Are New Drug Options Changing Treatment Standards and Strategies for Myeloma?

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Andrew Schorr:

Hello and welcome to Patient Power.  I'm Andrew Schorr.  We want to connect you with a leading expert in myeloma, Dr. Elsabet Manasanch—she's at MD Anderson Cancer Center in Houston—to really hear really the latest horizon for giving people with myeloma hope.  Thank you so much for being with us, doctor.  

Dr. Manasanch:

Thank you for an invitation. I'm happy to join you.   

Andrew Schorr:

So what I understand is you're having more sophisticated testing, and you have a broader range of treatments to allow people to live longer and it would seem live better with myeloma, and you're also understanding the subtypes of myeloma. Did I get it right?  I mean, is that all the transition that's going on?

Dr. Manasanch:

That is some of it and then some more.  So there's a lot of research right now into what is the best front-line treatment, or what is the best treatment diagnosis, and then what are the best treatments once the patient's myeloma comes back?  There's also a lot of research into what are the best ways to detect myeloma, both in the bone marrow and the blood?  There is also research into what we call the precursor stages of myeloma.  So before people actually develop myeloma, they actually have something that we can detect.  There's something in the blood or the bone marrow for a few years before that, so there's a lot of research into strategies to treat that, and so on. So there's a lot of stuff going on, yes. 

Andrew Schorr:

Okay.  Let me ask you on both ends.  So, first of all on the early end, what has been called smoldering myeloma, what's the thinking now about when to start myeloma and how do you know who? 

Dr. Manasanch:

So that is a very hard discussion between myeloma specialists.  It depends who you ask.  They will say that definitely it would not be ethical to wait until you actually are very advanced with myeloma to treat but you should treat earlier on, especially those patients that are so?called high?risk smoldering myeloma, whom we believe may have myeloma within the next two to three years, so that should be treated earlier.  However, there's a lot of controversy, because some specialists believe there is enough evidence in terms of long and large studies to have the—you know, that people live longer.  

So there's data saying that you can treat it, that people can do well when you treat smoldering myeloma. There's data saying that the responses also seem to be better when you treat it in the smoldering stage than when you treat it once it's newly diagnosed myeloma.  There's data with some agents in terms of that it takes longer for the myeloma to progress, so from the smoldering to multiple myeloma takes longer if you treat it, but there are not a lot of studies with overall survival large studies.  

And so some of the—some physicians really want to see that data first.  So it it's really right now still if you have smoldering myeloma the standard is to not treat, to just watch it, but this may change in the next few years, maybe even the next couple of years.  

Andrew Schorr:

Okay.  Let's look at the other end where you identify that somebody has myeloma and they have high?risk myeloma.  That had been very difficult to treat for a long time.  Are we making progress there?  

Dr. Manasanch:

Well, I think that myself and others are very hopeful on the next cell therapies.  I think that maybe immunotherapy will give some advantage there, so all the cell therapies that basically take out your own immune system and just manipulate your immune system to kill that type of myeloma, because, as you said, all the therapies we have seem to work very well for most patients with that subtype.  But I do want to say for patients with high?risk myeloma there are—you know, continuous therapy with good agents does seem to have an advantage.  And there is a subset of those patients that can actually do quite well, and so it's not all lost.   

But I think that what is going to hopefully make—give someone advantages it's going to be actually in immunotherapy, so all the cell therapies using your T cells maybe with again other oral therapies, infusing your immune system, I think that that might be better.  But to be honest with you right now, in the clinic we still use the same therapies that we would use for regular myeloma, and only everything that we do is we continue the same treatments.  We just continue them for a longer time.  And then we also encourage transplant.  But there is not a different therapy right now for this type of patients.   

Andrew Schorr:

Okay.  Couple of other things.  One is transplant.  So I know you still do a lot of transplant at MD Anderson, as many centers do, but not everybody needs transplant.  How do you know who should have a transplant?   

