Are Myeloma Clinical Trials More Critical for African Americans?

Are Myeloma Clinical Trials More Critical for African Americans? from Patient Empowerment Network on Vimeo

Are multiple myeloma clinical trials becoming more critical for African, Hispanic, Asian, and other racial and ethnic groups as U.S. demographics change? Watch as Dr. Sikander Ailawadhi from the Mayo Clinic explains the impact of low trial participation rates by African Americans and his experience with some of his myeloma patients.

See More From the Diverse Partners in Your Myeloma Care Program


Transcript:

Rebecca Law:

Dr. Ailawadhi, the demographic in America is changing quite rapidly. Does this mean clinical trial participation is more critical than ever?

Dr. Sikander Ailawadhi:

It absolutely is, Rebecca. There is no way to kind of shine enough of a bright light on this topic. And I’m glad that we’re talking about it. There is more interest and also more thought process being put behind it. So you’re right in saying that the demographics are changing quite a bit. So we don’t know how and when we’ll get all the 2020 Census data; but over the past few years, the Census Bureau has been releasing updates where we know that Hispanics are the fastest growing racial ethnic group in the country and followed by Asians and African Americans are already a huge part of our demographic. So whatever we’ve discussed before when we said that patients can present at different ages, they can present with different symptoms, we also know from our experience of other diseases like hypertension, high blood pressure, diabetes, that the way certain drugs are metabolized could be inherently genetically different between, let’s say, African Americans and whites.

Unfortunately, in myeloma, we don’t know any of that, because clinical trial participation overall in cancer and also especially in myeloma, in a disease where African Americans may be affected by this diagnosis way more, the clinical trial participation is extremely low, in single digits. Which means that all the drugs that we utilize are FDA-approved, have become FDA-approved with not enough safety or benefit data in racial ethnic minorities. Now, I’m not saying that there is any problem in using those drugs; we use them, they benefit patients outrightly. But I think that underscores the importance that clinical trial data and generating robust safety and benefit data in all racial ethnic groups, considering that our demographic 10 years from today is not going to be what it is now or what it was 10 years ago. So understanding the dynamics of drugs, their impact, their benefit, their safety, in all racial ethnic groups becomes extremely important. And that can only be done when either clinical trials are specifically done in those populations, which, as Diahanna mentioned very well, appropriately before, it’s a very challenging thing, because there has been a traditional lack of trust there. So it becomes very important.

I can tell you that I had mentioned earlier that we’re doing a questionnaire just to understand why patients don’t want to go on clinical trials, or do they not want to go on. It’s just maybe, it’s an access issue. And I distinctly remember—I cannot take an anecdotal look at it, because I’m a clinician, I’m a researcher, I’m not supposed to look at the end of one. But I’ve had at least two specific cases where newly diagnosed multiple myeloma African American patients who’ve come, and I’ve very clearly explained to them that I’m just wanting them to consider going on this study with a one-time questionnaire. No samples, no bone marrows, no treatment, no nothing. All I want to understand is what they think about clinical trials. It’s a five-page questionnaire, 50 questions, multiple choices. We’re not taking any other data. Both these patients took the—they signed the consent, so they took the questionnaire. They took it home, we could do it electronically, but they said they wanted to think about it.

“Know what? I don’t feel comfortable with going on a clinical trial, even though it’s a one-time questionnaire. I’m going to kind of respectfully decline.” And I initially could not understand the whole thought process because it seemed, “Well, it’s just a questionnaire. We do so many surveys online.” But I’ve talked to them several times since then, and the thought process, which Diahanna brought, up about that lack of trust, that came out loud and clear. These patients are still receiving their treatment with us, because initially there were concerns, they said, “Well, if I don’t do the questionnaire, maybe this doctor won’t treat me.” They’re receiving their treatment with us, they are continuing, we’re good, we have a very good relationship, but they decided not to go on those. So I think clinical trial participation is extremely important, especially because of the changing demographics, like you said.

How Can a Myeloma Patient Advocate/Financial Advisor Help?

How Can a Myeloma Patient Advocate/Financial Advisor Help? from Patient Empowerment Network on Vimeo.

Diahanna Vallentine has not only experienced life as a multiple myeloma caregiver and patient advocate but also as a financial advisor to patients. Watch as she shares things she’s learned talking with African American patients—and how she helps those in underserved communities with affordable access to myeloma treatment.

See More From the Diverse Partners in Your Myeloma Care Program


Transcript:

Rebecca Law:

Diahanna, we know many of the roadblocks to treatment boil down to access and the web of financial toxicity. In the work you do, how are you helping patients make informed decisions, and can you please provide some examples?

Diahanna Vallentine

I think one of the main variables that causes the disparity overall before even treatment is needed is a mistrust in the African American community as a result of past historical treatments, experiments that were done on the African Americans. And I find that talking to anyone. If I were to walk into any community, African American community, or underserved community, that is one of the first things. They’re going to be mistrustful of me. And it’s a very difficult barrier to overcome. And that also leads over into African Americans contributing, being donors, African Americans participating in trials. It all feeds over into everything that’s done in the African American community or underserved community in regards to healthcare.

Some of the things that I am doing is I try to be available to talk to anybody, no matter what time of day it is, talk to them where they’re wanting—where their needs are, listening to them and not making preconceived notions about who they are, where they come from, what their experiences are. And it’s an ongoing educational program for me, because we all come in—as difficult as we are, come in with preconceived notions of what our knowledge is, what our experience is, and how we’ve treated other people. And that has been one of the things that I have been practicing every day when I talk to patients, whether it’s in-person or on the phone. I have a unique perspective having been a financial advisor for more than 20 years, being a caregiver to a myeloma patient, being a patient advocate and not having the fear. I guess that’s something I grew up with. Not having the fear to talk to people or ask people questions, and let them know from the on-go that we all have something in common.

And once you establish that area of trust, then everything else comes easy. When you realize that that could be me in that bed, that could be my mother, my father in that bed, then we all become as one, per se. And so some of the things that I do is I talk to a person at the level they want to be spoken to. I ask them how they want me to communicate with them, how often they want me to communicate with them, is there anyone else they want to be involved in it. And then I take that information that they’re trying to gather and find resources for them so that financial toxicity will not become an issue, so that we can discuss with their caregivers what the treatment plan is, what the anticipated cost is, so that we can work around some of those financial barriers that they may come up against. And whether that’s looking at their current insurance plans, insurance plans they may have access to in the future, whether it’s through a spouse or their employers, or Medicare, Medicaid. We try to anticipate what those things are so that the financial toxicity does not become a burden, which again, affects their care, because stress affects your care and your outcomes.

What Do Disparities in Multiple Myeloma Look Like?

What Do Disparities in Multiple Myeloma Look Like? from Patient Empowerment Network on Vimeo.

How do health disparities in minority populations with multiple myeloma play out? Expert Dr. Sikander Ailawadhi from the Mayo Clinic joined to discuss data about African Americans and Hispanic Americans with myeloma. Watch as he shares the average age of disease onset, how their symptoms vary, transplant rates, new treatment rates and more.

See More From the Diverse Partners in Your Myeloma Care Program


Transcript:

Rebecca Law:

Dr. Ailawadhi, for our audience who might not understand what health disparities in myeloma look like, can you give a high-level definition and overview, please?

Dr. Sikander Ailawadhi:

So, there are disparities at a lot of different levels, just taking the case of multiple myeloma, specifically. So, for example, patients from different racial and ethnic backgrounds tend to present in a different way. So, African Americans present with the diagnosis at a much younger age. The presence of the myeloma precursor called MGUS, or monoclonal gammopathy of undetermined significance, is seen much more frequently in African Americans. Even I would say include Hispanics into that, because Hispanics also get diagnosed at a much younger age. The disease presents very differently, for example, African Americans will present much more frequently with anemia or kidney dysfunction, but they will present with much lesser bone fractures in multiple myeloma.

So, those are disparities in how the disease presents or how it becomes kind of evident. Now, when we talk about disparities, one of the very stark shades of disparities in myeloma is how treatment is given or made available to patients, especially when we talk about racial minorities. So, there has been a lot of literature looking at this, and it has been seen that patients who belong to racial and ethnic minorities, they do not get access to the same kind of treatment in the same timely fashion. So, for example, African Americans and Hispanics are much lesser likely to get a transplant when it comes to myeloma treatment. Now again, I don’t want to say that improvements have not happened. The rates of transplant, rates of new drug use, have increased across the board for all races and ethnicities, but when we compare, the rate of that increase has been much slower in African Americans.

In fact, one of the studies that we looked at, some national data, it took Hispanics a little more than 100 days from the time of diagnosis to get to initial treatment with bortezomib (Velcade), which is a cornerstone drug and is used almost across the board for initial therapy. So, the treatment, there are disparities. And similar, there are some outcome disparities. While on the face of analysis, it’s been said several times that races or different racial sub-groups will have similar outcomes, I think the important thing to understand is that biologically, African Americans have a less aggressive disease, which means that if given the right kind of treatment, African Americans are supposed to in fact have a slightly better outcome than even whites. And there’s one large analysis that came out of the VA system from the Dana-Farber group last year, which was actually highlighting that, because they were able to show that in an equal access system like the VA, African Americans actually had better outcomes, or better survivable. So, there are disparities at the time of presentation, at the time of how treatment is received, how timely is the treatment, and in fact also, outcomes. Because I would say that having an equal outcome for a racial minority is not necessarily lack of disparity, that may actually be underscoring the disparity.

