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Choosing Treatment for YOUR Myeloma

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Published on August 30, 2016

How do I choose the best treatment options for MY multiple myeloma (MM)? With more multiple myeloma treatments being approved and personalized for myeloma patients, Drs. Gareth Morgan, Faith Davies and Frits van Rhee, from the University of Arkansas for Medical Sciences (UAMS) Myeloma Institute, discuss the expanding armamentarium. Dr. Morgan reviews immunomodulatory therapies (IMIDs), checkpoint inhibitors and the continued role of chemotherapy. Dr. Davies focuses on proteasome inhibitors, while Dr. van Rhee explains monoclonal antibodies and antibody conjugates.

Clinical Trials Mentioned in This Program

Immunomodulatory Drugs (IMIDs)
Proteasome Inhibitor
Monoclonal Antibody
Antibody Drug Conjugates



University of Arkansas for Medical Sciences Myeloma Center

Transcript | Choosing Treatment for YOUR Myeloma

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. 

Andrew Schorr:

So, Dr. Davies, we’re really in this age of personalized medicine for myeloma where you have approved therapies. And you have really a range of investigational treatments that you might recommend to somebody for what you’re dealing with. 

Dr. Davies:           

No, that’s completely true. When we look at all of these tests, just as we may pick a therapy depending how fit a patient is or depending whether they’ve had previous side effects, and we maybe want to choose a therapy that doesn’t give that side effect. Again, we’re now in the position where we can individualize treatment so that we can actually say this treatment would be a good treatment for you based on the genes. Whereas another treatment might be a better treatment for you based on your genetic testing.

Andrew Schorr:                 

Okay. Let’s move on. You can see on the slides above us in the room, and you should be following with us along online, a list of the kinds of treatment types.

And Dr. Morgan, we’re going to go through these real quick. And then, we’ll get into some examples. Some people have heard about some of these medicines. But I’ll do a quiz here. So first of all, an IMID, immuno-modulator drugs, so what are you trying to do there? So I mentioned that cancer is a disease of the immune system. Your immune system let you down. So is this to try to help the immune system fight the cancer?

Dr. Morgan:        

So using the immune system is a really, really groovy way forward, I think. So I like strategy. And I use the word strategy a lot. So we should build using the immune system into our standard strategies. And so if transplantation gives us such good results, then, can we do even better if we build immunotherapy into it? And so the cool thing about the IMID drugs are not only do they kill the cancer cells, but they enhance Frits’ favorite word, which is natural killers.

So it enhances the activity of that natural killer cell to kill the myeloma itself. And some of these new drugs called checkpoint inhibitors, it’s like giving your immune system a set of glasses. So it allows them to see the cancer cell, go to it and kill it. So these strategies really sound a bit weird and a bit out there. But, actually, in the clinical world, they’re really, really working these days.

Andrew Schorr:                 

So I’m just going to use my weird example. Let’s see if the doctors like it. So have you ever sat on the porch maybe years ago, and there would be that kind of bug zapper on the porch, zap, zap, zap? Okay. Well, let’s say that’s your immune system, and it didn’t see the cancer. So they have these drugs now that are sort of turning on the bug zapper, and it’s able to see.

He said putting glasses on to see the cancer that sort of evaded it and proliferated. And that’s what’s going on. So IMIDs, we’ve had those. A lot of people take lenalidomide (Revlimid).

So people are familiar with that. Lenalidomide, do you remember? Or thalidomide (Thalomid), that’s been around a long time and, originally, was a medicine that they worried about because of defects and things like that in pregnant women. And then, they said oh, my God, it works for myeloma. And we can use it safely. And then, there are other medicines that have followed. The proteasome inhibitors, what is that? 

Because a lot of people have had some of these drugs, bortezomib (Velcade), carfilzomib (Kyprolis) came along, there’s Ninlaro, an oral drug. So tell us, what’s proteasome? What’s that? 

Dr. Davies:           

So the proteasome is a little bit like a recycling machine in the body. It breaks down proteins you no longer want and enables those proteins to be recycled and to make new proteins.

And so what those three drugs do is that they stop the recycling machine working. And, therefore, the body, or the myeloma cell particularly, can no longer make those proteins. And so it actually goes on and dies.

Andrew Schorr:                 

Now, you’re going to hear a term a lot today, inhibitors. So it’s trying to inhibit sort of a cancer process, right? Can you turn a switch off hopefully not without significant side effects where you can turn that off, and then, the cancer is knocked out? I often think of it like whack-a-mole. If we can’t get it to cure, can you whack it back? So Dr. van Rhee, what about monoclonal antibodies? This has just been in the recent years. And I know you have a lot of research. I think of a monoclonal antibody as like a cruise missile aimed at something on a cancer cell. Is that a fair way to look at it, a targeted therapy?

Dr. van Rhee:     

There are several types of monoclonal antibodies. There are antibodies, which directly target the tumors such as the newly approved antibody, daratumumab, or Darzalex. 

There are antibodies, which utilize the immune system. One of these is the new drug elotuzumab (Empliciti). And as Gareth already alluded to, there are drugs, which take the break of the immune system. So these antibodies block the inhibitory effect there is on cancer-specific T cells. So these antibodies re-awaken myeloma-specific immune cells, which become active and help to eliminate the tumor. 

And they’re very often paired with the immunomodulatory drugs such as Revlimid and pomalidomide (Pomalyst) in clinical trials, which also help to activate the immune system.

Then, there’s a very interesting other class of antibodies. They are linked to a chemotherapy agent. Their technical term is antibody drug conjugate. So on the one hand, you have the antibody. It carries a specific drug directly to the tumor. The antibody hooks onto the cancer cell, to the myeloma cell. It gets internalized, and it releases the anti cancer drug. One of these drugs has been approved for Hodgkin’s disease called brentuximab (Adcetris) and has been one of the important new developments in Hodgkin disease. And several of these antibodies are in development in multiple myeloma as well. 

Andrew Schorr:                 

Okay. So we’ve had these sort of naked antibodies that are infused. And then, they’re giving antibodies with high doses of powerful medicine with it. And it’s like a payload going straight to it. Often, doses that, if you didn’t have that targeting, you couldn’t withstand. So it’s bringing big guns right to where the cancer cell is. Okay. Now, Dr. Morgan, chemotherapy still gets used. So what’s the role of chemotherapy? And many people have had it related to transplant. So where does chemotherapy fit in now, because chemotherapy kind of gets a dirty word? People feel I don’t want chemo.

Dr. Morgan:        

So chemotherapy, we should not give up on it. It’s one of the most tried and tested regimens in our toolbox. And the way I see it is that the more tools in the toolbox you have, the better you’re going to be able to do building and, in this case, treating people.

And so I’m very approving of an expanding toolbox. But as we discussed earlier on, it’s about how do you use those tools? And certain tools go better together. And so you pick a hammer for a nail. You use combinations of these drugs that enhance their activity. And so what we’re in the process of doing is building drug combinations or cassettes of treatment. And then, the trick is how do you use those for an individual patient? So the face, diagnostic tests, the genetics, the aim is you do the genetics. You then go to your toolbox, pick the right tool for the job, and then, use that tool to get as many people into a complete response as you possibly can.

And that is, ultimately, what we’re trying to achieve when we talk about the big C, which in this case is the big cure, which is get people to a complete response, hold them in a response for as long as you can. And then, look to see, in 10 years, see if patients are still alive. So one of the joys of our program has been collecting the data so we know what happens in 10 years. And we have 60 percent of the people alive and well. And that’s sort of unparalleled.

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. 

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