Dr. Manasanch:

So most patients with newly diagnosed myeloma will have a transplant.  And just to make things clear, it's not really a transplant, right? It's high?dose chemotherapy.  And I know we talk in myeloma about chemotherapy, but the new agents in myeloma, they're not really chemotherapy, right? They're like targeted agents. They're biological drugs, so this is not the drugs.  We don't give drugs that when you lose your hair and you have—you know, lenalidomide (Revlimid) can give diarrhea, but it's not the diarrhea we're talking about with cyclophosphamide (Cytoxan) and vincristine (Oncovin) and neuropathy and I mean all the older drugs like daunorubicin (Cerubidine), that's not that type of chemotherapy.  

And so when we talk about a transplant we're talking about giving a very toxic chemotherapy drug that is called melphalan (Alkeran).  And so the transplant is just really giving you a chemotherapy drug.  So people that do the transplant, the difference is instead of getting the three drugs that usually most people get, they get the three drugs, and then they get the melphalan.  And so it's really just for us to be able to tolerate this really high dose of toxic medication called melphalan we need to get our stem cells collected first and then we have to put them back after the melphalan.  Otherwise, it would take forever for us to recover our platelets and white cells and everything, because the melphalan kills everything in the bone marrow, both the good cells and the bad cells.  But it's just another therapy.  

So this is why most patients will have melphalan, because it's just another therapy, and we're not curing most myelomas right now.  So people with start with one therapy and then go on.  One of the reasons why we still do a lot of transplants at MD Anderson with high-dose melphalan and why we give high?dose melphalan in the initial diagnosis is, because there are studies suggesting that when you give it in the very beginning the time of remission is longer.  And so we usually try to get the first remission, which is the remission you get right after initial treatment, to get the best remission we can get so to get rid as much of the myeloma as possible and then to have it last as long as possible.  And that maybe correlates with having better outcome, so many living more time without myeloma and maybe living more time.  And that's why we do it.  

And we do also a lot of—we do for these patients that don't want to do the transplant at diagnosis we do freeze and cryopreserve stem cells for later.  But all the transplant is is really just another treatment.  So the same as one gets diagnosed and you say, okay, I'm never going to take this drug.  Most people don't say that.  It's just another drug that we do for myeloma, but we still do it mainly because of the data with the remission, that's it's a longer remission.  That's mostly why we do it at MD Anderson.   

Andrew Schorr:

Okay.  So with more and more drugs being developed and new combinations in myeloma and ultimately immunotherapy, maybe CAR-T cell therapy, you were talking about T-cell therapy, should patients with myeloma knowing it still is not curable view the treatments along the way as, if you will, the bridge to what's next, get as good a remission as you can for as long as you can with the hope that if you need something else there will be something else there for you.  

Dr. Manasanch:

I think that that's a good approach.  I do think that there's probably a subset of patients that will—they will just—initial treatment of a small subset of patients that will just need initial treatment, and they may not need any more treatment after that.  That's a very small minority.  But I also feel that as we progress I feel that there are more and more patients like that.  So I think that when people are newly diagnosed the hope will be that you're just going to do your maintenance and stay on your maintenance forever.  That would be the ideal, that's the hope.  

But, yes, if the myeloma comes back, we have very good therapies for second- and even third-line treatment.  So yes, definitely wait for the next best thing.  There are a lot of new therapies coming out.  There's probably going to be some new medications approved also this coming year by a FDA.  So there are so many new medications that it really is where you are in your treatment and what are the new drugs coming out.  

For example, when daratumumab came out it helped a lot of people.  With the CAR-T cells, in the studies are helping a lot of people now that didn't have a lot of options for treatment.  So, yes, there are going to be new generation of CAR?T cells coming out as well.  There are new medications, so definitely, yes.  Try to do the best that you can until the next thing, definitely.  

Andrew Schorr:

So this is a hopeful time. 

Dr. Manasanch:

Yes, it's a very hopeful time in myeloma for sure.   

Andrew Schorr:

Okay.  Well, that's good news.  So I think for our audience then just be sure to connect with a myeloma specialist so you have a clear picture of what you're dealing with, and then you're in this dialogue as you're on this journey.  Hopefully your initial therapy will work, but if it doesn't there are others to help down the road.  Dr. Elsabet Manasanch, thank you so much for being with us.   

Dr. Manasanch:

Thank you for the invitation. 

Andrew Schorr:

I'm Andrew Schorr. Remember, knowledge can be the best medicine of all.  

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.