How Can I Get the Best Multiple Myeloma Care No Matter Where I Live?

How Can I Get the Best Multiple Myeloma Care No Matter Where I Live? from Patient Empowerment Network on Vimeo.

“Myeloma patients who are African-American and Hispanic typically get to the right treatment much later. In a lot of cases they may not get to the right treatment at all. We also know that the burden of cost of care is much higher for minority patients.” – Dr. Sikander Ailawadhi

There is a critical need to raise awareness of the treatment gaps among minority populations living with multiple myeloma. How can myeloma patients get the best care no matter where they live when factors like age, geography, socioeconomic status, ethnicity, gender, and insurance type heavily influence the path to empowerment?

In this replay, a panel of distinguished myeloma experts and patient advocates tackle how we achieve health equity for multiple myeloma patients no matter geography.

See More From the Diverse Partners in Your Myeloma Care Program


Transcript:

Rebecca Law:

Hello, I am Rebecca Law, and this is a Patient Empowerment Network program produced by Diverse Health Hub. We know the myeloma burden and treatment gaps among blacks highlights the critical need for raising awareness and working towards equal access for treatment. What we are really talking about is, “How can we achieve health equity and improve outcomes in multiple myeloma?” Our distinguished panel is at the heart of research for multiple myeloma patients of color, seeking a path for empowerment.

First on our panel is Diahanna Vallentine, a Board-Certified Patient Advocate and Myeloma Financial Coach with Myeloma Crowd. We also have Dr. Sikander Ailawadhi, Professor of Medicine in the Division of Hematology and Oncology at Mayo Clinic in Florida. We have Dr. Saad Usmani, Chief End Plasma Cell Disorders Program Director at Levine Cancer Institute, Atrium Health. And we also have Jenny Ahlstrom, founder of Myeloma Crowd. Thank you all for being a part of such an important program Diahanna, rooting out disparities and roadblocks within the myeloma community is a big priority for you. Why is that?

Diahanna Vallentine:

Well, disparities in healthcare include community access to care, ability to pay for care, feeling empowered to ask questions about care, understanding treatment plans, and many other variables that is impossible to pin point one that’s the primary driver, I guess, of this disparity. And as a black person, having been a caregiver and advocate to my husband who had myeloma for 12, almost 13 years, prior to him being diagnosed with myeloma and then going back into the hospital for various reasons, I found that there was a huge disparity in the way that he was treated. And some of those things have led me to do what I’m doing now with the Myeloma Crowd. There was an attempt for him to be put on an experimental treatment while he was on life support, with a doctor coming into the room with other doctors saying that, “This is what we’re going to do.” And I stood up and said, “Well, what is this treatment? What is the experiment? What were the outcomes of the experiment?”

And the doctor got in my face, six inches, yelling at me, and said, “You don’t have the right to ask questions, we’ll normally do this and you’ll find out about it later.” And that was very disparaging, especially since posted on all of their walls outside and one outside of my husband’s door, was, “Families are very included in the care and treatment of their patients”, because they found the outcomes were so much better. And that was not the case. That was one incident. Another incident was him being in the hospital, in rehab, and was almost comatose when I walked into the room, and they were insisting him get rehab treatment post hospitalization.

He was basically comatose. His resting blood pressure was 172 beats per minute. And it took me hours to get the doctor to even come in to see him before they actually agreed to release him to go back into intensive care, which was only a block away. And he died during that transport, and they weren’t able to resuscitate him at the emergency room doors. So, just the ability to be able to talk to the doctors, to be strong enough, empowered enough to question the doctors, to find out what the cost of care is going to be so that you can plan and make the appropriate and prudent decisions based on care, I found was somewhat lacking in the minority population.

And it had nothing to do with the education of the patient there, sometimes it had nothing to do with their economic backgrounds or situations, it was a matter of stereotypes that were being used, sometimes unconsciously, and I hope it’s unconscious, by some of the caregivers during his treatment. And as a result of that, some of the decisions that were made were not necessarily in a financial benefit of the patient, and therefore, when treatment plans were put into place there was a cost associated with getting help… Not just financial cost, but there was a physical cost and a mental cost for getting out of those treatments to get into better treatments. And that’s led me to work with Myeloma Crowd where they’re just so open, and to trying to help people in unserved communities, specifically people of color, to have the appropriate access and to have the appropriate treatment based on their needs.

Rebecca Law:

Thank you for sharing your story. Now, Dr. Ailawadhi, for our audience who might not understand what health disparities in myeloma look like, can you give a high-level definition and overview, please?

Dr. Sikander Ailawadhi:

Sure. Thanks Rebecca, and thanks for having me on this panel. Diahanna, first of all, I think I want to take a second and really appreciate you for having the courage to share that. And not only just to share that, but to devote your life and devote your time to this extremely, extremely important cause. We keep talking about so many advancements that are happening in the field of myeloma, and by all means there are. I don’t want to discount any of those advancements and how outcomes have improved tremendously for patients across the globe. But when we start looking at the details and the nitty gritty and we see that how the benefit or the impact of a lot of those things are different even based on race and ethnicity, it’s stark. So, Rebecca, you asked me to just talk about a very high-level discussion about what kind of disparities exist in myeloma? Or what do disparities mean when it comes to multiple myeloma?

So, there are disparities at a lot of different levels, just taking the case of multiple myeloma, specifically. So, for example, patients from different racial and ethnic backgrounds tend to present in a different way. So, African-Americans present with the diagnosis at a much younger age. The presence of the myeloma precursor called MGUS, or monoclonal gammopathy of undetermined significance, is seen much more frequently in African-Americans. Even I would say include Hispanics into that, because Hispanics also get diagnosed at a much younger age. The disease presents very differently, for example, African-Americans will present much more frequently with anemia or kidney dysfunction, but they will present with much lesser bone fractures in multiple myeloma.

So those are disparities in how the disease presents or how it becomes kind of evident. Now, when we talk about disparities, one of the very stark shades of disparities in myeloma is how treatment is given or made available to patients, especially when we talk about racial minorities. So, there has been a lot of literature looking at this, and it has been seen that patients who belong to racial and ethnic minorities, they do not get access to the same kind of treatment in the same timely fashion. So, for example, African-Americans and Hispanics are much lesser likely to get a transplant when it comes to myeloma treatment. Now again, I don’t want to say that improvements have not happened. The rates of transplant, rates of new drug use, have increased across the board for all races and ethnicities, but when we compare, the rate of that increase has been much slower in African-Americans.

In fact, one of the studies that we looked at, some national data, it took Hispanics a little more than 100 days from the time of diagnosis to get to initial treatment with Bortezomib, which is a cornerstone drug and is used almost across the board for initial therapy. So, the treatment, there are disparities. And similarly, there are some outcome disparities. While on the face of analysis, it’s been said several times that races or different racial sub-groups will have similar outcomes, I think the important thing to understand is that biologically, African-Americans have a less aggressive disease, which means that if given the right kind of treatment, African-Americans are supposed to in fact have a slightly better outcome than even whites. And there’s one large analysis that came out of the VA system from the Dana-Farber group last year, which was actually highlighting that, because they were able to show that in an equal access system like the VA, African-Americans actually had better outcomes, or better survivable. So, there are disparities at the time of presentation, at the time of how treatment is received, how timely is the treatment, and in fact also, outcomes. Because I would say that having an equal outcome for a racial minority is not necessarily lack of disparity, that may actually be underscoring the disparity.

Rebecca Law:

Wow, that’s very interesting. Dr. Usmani, can you speak to key studies you and your colleagues are leading, which focus on racial inequities plaguing myeloma research, and what are some of the commonalities you observe in the studies?

Dr. Saad Usmani:

Thank you, Rebecca. So, I want to acknowledge the fact that we’re getting this panel together to talk about some very important difficult questions when it comes to racial disparities here. And when I moved from the myeloma program in Arkansas to the City of Charlotte to start a myeloma program, one of the striking things that we saw was the proportion of African-American patients that we were seeing in our practice, almost 35% of the patients that we care for in our myeloma program are African-American. And before we came here, when we looked at the data beforehand out in the community, there was clearly disparity in access to care, as well as to cellular therapies, as well as clinical trials to African-American patients. So, within our whole department of hematology, across the board, not just for myeloma but for other hemalignancies, looking at racial disparities and how to overcome them became one of the big clinical research foresights.

And so, our group, as well as lymphoma and leukemia colleagues, have actually looked at the survival outcomes, the disease features at baseline and other features to document the clinical characteristics within our population. And I echo what Sikander has already mentioned, that we find that the disease appears to be less biologically aggressive in African-American patients, and when we give them the same access to care, their outcomes are actually better than the Caucasian patients. And I believe Sikander has already published some data looking at the SEER database from previous years, but in their novel therapies with the availability of produce from inhibition, immunomodulatory drugs, as well as monoclonal antibodies, we’re finding this difference is pretty clear. African-American patients do benefit more than other groups when it comes to myeloma therapy. So, our ongoing focus now within our community at large is to embark on an ambitious screening study for our county, which has close to 3 million inhabitants, and more than 30% of those are African-Americans. So, what we are trying to do is create a campaign of awareness, as well as start a screening project to identify plasma cell disorders early within our county.

