not "cost-effective", and that the NHS should not pay for said drug. Thus, some small minority of patients who would in fact have had their lives extended by many years had they gotten this drug will not get it, and will die very prematurely. Of course, on the other side of the coin, we have the problem of limited NHS resources: any money spent on said drug, mostly to very limited effect, cannot be spent on other things; if spent on these other things, conceivably many more people could have their lives extended or improved. This is what the term "cost-effective" is supposed to mean in the first place; but you see the problem, which is that the NHS must explicitly ration health care resources, and politically (morally?) it must do so on some basis that appears to be at least vaguely objective, which it calls "cost-effectiveness".

I was surprised to learn that the NHS does not negotiate drug prices; isn't this supposed to be one of the major advantages of single-payer systems? Instead, NICE must be approached by the provider of a proposed therapy with a pricing model under which the provider would be compensated by the NHS; NICE then makes a binary yes/no decision on the cost-effectiveness of the therapy, based on the proposed pricing model, and on whatever scientific evidence is available regarding the therapeutic efficacy of the therapy.

Until early 2009, NICE apparently was opposed to approving Revlimid for any purpose whatsoever. Then Celgene, the maker of Revlimid, offered a deal: if the NHS paid for the first two years of a patient's Revlimid treatments, Celgene would pick up the tab itself after that, for as long as the patient lasted. Based on this proposal, NICE reversed itself to some degree, approving Revlimid for multiple myeloma patients who had received two prior therapies. In other words, my usage of Revlimid as front-line therapy would not have been paid for by the NHS. Perhaps my current usage as maintenance therapy would pass muster, depending on exactly what is meant by "two prior therapies"; would induction therapy count as one therapy, and the stem cell transplant as a second? I'm not certain. I'm also not certain whether NICE considered Revlimid for front-line therapy and turned it down for that, or whether this usage was not even on the table.

And this reminds me of an anomaly in my own case: technically, Revlimid is not approved as a front-line therapy by the FDA either; yet I got it for such, and the medical insurance company was just fine with that. The US rations health care resources as well, but no one is allowed to admit that this is both necessary and inevitable, and should be properly called by that name; it is currently carried out based on the seemingly arbitrary policies of whatever medical insurance provider one happens to have, or on the fact that one has none. News flash: We already have "death panels" de facto. But no one calls them NICE.