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Understanding Changes in Treatment Guidelines for Myeloma

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Published on October 19, 2016

Do smoldering myeloma patients need treatment? Dr. Larry Anderson from UT Southwestern Medical Center in Dallas, Texas discusses changes and progressions within the research and treatment of myeloma. Dr. Anderson explains diagnostic criteria for smoldering myeloma, promising research in the lab, and a bright future for myeloma.

Clinical Trials Mentioned in This Video

Smoldering Myeloma Clinical Trials
High-Risk Myeloma Clinical Trials
daratumumab (Darzalex) Clinical Trials
Monoclonal Antibody Clinical Trials
Checkpoint Inhibitor Clinical Trials

This virtual town meeting was produced by Patient Power in partnership with The University of Texas MD Anderson Cancer Center, Patient Empowerment Network and Myeloma Crowd. On behalf of our partners, we thank AbbVie Inc. and Takeda Oncology for their support.

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Transcript | Understanding Changes in Treatment Guidelines for 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.

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:

Hello and welcome to Patient Power. I'm Andrew Schorr. We're always trying to bring you the latest news connecting you with experts from around the country. Well, here's one we haven't introduced you to before, Dr. Larry Anderson from Dallas, myeloma specialist from UT Southwestern Medical Center.  Thank you for being with us. 

Dr. Anderson:

Thank you so much for having me. I'm glad to be here.

Andrew Schorr:

Sure. So, Dr. Anderson, I want to ask you about areas of myeloma where things may be changing.  So first about smoldering myeloma, many people told they have smoldering myeloma or even sometimes earlier MGUS. But they are told at some point smoldering myeloma, and they're wondering, well, do they need treatment?  What's the thinking about that now? 

Dr. Anderson:

Yeah, so the—regarding smoldering myeloma, well, first of all, the guidelines have changed in the past year-and-a-half or so, and we no longer have the same criteria we used to. We used to go by CRAB criteria for deciding if a patient with smoldering—or a patient with myeloma needed to be treated. 

Andrew Schorr:

What does that mean, CRAB?

Dr. Anderson:

So CRAB would be, the C is for calcium elevation, R for renal failure, kidney failure, A for anemia, and B for bone lesions. So those are historically the things that we looked at to say, okay, if they don't have those, they don't need treatment.  

Now with further review of data from patients and outcomes, we realize that there are some other patients that we thought were smoldering or asymptomatic, but now we realize that those patients are—essentially should be called active myeloma and should undergo treatment. And those would include patients with 60 percent plasma cells or more in their bone marrow. We used to watch and wait with those patients.  Now we know we should treat them, because most of those patients will develop symptoms within two years. 

Also patients with light-chain ratios over 100 should be treated as active myeloma.  Patients with MRI bone lesions, focal bone lesions of two or more should be treated as active myeloma.  There are still patients that have high?risk myeloma that don't meet those criteria that we still wonder should we be treating them?  That's an area of active investigation at this time.

There are several different clinical trials at UT Southwestern.  We're participating in the ECOG study looking at lenalidomide (Revlimid) versus observation, which was spurred by some data from the Spanish study where they looked at Revlimid versus observation and found improved survival in those patients. But it was a somewhat small study, and the patients—a lot of the patients may have actually had this newer criteria of active myeloma, wasn't controlled for chromosome rearrangements. And so we're really trying to do a larger randomized study here in the U.S. to really answer that question.  But until then outside of a clinical trial we're recommending observation for smoldering myeloma. 

Andrew Schorr:

Okay. But if they go to a center such as yours, a reasonable question is what tests do you need to do to really take a close look at me and then recognizing there may be clinical trials that could be promising in this area. That would be part of the discussion. 

Dr. Anderson:

Right.  So in addition—if a patient has smoldering myeloma in addition to the regular workup including skeletal survey, we would now recommend an MRI exam either of the spine and pelvis would be the main areas to look at or if—some centers may have a whole body MRI.  But that would be an additional thing to include in addition to the light chains and the usual workup.  

Andrew Schorr:

Okay. Now let's talk about another side of myeloma, and that's so called high?risk. Okay?  So in interviewing some of your colleagues over the years they said, well, we've made so much progress but we're really having a tough time working on people who are seen as high?risk myeloma. 

Dr. Anderson:

Right.

Andrew Schorr:

Now where are we? 