Rebecca Law:

Well, that’s great. Dr. Ailawadhi, if there’s anything you’d like to add in regards to studies or commonalities that you have observed in studies.

Dr. Sikander Ailawadhi:

Rebecca, one thing I want to add to that, and just like Dr. Usmani mentioned, and I’m also kind of building upon a little bit on what Diahanna mentioned in the beginning. When we talk about disparities, there has been a lot of literature showing how disparities exist and where they exist. I think now we’re to the point that we need to try to address them, and we need to try and figure out how to overcome them. And in fact, whenever this term is brought up in the literature or in discussions, it’s always brought up very frequently, “Yeah, it’s got to be an access issue”, that African-Americans or Hispanics are going to be lower socioeconomic status and there could be inequalities and that’s why they don’t have access to the right treatment. But I think what Diahanna just mentioned at the beginning of the discussion, that underscores that very thing. They did not have lack of understanding, they did not have maybe lack of insurance or healthcare availability, ’cause her husband did have access to rehab facility, ICU, etc. But there are probably stereotypes, and the last thing we want to do is stereotype our research into that box.

So, for example, one of the studies we’re doing right now is exactly on this thought process of clinical trial and participation. So, we know that in the US, less than 20% of individuals who are eligible to go onto clinical trials, go onto clinical trials. And when it comes to minorities, the number is somewhere about 5%-7% only. So, while we talk about the fact that, “Well, minorities need to get onto clinical trials”, yeah, sure, but we need to understand why this disparity exists. So, we’re doing a study where we’re actually bringing that understanding to try and see, “Well, why don’t patients want to go on clinical trials?” I mean, as it is, even with whites, we do a pretty dismal job. So, we’re doing a questionnaire. The goal of that is to run the questionnaire in about 500 cancer patients who come to Mayo Clinic as an initial kind of visit, and we’re asking them what are their thoughts about clinical trials. And the hope is that we’re going to get about 200 whites, 150 African-Americans and 150 Hispanics, and then try to compare that. Because unless and until we know where the gaps are, we won’t be able to address that.

So, the only thing I want to add to what Dr. Usmani rightly mentioned was that it’s important not to box our research also in stereotypes, and to really try our best to try and overcome these disparities, which I think a movement has already started. I think it is gaining momentum. I think we need to just keep working in that direction, whether it is from lawmakers, from patient advocacy groups, from large foundations and societies, and even from pharma. I think there is a lot of support that is building towards it, we just need to keep moving in that direction.

Rebecca Law:

I agree. I think we all agree Dr. Ailawadhi or Dr. Usmani, what do we know about how myeloma behaves in patients of color versus other races? Are there differences in risk factors? And if yes, what do we know?

Dr. Sikander Ailawadhi:

So, Rebecca, what we have learned from studying myeloma and its precursor diagnosis, MGUS, in African-Americans and Hispanics and Whites is that in African-Americans MGUS presents much more frequently. In African-Americans, the conversion from MGUS to myeloma happens at a younger age. In African-Americans, myeloma is diagnosed at a significantly younger age. And for that matter, I would say also in Hispanics it is diagnosed at a significantly younger age. We know that in African-Americans, the myeloma risk stratification or the risk category is different because African-Americans, in general, have a less aggressive kind of variety of multiple myeloma so they tend not to have the high-risk mutations, which means that if they are given the similar treatments, we should be getting better outcomes, not just the same. So that is what is known about the biology and presentation.

Dr. Saad Usmani:

Yeah. So, in addition to what Dr. Ailawadhi has already mentioned, I’d say that in our experience, within our prospective data base we have close to 5000 individuals with various plasma cell disorders, and a third of those are African-American. For patients who’ve got active myeloma, I would echo what Sikander has already mentioned, African-American patients are presenting at a younger age. So, we see in our database a median of 58 years of age at the time of diagnosis with active myeloma requiring therapy, compared to 63 years for the Caucasian patients. And then even Hispanics are presenting at a similar age to the Caucasian patients, at least in our data set. But interestingly, we see a numerically lower incidence of high-risk features in these patients, and they do quite well in terms of treatment.

And the pattern of relapse is also very interesting. We are finding more biochemical relapses where we actually have time to act on that relapse, and with some luxury of time at hand, and get those patients to either clinical trials with much ease compared to the Caucasian patient population. And then I want to build on the availability of clinical trial piece that Sikander had mentioned. We have, at our program, been able to get a 30% plus enrollment of African-American patients on clinical trials. And a big part of that has been creating awareness about disease, about getting diagnosed early, within the community and building those community partnerships.

Rebecca Law:

Jenny Ahlstrom, thank you again for joining us. I have a question for you. So, in the COVID era where health disparities have been exacerbated for vulnerable communities, how can myeloma patients not get lost in the shuffle and become a disparity within a disparity?

Jenny Ahlstrom:

I think this is a big challenge. I think it’s a challenge for myeloma patients, and I think the first two months we were all stunned. From what I’ve heard now, the facilities and the myeloma specialists are doing an incredible job now in treating patients. But we wanted to know what the impact was on COVID in the myeloma population, including racial disparity groups. And so, we opened a study using our HealthTree platform for — I think we have 1100 patients who joined the study in a four-week period, which I was surprised and delighted at. And we’re trying to figure out, “How were they impacted? Did they have worse access to care? Who are the high-risk patients?”

I think that’s a topic that is really important, especially when you think about Black or Hispanic communities, because is it just that somebody has hypertension or diabetes regardless of race? Or is it something else that’s another layer on top of an access issue, or what Diahanna was talking about before? Just somebody, a practitioner, taking somebody seriously when they say they come in with COVID symptoms and needing the right care regardless of race. So, we decided to run that study and we’re working on the results right now to just learn more about that. But it does… COVID adds another layer of challenge for all patients, and I think even more so for the disparity groups. And that can include rural groups as well, in addition to ethic communities.

Rebecca Law:

Well, I can’t wait to see those results, and thank you for that information. What I would like to shift to now is exactly what you were talking about, myeloma care in underserved communities, and eliminating treatment gaps. So Diahanna, we know many of the roadblocks to treatment boil down to access and the web of financial toxicity. In the work you do, how are you helping patients make informed decisions, and can you please provide some examples?

Diahanna Vallentine:

I think one of the main variables that causes the disparity overall before even treatment is needed is a mistrust in the African-American community as a result of past historical treatments, experiments that were done on the African-Americans. And I find that talking to anyone… If I were to walk into any community, African-American community, or under-served community, that is one of the first things. They’re going to be mistrustful of me. And it’s a very difficult barrier to overcome. And that also leads over into African-Americans contributing, being donors, African-Americans participating in trials. It all feeds over into everything that’s done in the African-American community or underserved community in regards to health care.

Some of the things that I am doing is I try to be available to talk to anybody, no matter what time of day it is, talk to them where they’re wanting… Where their needs are, listening to them and not making pre-conceived notions about who they are, where they come from, what their experiences are. And that has been one of the things that I have been practicing every day when I talk to patients, whether it’s in person or on the phone. I have a unique perspective having been a financial advisor for more than 20 years, being a caregiver to a myeloma patient, being a patient advocate and not having the fear… I guess that’s something I grew up with. Not having the fear to talk to people or ask people questions, and let them know from the on-go that we all have something in common.

And once you establish that area of trust, then everything else comes easy. When you realize that that could be me in that bed, that could be my mother, my father in that bed, then we all become as one, per se. And so, some of the things that I do is I talk to a person at the level they want to be spoken to. I ask them how they want me to communicate with them, how often they want me to communicate with them, is there anyone else they want to be involved in it. And then I take that information that they’re trying to gather and find resources for them so that financial toxicity will not become an issue, so that we can discuss with their caregivers what the treatment plan is, what the anticipated cost is, so that we can work around some of those financial barriers that they may come up against. And whether that’s looking at their current insurance plans, insurance plans they may have access to in the future, whether it’s through a spouse or their employers, or Medicare, Medicaid. We try to anticipate what those things are so that the financial toxicity does not become a burden, which again, affects their care, because stress affects your care and your outcomes.

25:21

Rebecca Law:

Absolutely. Absolutely. Also, Diahanna, what do you see as some of the main drivers of health disparities in targeting the underserved communities?

Diahanna Vallentine:

Wow. That’s a big one. That’s one of the things that… I don’t know if there is enough knowledge in the underserved communities to know what resources are available. A lot of people have not heard of The Myeloma Crowd. A lot of people are not aware of The Leukemia and Lymphoma Society because, unfortunately, I felt that myeloma was a step child of The Leukemia and Lymphoma Society because that’s all you heard about, was leukemia and lymphoma. You never heard about the myeloma. And when I became the board chair, I realized, “Oh my God, there’s that other blood cancer out there that nobody’s talking about, the one that my husband actually succumbed to.” So, I think getting into the community so people can… Where they are, not where we expect them to be, but where these people actually are, to let them know there are resources available to them. And making it an open environment, a non-transparent environment where the trust will come and that those disparities can be seen and they can be acknowledged and worked on at that point.

Rebecca Law:

Great, thank you. The other question, and anyone can chime in. You hear stories all the time like what Diahanna described earlier. Can patients truly get the best myeloma care no matter where they live?

Diahanna Vallentine:

I found that even people who are in regions where there are specialists for myeloma found that they didn’t know there were specialists there or they had to go travel outside of their treatment facility to get care. And for some people, that is an extreme hardship not only to be able to have the access to travel, the funds just to be there, the days of testing that might be involved, understanding what their insurance is going to cover or won’t cover if they’re in or out of network. There is a huge problem with that. There aren’t enough… I don’t think there is enough information in the places where those people are, whether it’s the doctors allowing this information to be in their plan. Unfortunately, a lot of African-Americans, when they do seek medical care, they’re comfortable with those doctors. They’ve been with those doctors for a long time and they have a difficult time separating or using that doctor to collaborate with a specialist. And I think therein is an inherent problem, is letting them know what resources are available, and then how to get to those resources.

Dr. Saad Usmani:

So, I want to build on what Diahanna has shared. I think in general, in the year 2020, there are more resources available to myeloma patients across the country. There’s more awareness by virtue of having organizations like The Myeloma Crowd doing good work and spreading knowledge amongst the myeloma patient community, as well as for caregivers. There’re aren’t enough myeloma experts in the world to see every myeloma patient, but there’s no reason why any given myeloma patient regardless of which geographic area they live in can’t have a myeloma expert in their back pocket, if and when they need help. It takes quite a bit for a patient to develop trust and a relationship with their own physician. And our job as myeloma experts is not to take care of every myeloma patient, but be there for them and provide guidance if and when needed, along with the physicians who are already caring for that patient. And in the era of COVID-19 pandemic, and Dr. Ailawadhi can speak to this as well, the capability to do virtual consultations and provide distance consults and advice to patients has also opened up a big opportunity for patients throughout the country. I do not see a reason why all myeloma patients can’t get the best optimal care in today’s day and age.

Dr. Sikander Ailawadhi:

I completely agree with that. And actually, I was going to add exactly the same thought process, that this is a very difficult time for everybody, myeloma patients and for literally the whole of this world with the COVID-19 situation. But I think this whole concept of telehealth has come about as somewhat of a silver lining. So I can tell you, I can share from at least my experience right now in clinic, that when we get a request for a patient to be seen, the way we have it set up is that actually a triage request comes for one of us in the disease group to confirm that the patient is actually coming to the right physician. So if, let’s say, someone by mistake may have said myeloma, but the patient has leukemia, then one of our job would be to make sure that rather than coming in and then the patient finding out that, “Hey, you are with the wrong doctor”, they end up seeing the right doctor even from get-go. So, when we’re doing these triage requests and we’re sorting them out, patients are actually reaching out and asking directly, saying, “Hey, I would like another opinion. I’ve been told I have a diagnosis of myeloma or smoldering myeloma or MGUS or something, I’m going to be sending in my records and I would like to do a virtual consult.”

And so, patients are actually reaching out that way, which gives us this opportunity that, “Hey, not everybody can come here, let alone the fact that we cannot accommodate.” And I’m not even going get to the point of we not being able to accommodate. We’re doctors, we’re institutions, health care workers… This is our job, to help as much as we can. But looking at it from the patient’s perspective, the patient cannot always have the resources to come. It’s not appropriate for us to expect, “Hey, we’ll build a hospital, you’ll have to come here.” I think in today’s day and age, when we can do so much more with technology, it’s… Healthcare was actually in some way lagging behind, but I’m glad that it’s coming up to that step. So, to be able to get the patients to get the consult, to get the opinion, to get that reassurance that what they are doing, what they’re getting in their area, in their community is actually right, because I can tell you and I think Dr. Usmani will agree with that, that nine out of 10 times, we actually fully agree with what’s being done for the patient or by the physicians, it’s just that they may not have access to a clinical trial, so they’re seeking it or the patient is just looking in for that reassurance.

So, I think now we have that opportunity to provide it for the patient. So, what we need is awareness, so that the patients, like Diahanna mentioned, they feel confident about asking for an opinion, asking for a consult and knowing that they have resources where Myeloma Crowd helps, where Leukemia Lymphoma Society helps, where International Myeloma Foundation helps, where they kind of bridge this knowledge gap. Once the patients know… It’s easier said than done to say, “Hey, be your own advocate.” But if a patient or a caregiver does not know what advocacy is, they’re not going ask the right questions. So, we need to educate them and we have the tools that we can help more patients across the world, across the country, and bring the advancements of myeloma care to everyone.

Jenny Ahlstrom:

Dr. Ailawadhi, I think that point is so important, and Diahanna referred to it earlier. Let me give you an example. So, we went across the country and visited 50 cities while we were building this HealthTree platform, we probably met with 850 patients. And we wanted to see all ethnic communities, all rural, big cities. We just wanted to see across the board what was happening. And as part of that, we met a woman named Cassandra. She had smoldering myeloma, she had severe back pain, she was just enduring this back pain for over a year. And because we met and we built that relationship, that one-on-one relationship, she felt comfortable calling me and saying, “I have this really severe back pain, what do I do about it?” She didn’t know that… She was going to a major cancer center, but no myeloma specialist necessarily, and I had to say, “What you’re enduring is inexcusable, you really need to push.” And she had been pushing, but she didn’t really know how.

So, I set her up with an appointment with a myeloma specialist that was just an hour drive away, and then she was able to get the proper care. So sometimes it’s this training of, “How are you an advocate? What education do you need to acquire so you can ask the right questions of your doctor? You should be seeing a specialist; how does that process work?” And just really walking the patients through this, because it’s confusing and they don’t feel good, and there is a lot. So, it’s really important, the points that both of you made.

Rebecca Law:

Yes, it is. Going back to telemedicine, do you guys think telemedicine will be a game changer for underserved communities, especially patients facing a myeloma diagnosis?

Jenny Ahlstrom:

I say yes. Completely.

So, in our study, we saw that, we asked that question, “Did you use telemedicine beforehand?” And either they said yes or sometimes, and it was at 9% prior to COVID, and then after COVID it’s at 60%. So, patients are using it, and I’m hearing some of the researchers, and I’m sure they’ll have their own experiences, say, “We never realized how much we could do via telehealth.”

Dr. Saad Usmani:

So, this is a time of innovation. I think we’ve seen a lot of innovative approaches to taking care of patients come about over the last four months. One of the limiting steps in doing virtual medicine however, is the reality that it does require insurance coverage. And so, Medicaid allows the virtual visits to be a billable service during the COVID pandemic, but I think right now there’s a push to reverse that ruling by the end of August. So, it will take a lot of partnership between patient support group organizations to actually push for this, because there’s no reason why you want to go back to the dark ages. You want to have these platforms available to provide better care for patients. It just opens up so many possibilities of providing optimal care to patients, especially in the remote areas. So, I think this is going to be a very active area of discussion, and will require engagement with legislature on parts of both physician organizations as well as patient organizations.

Rebecca Law:

Okay, let’s move on to disparities and its impact on myeloma clinical trial participation. So, Dr. Ailawadhi, the demographic in America is changing quite rapidly, does this mean clinical trial participation is more critical than ever?

Dr. Sikander Ailawadhi:

It absolutely is, Rebecca. There is no way to kind of shine enough of a bright light on this topic. And I’m glad that we’re talking about it. There is more interest and also more thought process being put behind it. So, you’re right in saying that the demographics are changing quite a bit. So, we don’t know how and when we’ll get all the 2020 census data; but over the past few years, census bureau has been releasing updates where we know that Hispanics are the fastest growing racial ethnic group in the country and followed by Asians. And African-Americans are already a huge part of our demographic. So whatever we’ve discussed before when we said that patients can present at different ages, they can present with different symptoms, we also know from our experience of other diseases like hypertension, high blood pressure, diabetes, that the way certain drugs are metabolized could be inherently genetically different between, let’s say, African-Americans and Whites.

Unfortunately, in myeloma, we don’t know any of that because clinical trial participation overall in cancer and also especially in myeloma, in a disease where African-Americans may be affected by this diagnosis way more, the clinical trial participation is extremely low, in single digits. Which means that all the drugs that we utilize are FDA-approved, have become FDA-approved with not enough safety or benefit data in racial ethnic minorities. Now, I’m not saying that there is any problem in using those drugs; we use them, they benefit patients outrightly. But I think that underscores the importance that clinical trial data and generating robust safety and benefit data in all racial ethnic groups, considering that our demographic 10 years from today is not going to be what it is now or what it was 10 years ago. So, understanding the dynamics of drugs, their impact, their benefit, their safety, in all racial ethnic groups becomes extremely important. And that can only be done when either clinical trials are specifically done in those populations, which, as Diahanna mentioned very well, appropriately before, it’s a very challenging thing because there has been a traditional lack of trust there. So, it becomes very important.