Dr. Anderson:

So with high?risk myeloma, I think we've made some progress.  In some of the chromosome rearrangements, for example, the 414 translocation, we used to call high?risk, now we call an intermediate risk, because it's largely overcome by a proteasome inhibition therapy.  But there are still certain patients, for instance, with 17p deletion and a few others, that are still characterized as high?risk that we really don't know the best way to treat them at this point, but whatever we do we are trying to use more aggressive or more intensive therapy, combination therapies, up front as well as more intensive maintenance therapies for those patients to try to keep them in remission longer and overcome that. 

Andrew Schorr:

Now, 17p I'm familiar with, because I'm actually a CLL patient, chronic lymphocytic leukemia. And that was a difficult group, that 17p deletion in CLL, and they've been developing drugs that have been approved in that area and are in trials for myeloma. So can you get at that 17p group with maybe some things that are effective in other illnesses?

Dr. Anderson:

Right. So I don't think we know for sure any way to definitely overcome the 17p deletion in myeloma, but some of the things that are looking very promising are the immune therapies, monoclonal antibodies such as daratumumab (Darzalex), such other therapies such as the checkpoint inhibitors. We're hoping combining these with the current therapies may help better overcome that. 

Andrew Schorr:

All right.  Let's go into that for just a second.  For in the last two or three years monoclonal antibodies have been kind of a big deal in myeloma, and then you add on to that what's been at work in lung cancer and melanoma, these checkpoint inhibitors manipulating the immune system.  So is this now landing hard on myeloma, and you think expanding the field and hope for patients?

Dr. Anderson:

Correct. As you have seen last year, two monoclonal antibodies were already approved for the use in myeloma.  I think current trials are trying to introduce those earlier on in therapy and in combinations with other medications that make them even more effective. 

Right now the ones that are approved are targeting surface molecules on the myeloma cells. Other ones that are in trials that look very promising are blocking the tumor?mediated immune disregulation, that is, there are molecules on the myeloma cells that block the immune system from recognizing them. And these newer antibodies are blocking that blockade, so… 

Andrew Schorr:

Sort of a decloaking device.

Dr. Anderson:

Right, exactly.  So that the immune system can better see the myeloma cells, and those I think are going to be game changers, and the early trials are very promising.  We're hoping to see continued success with those and finding out the right combination with those. 

Andrew Schorr:

Mm?hmm.  So lastly, for you, Dr. Anderson, when a patient comes to see you at UT Southwestern in Dallas, newly diagnosed, and they're terrified, you get to know their situation, of course, and personalize the medicine. But overall they and the family say will myself or my loved one, do I have hope, and given what you're seeing with all these different variations of myeloma, who would you say?  

Dr. Anderson:

I would say there's a lot of hope these days for patients with myeloma.  Many years ago or several years ago, we would say patients may have three or five years on average.  Now many experts are estimating eight to 10 years of average survival.  That means half the patients are probably living well beyond that, and that's before all the new drugs were approved last year. And so each year the survival is steadily improving in myeloma. 

Andrew Schorr:

Okay. So you're rewriting history. 

Dr. Anderson:

Right.

Andrew Schorr:

And you're looking at what's going on in the lab as well.  Are you excited about some of that?  

Dr. Anderson:

Yes, very excited. A lot of good things coming down the pipeline for myeloma, and just I think the future is bright.

Andrew Schorr:

One last thing then. Is the conversation with your doctor then about helping me be as well as I can now but also a bridge to what's next?

Dr. Anderson:

Right. I think a lot of the things we do in myeloma are trying to keep patients going, trying to keep them—keep their disease under control long enough until we have better drugs later.  We know that at this point it's still technically incurable and will become resistant to the current treatments. But as long as we can find treatments to keep them going for many years, we can hopefully bridge them to something even better later.

Andrew Schorr:

It's like a new antibiotic in a way. 

Dr. Anderson:

Right.

Andrew Schorr:

Okay.

Dr. Anderson:

Or sort of a maintenance of their disease, sort of like controlling hypertension or diabetes.  

Andrew Schorr:

Okay. And go on with your life. 

Dr. Anderson:

Right. 

Andrew Schorr:

Okay. Well, thank you for all you do, Dr. Anderson in Dallas, and thank you for being with us on Patient Power. 

Dr. Anderson:

Pleasure. Thank you.  

Andrew Schorr:

I'm Andrew Schorr. Great to get an update from Dr. Larry Anderson from UT Southwestern in Dallas.  And, of course, the key point always is 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. 

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