I can tell you that I had mentioned earlier that we’re doing a questionnaire just to understand why patients don’t want to go on clinical trials, or do they not want to go on. It’s just maybe, it’s access issue. And I distinctly remember… I cannot take an anecdotal look at it because I’m a clinician, I’m a researcher, I’m not supposed to look at the end of one. But I’ve had at least two specific cases where newly diagnosed multiple myeloma African-American patients who’ve come, and I’ve very clearly explained to them that I’m just wanting them to consider going on this study with a one-time questionnaire. No samples, no bone marrows, no treatment, no nothing. All I want to understand is what they think about clinical trials. It’s a five-page questionnaire, 50 questions, multiple choices. We’re not taking any other data. Both these patients took the… They signed the consent, so they took the questionnaire. They took it home; we could do it electronically but they said they wanted to think about it.

And for both these patients, they called back and they said, “You know what? I don’t feel comfortable with going on a clinical trial even though it’s a one-time questionnaire. I’m going to kind of respectfully decline.” And I initially could not understand the whole thought process because it seemed, “Well, it’s just a questionnaire. We do so many surveys online.” But I’ve talked to them several times since then, and the thought process, which Diahanna brought, up about that lack of trust, that came out loud and clear. These patients are still receiving their treatment with us because initially there were concerns, they said, “Well, if I don’t do the questionnaire maybe this doctor won’t treat me.” They’re receiving their treatment with us, they are continuing, we’re good, we have a very good relationship, but they decided not to go on those. So, I think clinical trial participation is extremely important, especially because of the changing demographics, like you said.

Rebecca Law:

Jenny, so many experts try to tackle this problem. What are organizations like Myeloma Crowd doing to open up access to those who have access issues?

Jenny Ahlstrom:

Well, I think this is a very common problem, and one I think a lot of the different foundations are working on. It’s a big challenge, as you heard. Like when we were talking about the clinical trial aspects, it’s hard to join a clinical trial regardless of your race, and then you layer on the trust issues or travel or those types of issues and it becomes even harder. I think we need to go back to what Diahanna said. To me, this is all about relationships. So, if you’re building solid on-the-ground relationships with individuals, they’re more likely to understand the importance of becoming your own advocate or getting educated about the disease so you can ask the right questions. We’re trying to build a lot of different tools for patients to use, but then you need to go back and invite them to use them or kind of teach them to use them because you have that relationship. So, for example, we’re building HealthTree University, where Dr. Usmani and many others, and Dr. Ailawadhi, hopefully you as well, will participate in teaching myeloma patients about multiple myeloma. So, we have over 30 classes planned, over 600 lessons. And that’s something that people would be able to go and get educated about myeloma at home, so that when they go to the clinic and are talking to their doctor, they start to ask better questions. So, that is kind of the beginning.

Rebecca Law:

Dr. Usmani, as you can see by turning on any news station, racism is very real in the US. Do you think some experts may be less willing to give patients state-of-the-art treatment, given they feel they have a special resilience?

Dr. Saad Usmani:

I think the racism question, it’s certainly at the top of our minds right now, especially in the context of recent events. But it has been inherently prevalent, and there’s been more of a divide in our country over the last five to six years. And I don’t want to get too political, but the bottom line is this issue is real. And for the most part, the physician community tends to be agnostic to it because with our job is to serve humanity, our job is to provide the best possible care. There are going to be, just like in any other profession, average, above average and exceptional physicians.

Diahanna Vallentine:

I have experienced it in my family with my husband, and I have been in hospital as an advocate watching other people experience the same thing. And one of the prevailing things that’s really surprising to me is that even in a educational setting in medical schools, there are a lot of physicians in training, and physicians that are practicing, believe that African-Americans do not have the pain, their skin is too thick, they don’t experience pain as other Caucasians may experience, and therefore may not be prescribed pain medicine as appropriate. And that could become very, very difficult, especially if you’re treating a chronic and sometimes a very painful disease as myeloma, with bone fractures and things. And so, their health outcomes, I think, are somewhat mitigated or lessened as a result of that type of treatment. My husband did experience that, and it became very difficult for us to finally get a physician to say, “Yes, he does have… Yes, there is a fracture, a multiple fracture. And there is bone pain associated, and aspirin and Tylenol is just not going be enough to manage his pain.” And I’ve witnessed that on several occasions with other people as well. So that is an ongoing problem. When we talk about disparities in access to, or getting into the community, I think one of the predominant problems is African-Americans and maybe people of color will be more likely to associate people that they relate to.

And that person of relation may be another African-American, a professional maybe in a community that can talk to them. Because now they see a face that looks like them. They have a face that may have experienced some of the same things they are going through, and they are open and willing to accept recommendations or information from people that they can relate to. And I think a lot of professional communities do not have that available, whether it’s through lack of education for minorities to be in positions like that, or just a lack of understanding what the actual community needs are.

Rebecca Law:

We tackled a big topic today, and as I close, I want to ask each of you to answer a question. So how can we achieve health equity in the care of multiple myeloma patients sooner rather than later?  

Diahanna Vallentine:

I think we all appreciate the fact that the African-American or underserved communities do not have enough people that are either willing or know that we need to go into those communities the way they are, meet the people the way they are, so that we can provide them with education, with resources, that are available. I think that is one of the first steps. And fortunately, or unfortunately, with the racial problems we’re having in our country right now, a lot of governors and mayors are opening up opportunities that we got to get into the communities. And I think this might be a great opportunity for the myeloma community to perhaps step up and say we would like to be presented or represented in the community when there are funds and when the interest is really high. I think that if we could establish a foot-hold that way, then we can just go on and work toward lessening that gap and disparities in the undeserved communities.

Sikander Ailawadhi:

Diahanna, that was really nicely put. I think what I can add to that is that we basically are already seeing a lot more discussion, a lot more focus coming up to this topic of racial disparity in multiple myeloma at different levels. So, what we need to do is continue to build upon that momentum, continue to build the relationships so that there is actually a combined force from various aspects. I would love to do telehealth going forward, but like Dr. Usmani brought up, if there is not enough reimbursement or leadership or legislation to support all of that, then our wants and needs may not be served fully. So, I think developing those relationships, developing those partnerships and moving forward as we’re gaining momentum to address this particular question, this particular issue is extremely important. And I feel it is more hopeful and exciting in the future as compared to where we’ve come from.

Jenny Ahlstrom:

I would just reiterate what Diahanna said. I think it’s in building the programs that are simple enough for everybody to understand and utilize that makes just the usability of them as available as possible, and then building that relationship in those communities where the needs are. I totally agree with what Diahanna’s saying, you need to take the programs to the people where they are and not to expect them to come to your programs.

Dr. Saad Usmani:

I agree with everything that has been said on this topic. And I have to say that this is going to be a two-way dialogue, a two-way partnership. That’s the only way that this can succeed moving forward. Racial disparities are an inherent part of our everyday life, whether it’s in healthcare, whether it’s in other interactions we have with each other, and there’s a lot of historic perspective and context to that. This is not going to be a quick fix; this is going to be a long-term process. But it will have to be a partnership. And I’m talking on a broader level with myeloma care and better survival outcomes for all myeloma patients as the goal. But then looking at the overall societal goals as well, and trying to see how we can remove the inherent biases that everyone has and develop more fruitful productive relationships going forward in our respective geographic regions, but overall in our country as well. I think that’s the overarching theme and tone of the conversations we’re having in the country right now, and it certainly makes sense to do that for myeloma care as well.

Rebecca Law:

I want to take the time to thank each and every one of you for joining me today. On behalf of the Patient Empowerment Network and Diverse Health Hub, I am Rebecca Law. Thank you.

A Multiple Myeloma Advocate’s Uphill Battle to Care

A Multiple Myeloma Advocate’s Uphill Battle to Care from Patient Empowerment Network on Vimeo.

Diahanna Vallentine of Louisville, Kentucky shares how advocating for her late husband of 28 years following his myeloma diagnosis “felt like an uphill battle.” As any care partner in this position, Diahanna’s multiple myeloma research uncovered more questions than answers. When she sought clarity from her husband’s care team, she was met with hostility. The toll of emotional and financial toxicity ate into their life savings. Following her husband’s passing, Diahanna has made it her life’s mission to help other patients and families facing a multiple myeloma diagnosis avoid inequitable roadblocks to care.

Diahanna’s advice,“Find your voice, talk to your doctor and feel empowered to question your care team. These actions are key to staying on your path to empowerment.”

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Is Myeloma Hereditary? The Facts.

Is Myeloma Hereditary? The Facts. from Patient Empowerment Network on Vimeo.

 Can myeloma be inherited? Dr. Irene Ghobrial, a myeloma expert and researcher, explains whether myeloma is hereditary.

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

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Transcript:

Patricia:

How about this one? “Myeloma is hereditary.”

Dr. Ghobrial:

It’s a very good question. So, it’s not hereditary specifically. However, there is a 2x increased risk in family members, and that goes back to that PROMISE study.

We are screening people who have first-degree relatives with myeloma. So, what does it mean? Why do I have a higher risk if I have a family member with myeloma? I recently saw a patient who – the patient had myeloma, the mother had myeloma, and the grandmother had myeloma, and you’re thinking, “Okay, there is something we’re inheriting.”

So, we don’t know. There are some susceptibility genes that we could potentially be inheriting, germ line, and we’ve done something called “germ line,” which means you have it from Mom and Dad, that can increase your risk. It could be other factors come in and we’re still trying to understand all of these factors. What are the genes that can increase your risk? Is there an immune factor that can increase your risk, and can we identify those early in the family members?

The Truth About MGUS

The Truth About MGUS from Patient Empowerment Network on Vimeo.

Is MGUS the same as smoldering myeloma? Myeloma expert, Dr. Irene Ghobrial, provides a detailed overview of MGUS, including the risk of progression.

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

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Transcript:

Patricia:

What about this one? “An MGUS diagnosis will lead to myeloma.”

Dr. Ghobrial:

Great question. So, let’s talk about MGUS in general. In the general population, once you’re over the age of 50, there’s a three percent change of having MGUS incidentally found, and that’s known from the big studies from Dr. Robert Kyle. Any of us walking around probably may have MGUS, and we don’t know.

We started recently a big study called the PROMISE study where we actually screen for the first time to look for myeloma – or, for MGUS – and the reason for that is we said, “You go screening for mammography with breast cancer, you go screening with a colonoscopy for colon cancer; we don’t screen for myeloma, which is an easy blood cancer with a blood test. Let’s screen for it.” So, that’s available online – promisestudy.org.

The other thing that we said is if you have MGUS, your chance of progression is only one percent per year. That’s very important to know. So, that means that in 10 years, you have a 10% chance of progression to myeloma. In 20 years, you have a 20% chance. So, if you’re 70 or 80, you may have something else that happens before you even develop myeloma or before you are at risk of myeloma.

However, that doesn’t mean that you don’t have the chance. You have a very small chance; it’s a precursor to myeloma, but it’s one of the biggest precursors to myeloma, so we always tell you, “Please go see your doctor, please do follow up with us because the one thing that’s important is we catch it early before it happens.” So, it does not always go to myeloma, but if we live for another 100 years, it may actually progress to myeloma because of the 1% chance per year.

Patricia:

How about this one? “MGUS and smoldering myeloma are the same.”

Dr. Ghobrial:

That’s not true. That’s a very important question. So, in general, MGUS is diagnosed as having less than 10% plasma cells and a small monoclonal protein, less than 3 grams, and you don’t have any organ damage.

Smoldering myeloma – and, the name says it; it’s almost myeloma, it has a higher chance of progressing to myeloma – in general, it’s about 10% per year, and usually, the bone marrow has more than 10% plasma cells. Now, you start telling me as a patient, “Well, if my bone marrow is nine percent, I’m MGUS, and if it’s 11%, I’m smoldering myeloma, that doesn’t make sense.” So, it’s correct. In general, those demarcations or numbers are more for us as physicians to talk to each other about what we’re calling rather than the patient themselves. The patient is a continuum.

So, you may move from MGUS to smoldering at a certain point, and it’s not really that extra percentage of bone marrow that moves you into the 10% risk. In general, again, smoldering myeloma, you have a higher chance of going to myeloma. So, I saw a patient recently who’s 30 who has smoldering myeloma. The chances of progressing to myeloma is 10% per year. In five years, you have a 50% chance.

You want to make sure that patient is followed up carefully, and you want to offer, potentially, clinical trials because we want to prevent progression. The hope in the future is you don’t want until you have lytic lesions, fractures in your bones, kidney failure, and then we treat. The hope is we treat you earlier and we can make a huge difference in that early intersection for myeloma.

Patricia:

It sounds like staying engaged with your care team is critical.

Dr. Ghobrial:

Absolutely, and I would say myeloma is a specialty field. Come and see a myeloma expert, wherever it is, even for a one-time consult, because it’s really complicated and it’s not a common disease, so it’s not something easy for everyone to know what to do with MGUS, what to do with smoldering, what to do with overt myeloma. I relax for the first time. All of these things are important, and just like you go and see the best specialist in anything, I would say care about your myeloma in a very specific way, ask your doctor questions, go online and look it up, and always ask an expert if you want to have a second opinion.

Why Should Myeloma Patients Visit the Dentist Frequently?

Why Should Myeloma Patients Visit the Dentist Frequently? from Patient Empowerment Network on Vimeo.

 Dr. Irene Ghobrial, a renowned myeloma specialist, explains why myeloma patients should be more vigilant about visiting the dentist.

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

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Transcript:

Patricia:

Dr. Ghobrial, let’s talk about some of the things that patients are concerned about when they come in about treatment side effects, and maybe some of those things aren’t true. Myeloma patients should visit the dentist more frequently.”

Dr. Ghobrial:

So, there is something about the bisphosphonates that we give patients, and they can cause – in a very rare number of patients – something called osteonecrosis of the jaw.

In the old days, when we didn’t know about that side effect, people would go get a root canal, come back, and have a big problem of osteonecrosis of the jaw with severe pain, and it doesn’t recover.

So, we’ve learned our lesson. We know very well that we hold Zometa or zoledronic acid if they’re getting any procedures. We make sure they don’t get surgical procedures – it doesn’t mean don’t get dental cleaning, please do the usual things for dental health, but don’t go into surgical procedures when you’re getting zoledronic acid – and we’re very careful with that.

We talk to our patients. Most dentists know about it, so I think this is something that in the old days, it was a problem. Now, we know how to medicate that.

The Truth About Myeloma Treatment Side Effects

The Truth About Myeloma Treatment Side Effects from Patient Empowerment Network on Vimeo.

 Managing myeloma treatment side effects can be overwhelming. Dr. Irene Ghobrial reviews common side effects and shares how life can go on, even while undergoing treatment for myeloma. Download the Program Resource Guide, here

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

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Transcript:

Patricia:                      

What are the common myeloma misconceptions about treatment side effects?

Dr. Ghobrial:              

I think the biggest thing is the loss of hair, the nausea, and fatigue, and to the point that I cannot travel, I cannot see my family, I’m gonna be so immunosuppressed. And again, that’s a huge misconception. Yes, there is toxicity for every drug. Even if you take aspirin, you have toxicity from it.

But, every drug has risks and benefits, and currently, the combinations we have are just impressive that they are well tolerated in general. I’m not saying there is no side effect – there is, for every different class of agents, there are, and you will go through those side effects with your doctor in detail – but in general, yes, you’re slightly immunosuppressed, you have to take care of it, and I said it yesterday to one of my patients – if someone is looking very sick in front of you, don’t go and hug them.

Christmas is around the corner, and we want to make sure people celebrate and enjoy life and enjoy the holidays with their family members.

Patricia:                      

Dr. Ghobrial, let’s talk about some of the things that patients are concerned about when they come in about treatment side effects, and maybe some of those things aren’t true. You tell me. Treatment side effects are unavoidable – we already talked a little bit about that. How about this one? “Myeloma patients should visit the dentist more frequently.”

Dr. Ghobrial:              

So, there is something about the bisphosphonates that we give patients, and they can cause – in a very rare number of patients – something called osteonecrosis of the jaw.

In the old days, when we didn’t know about that side effect, people would go get a root canal, come back, and have a big problem of osteonecrosis of the jaw with severe pain, and it doesn’t recover.

So, we’ve learned our lesson. We know very well that we hold Zometa or zoledronic acid if they’re getting any procedures. We make sure they don’t get surgical procedures – it doesn’t mean don’t get dental cleaning, please do the usual things for dental health, but don’t go into surgical procedures when you’re getting zoledronic acid – and we’re very careful with that.

We talk to our patients. Most dentists know about it, so I think this is something that in the old days, it was a problem. Now, we know how to medicate that.

Patricia:                      

Sure. How about this one? “Treatment causes increased risk for blood clots.”

Dr. Ghobrial:              

So, a couple of the drugs that we have – especially immunomodulators – can increase your risk for DVTs, blood clots, or pulmonary embolism, PE. So, the first thing we say is, “Let’s assess your baseline risk.

Are you someone who is at risk of clotting anyways?” Remember, myeloma also increases your risk of clotting, so you’re double. So, if you are at a high risk of clotting, then we would give the full anticoagulation. If you are not, then we would say aspirin is good enough to control that inflammation and endothelial damage that happens early on with therapy, and that can take care of it.

Patricia:                      

How about this one? “Side effects can be managed by diet and lifestyle.”

Dr. Ghobrial:              

So, I am a big believer that exercise and good, healthy living helps you in general. It makes your mood better, it makes you feel stronger, it gives you that energy because of the fatigue from the side effects, it helps with the dexamethasone because dex is a steroid, so you’re gonna be hungry, you’re gonna be eating more, and the on-and-off makes you fatigued and tired.

So, absolutely, diet and good healthy living – I’m not saying you have to go into extreme starvation and things like that. We say in general, be good, healthy living; exercise if you can.

Patricia:                      

What do you hear from your patients about side effects and treatments that they may think is true?

Dr. Ghobrial:              

I think neuropathy is very important, and we underestimate the neuropathy, so if you have numbness or tingling, tell your doctor.

That comes from Velcade; it comes from thalidomide when we used to use thalidomide, but it can happen in many patients who have an underlying amyloidosis and we did not diagnose it yet, or it can just happen as you go on from myeloma, rarely. So, tell your doctor about this.

I think the fatigue is very important to know about it because people suddenly change their life, and they want to know about that. I think the rashes that can happen with many of the drugs are very important to know about so that you’re not surprised when you get the rash. We know, for example, Revlimid can cause itching of the scalp, and that’s something that if we don’t tell the patients and they start going like this, then there is a problem.

So, it’s small things, but we want to let them know. We usually tell the patients everything, to a point of just going through all the side effects. It’s better to be aware of it, and then, if you get or not, at least you were aware.

Patricia:                      

Sure. How does one distinguish treatment side effects from comorbidities like fatigue?

Dr. Ghobrial:              

I think that’s important, and again, talking to your doctor is very important. Keeping a diary on the side is very important because you may have had some of those problems, and that could be from myeloma before you even started the drugs, and making sure that we know what’s from myeloma, what’s from your thyroid issue, what’s from your lung problems if you have asthma or COPD, what’s your diabetes if you have that or your other medications, from what are you doing with those medications.

I think that’s why when you start therapy, we tell you, “Try not to take too many other medications that we don’t know about, herbal medicines and other things, because then we don’t know what are the side effects and what’s causing what.”

Patricia:                      

Sure. You mentioned neuropathy. Let’s talk a little bit about what that is.

Dr. Ghobrial:              

So, neuropathy can come in different ways, but the most common one is numbness and tingling that you have in your tips of toes and tips of your fingers, and that can happen from medications, as we said, or from the underlying myeloma or amyloidosis. It can be painful, and we’re careful that if you have this, tell your doctor because if it get worse and worse, it’s very hard for us to reverse neuropathy, so just always tell us because we can stop the drug, we can decrease the dose rather than having you go through it.

Addressing Clinical Trial Misconceptions: The Facts

Addressing Clinical Trial Misconceptions: The Facts. from Patient Empowerment Network on Vimeo.

Dr. Irene Ghobrial, a myeloma specialist and researcher, dispels common myths associated with clinical trials, including a review of each phase of the clinical trial process.

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

See More From Fact of Fiction? Myeloma

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Evolving Approaches to Myeloma Treatment: Staying Up-to-Date

Transcript:

Patricia:

Sure. What about clinical trials? What common misconceptions do you hear from patients enrolling in trials?

Dr. Ghobrial:

There’s a lot of misconceptions, and it’s unfortunate. I would say I would absolutely go on a trial if I can. I’m a believer in clinical trials because they’re the way forward to bring in new therapies and new options. I think a lot of people think that we’re experimenting on them when we’re doing clinical trials, meaning that it’s first in human, meaning it’s the first time we try this drug, and I would say that most of our clinical trials are not first in human.

They’re not the very first time we’ve tried them. Likely, those are drugs we’ve tried, we know the side effects, we know the toxicity, but it’s the first time we’ve put it in a different combination or it’s the first time we’ve put it in a specific subset of patients to look at response or at overall survival.

Most of the trials – so, before you decide “Oh, it’s a trial,” just think – is this a phase 1, a phase 2, or a phase 3? Phase 1 are usually that first time that we try in a population. Phase 2 are usually we know already what happens, we know the toxicity, we’re bringing it to look at the response rate in general or the survival, and then, phase 3s are the bigger studies, going to the FDA for approval.

The second thing is you want to think about is there a placebo arm in it. Most of my patients really worry about “Oh my God, you’re gonna give me the placebo,” and I’m like, “No, we don’t have a placebo arm in this trial. You’re taking the drug that we tell you about.” So again, depending on the trial – read it carefully – there may be a placebo arm, but in most of them, it’s not a placebo arm.

So, I would personally go ask the doctor every time, “So, you’re talking about standard of care. What else do you have? Do you have clinical trial options or not? What’s new?” Almost every single new drug that we’re gonna get approved in the next 5-10 years from now is what we have today in clinical trials. It would be cool to try and get access to those earlier.

Patricia:

So, there’s a significant amount of vetting that goes on before clinical trials are actually in process on humans.

Dr. Ghobrial:              

Oh, absolutely.

Myeloma Treatment Options: What’s Available?

Myeloma Treatment Options: What’s Available? from Patient Empowerment Network on Vimeo

Renowned myeloma researcher, Dr. Irene Ghobrial, provides an overview of current treatment options for myeloma, including an explanation of the now commonly used four-drug regimen.

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

See More From Fact of Fiction? Myeloma

Related Resources

Addressing Clinical Trial Misconceptions: The Facts

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Office Visit Planner

Transcript:

Patricia:

Let’s get an overview of available myeloma treatments.

Dr. Ghobrial:

Oh, boy. Okay, how long do we have here? It depends. The moment I see a patient – and again, maybe we can start with smoldering myeloma because that’s an area I’m really excited about.

If you have asymptomatic disease, it does not mean you have to watch and wait until you fall apart, until you have bone lesions, until you have anemia. We want to see those patients early because we have a lot of clinical trials, and potentially, the cure may actually be in an earlier precursor session when we treat you earlier before you have the disease.

But, the standard of care is when you have symptoms – anemia, hypercalcemia, lytic lesions, and renal failure, or other things like 60% plasma cells – we say you have active multiple myeloma, and in that case, we start saying, “Well, are you a transplant candidate or not?” In the old days, it used to be by age, but now, we say age is just a number, so it really depends on if you have good organ function, are you in an active good state, do you have good lungs, good heart, are you willing to take the transplant, because now, there’s a big discussion whether we should transplant patients or not.

And then, at the end of the day, we’re starting to actually blur that, saying that most of our treatments are almost identical, whether you are old or young, whether you’re a transplant candidate or not. It depends on frailty. Can you tolerate this treatment or not? Maybe a few years ago, we used to say a three-drug regimen is the best way to go.

Now, most of us are starting to say four-drug regimen up front is the way to go, which is an antibody – currently, it’s daratumumab – a proteasome inhibitor – it could be bortezomib or carfilzomib – an immunomodulator – likely, this is lenalidomide – and then, dexamethasone. That’s sort of the option that we have right now, at least in the U.S.

If you go to Europe, you’ll find us using different drugs, like thalidomide or other things, but most of us are thinking of a four-drug regimen to think of our up-front myeloma treatment to get you the best remission, eventually MRD-negative disease, and then we talk about transplant or no transplant, and then, of course, we talk about maintenance.

We want to keep everyone on maintenance therapy; the question is how long, which maintenance, do we use one drug or not? So, there is a lot to be discussed in treatment of myeloma, and that’s the beauty of it. It’s truly an art and science together. It’s not just “Here’s a combination because you have this treatment.” We really personalize therapy for you.

We look at your cytogenetics, your FISH. We say you have high-risk cytogenetics or not, you’re young or not, you have good organ function or not.

There are so many things that we put in consideration when we come up with a treatment plan for a patient.

Fact or Fiction? Myeloma Treatment & Side Effects

Fact or Fiction? Myeloma Treatment & Side Effects from Patient Empowerment Network on Vimeo.

When it comes to online myeloma information, how do you separate fact from fiction? Dr. Irene Ghobrial shares facts about current myeloma treatments, common side effects and emerging research. Download the Program Resource Guide, here

Dr. Irene Ghobrial is Director of the Clinical Investigator Research Program at Dana-Farber Cancer Institute and Professor of Medicine at Harvard Medical School. Dr. Ghobrial specializes in multiple myeloma (MM) and Waldenström macroglobulinemia (WM), focusing on the precursor conditions of monoclonal gammopathy of undetermined significance (MGUS) and smoldering myeloma. More about this expert here.

See More From Fact of Fiction? Myeloma

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Key Considerations When Choosing Myeloma Treatment: What’s Available?

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Discussing Treatment with Your Doctor: Key Questions to Ask

Transcript:

Patricia:

Welcome to Fact or Fiction: Multiple Myeloma Treatment and Side Effects. Today, we’ll review common misconceptions about myeloma. I’m Patricia Murphy, your host for today’s program. Joining me is Dr. Irene Ghobrial. Dr. Ghobrial, why don’t you introduce yourself?

Dr. Ghobrial:

My name is Irene Ghobrial. I’m a professor of medicine at Dana-Farber Cancer Institute, Harvard Medical School.

Patricia:

Great, thanks so much. Before we get started, just a reminder: This program is not a substitute for medical advice, so please consult your care team before making any treatment decisions. Okay, Dr. Ghobrial, let’s get started.

Let’s talk about some of the things, first, that we hear from patients. You tell me whether or not this is fact or fiction. Here’s one: “There are a number of treatment options for myeloma.”

Dr. Ghobrial:

Fact. It’s amazing because I trained in the old days – and, this shows you how old I am – when we only had bad chemotherapy: Vincristine, Adriamycin, and dex. None of you would even know about it.

Then, we had had high-dose dexamethasone, and that was it, and then we had stem cell transplant, and that’s all we had until suddenly, we had thalidomide, lenalidomide, bortezomib, carfilzomib, ixazomib, and you think about it, we are now in an era where we have 15-20 new drugs, we have another 15-20 coming up, we have an amazing time to completely cure myeloma in the future, and that’s just an exciting time to see that happening in the last 15 years of our lifetime, when patients were living three years, when we had – I remember five percent complete remission rate.

Now, we expect that all of our patients should get into a deep remission into potentially MRD-negative disease, and that’s just the beauty of how myeloma has changed completely.

Patricia:

Well, you’ve already busted our second myth, I guess, that there is no cure for myeloma.

Dr. Ghobrial:

That’s correct. There is no cure for myeloma, but there is a long remission, and the question is if someone lives for 20, 25, 30 years without evidence of myeloma and they die from something else, it’s a step forward. I would love to see us say to a patient, “You are cured,” but until then, we’re getting longer and longer remissions.

Patricia:

How about this one? “Only blood relatives can be donors for bone marrow or stem cell transplant.”

Dr. Ghobrial:

That’s not correct at all. If we think about it, what is stem cell transplant? There are two types. There’s something called autologous stem cell transplant, meaning it’s from myself, so that means that I’m taking my own stem cells, and the whole idea of that autologous transplant is basically high-dose chemotherapy.

So let’s take your own cells before we give you that high-dose melphalan, give the chemo, and then give them back to you, so that you’re not with low blood counts for two weeks, four weeks, you’re only with low blood counts for a couple of weeks. So, that’s autologous transplant; that means I’m giving my own stem cells to myself.

Allogeneic stem cell transplant, which we rarely do now in myeloma, is from another person, and that could be from a relative, but also can be from unrelated donors if they are matching us, but that’s very few cases.

Patricia:

Let’s get an overview of available myeloma treatments.

Dr. Ghobrial:

Oh, boy. Okay, how long do we have here? It depends. The moment I see a patient – and again, maybe we can start with smoldering myeloma because that’s an area I’m really excited about.

If you have asymptomatic disease, it does not mean you have to watch and wait until you fall apart, until you have bone lesions, until you have anemia. We want to see those patients early because we have a lot of clinical trials, and potentially, the cure may actually be in an earlier precursor session when we treat you earlier before you have the disease.

But, the standard of care is when you have symptoms – anemia, hypercalcemia, lytic lesions, and renal failure, or other things like 60% plasma cells – we say you have active multiple myeloma, and in that case, we start saying, “Well, are you a transplant candidate or not?” In the old days, it used to be by age, but now, we say age is just a number, so it really depends on if you have good organ function, are you in an active good state, do you have good lungs, good heart, are you willing to take the transplant, because now, there’s a big discussion whether we should transplant patients or not.

And then, at the end of the day, we’re starting to actually blur that, saying that most of our treatments are almost identical, whether you are old or young, whether you’re a transplant candidate or not. It depends on frailty. Can you tolerate this treatment or not? Maybe a few years ago, we used to say a three-drug regimen is the best way to go.

Now, most of us are starting to say four-drug regimen up front is the way to go, which is an antibody – currently, it’s daratumumab – a proteasome inhibitor – it could be bortezomib or carfilzomib – an immunomodulator – likely, this is lenalidomide – and then, dexamethasone. That’s sort of the option that we have right now, at least in the U.S.

If you go to Europe, you’ll find us using different drugs, like thalidomide or other things, but most of us are thinking of a four-drug regimen to think of our up-front myeloma treatment to get you the best remission, eventually MRD-negative disease, and then we talk about transplant or no transplant, and then, of course, we talk about maintenance.

We want to keep everyone on maintenance therapy; the question is how long, which maintenance, do we use one drug or not? So, there is a lot to be discussed in treatment of myeloma, and that’s the beauty of it. It’s truly an art and science together. It’s not just “Here’s a combination because you have this treatment.” We really personalize therapy for you.

We look at your cytogenetics, your FISH. We say you have high-risk cytogenetics or not, you’re young or not, you have good organ function or not.

There are so many things that we put in consideration when we come up with a treatment plan for a patient.

Patricia:

We’ve been talking a little bit about what patients believe when they come in, some of the things they’re thinking about. What else do you hear from patients that you either have to correct or affirm when they come into your office?

Dr. Ghobrial:

A lot of things. I think the first thing is, of course, they say myeloma is fatal, and they’re so scared, and absolutely, I understand that, but the median survival has become so much better, so much longer. There is a lot of hope, enthusiasm, and excitement right now with the treatments we have. The second thing is most of our treatments are not your typical chemotherapy, so unlike breast cancer or other cancers where you lose your hair, you’re throwing up, you cannot work, you have to take time off, most of our drugs now, people are working full-time, they’re active, you don’t lose your hair, so probably, no one has to know unless you tell them.

And, I think that’s something important for a patient to think about. It’s their own personal life, and not having to interrupt that. I think that’s very unique. So, these are a couple things that, as they come in, that anxiety of “Oh my God, I have cancer,” and then, taking a deep breath and saying, “Now, how do I handle this situation?”

Patricia:

Sure. What about clinical trials? What common misconceptions do you hear from patients enrolling in trials?

Dr. Ghobrial:

There’s a lot of misconceptions, and it’s unfortunate. I would say I would absolutely go on a trial if I can. I’m a believer in clinical trials because they’re the way forward to bring in new therapies and new options. I think a lot of people think that we’re experimenting on them when we’re doing clinical trials, meaning that it’s first in human, meaning it’s the first time we try this drug, and I would say that most of our clinical trials are not first in human.

They’re not the very first time we’ve tried them. Likely, those are drugs we’ve tried, we know the side effects, we know the toxicity, but it’s the first time we’ve put it in a different combination or it’s the first time we’ve put it in a specific subset of patients to look at response or at overall survival.

Most of the trials – so, before you decide “Oh, it’s a trial,” just think – is this a phase 1, a phase 2, or a phase 3? Phase 1 are usually that first time that we try in a population. Phase 2 are usually we know already what happens, we know the toxicity, we’re bringing it to look at the response rate in general or the survival, and then, phase 3s are the bigger studies, going to the FDA for approval.

The second thing is you want to think about is there a placebo arm in it. Most of my patients really worry about “Oh my God, you’re gonna give me the placebo,” and I’m like, “No, we don’t have a placebo arm in this trial. You’re taking the drug that we tell you about.” So again, depending on the trial – read it carefully – there may be a placebo arm, but in most of them, it’s not a placebo arm.

So, I would personally go ask the doctor every time, “So, you’re talking about standard of care. What else do you have? Do you have clinical trial options or not? What’s new?” Almost every single new drug that we’re gonna get approved in the next 5-10 years from now is what we have today in clinical trials. It would be cool to try and get access to those earlier.

Patricia:

So, there’s a significant amount of vetting that goes on before clinical trials are actually in process on humans.

Dr. Ghobrial:              

Oh, absolutely.

Patricia:                      

What are the common myeloma misconceptions about treatment side effects?

Dr. Ghobrial:              

I think the biggest thing is the loss of hair, the nausea, and fatigue, and to the point that I cannot travel, I cannot see my family, I’m gonna be so immunosuppressed. And again, that’s a huge misconception. Yes, there is toxicity for every drug. Even if you take aspirin, you have toxicity from it.

But, every drug has risks and benefits, and currently, the combinations we have are just impressive that they are well tolerated in general. I’m not saying there is no side effect – there is, for every different class of agents, there are, and you will go through those side effects with your doctor in detail – but in general, yes, you’re slightly immunosuppressed, you have to take care of it, and I said it yesterday to one of my patients – if someone is looking very sick in front of you, don’t go and hug them.

Christmas is around the corner, and we want to make sure people celebrate and enjoy life and enjoy the holidays with their family members.

Patricia:                      

Dr. Ghobrial, let’s talk about some of the things that patients are concerned about when they come in about treatment side effects, and maybe some of those things aren’t true. You tell me. Treatment side effects are unavoidable – we already talked a little bit about that. How about this one? “Myeloma patients should visit the dentist more frequently.”

Dr. Ghobrial:              

So, there is something about the bisphosphonates that we give patients, and they can cause – in a very rare number of patients – something called osteonecrosis of the jaw.

In the old days, when we didn’t know about that side effect, people would go get a root canal, come back, and have a big problem of osteonecrosis of the jaw with severe pain, and it doesn’t recover.

So, we’ve learned our lesson. We know very well that we hold Zometa or zoledronic acid if they’re getting any procedures. We make sure they don’t get surgical procedures – it doesn’t mean don’t get dental cleaning, please do the usual things for dental health, but don’t go into surgical procedures when you’re getting zoledronic acid – and we’re very careful with that.

We talk to our patients. Most dentists know about it, so I think this is something that in the old days, it was a problem. Now, we know how to medicate that.

Patricia:                      

Sure. How about this one? “Treatment causes increased risk for blood clots.”

Dr. Ghobrial:              

So, a couple of the drugs that we have – especially immunomodulators – can increase your risk for DVTs, blood clots, or pulmonary embolism, PE. So, the first thing we say is, “Let’s assess your baseline risk.

Are you someone who is at risk of clotting anyways?” Remember, myeloma also increases your risk of clotting, so you’re double. So, if you are at a high risk of clotting, then we would give the full anticoagulation. If you are not, then we would say aspirin is good enough to control that inflammation and endothelial damage that happens early on with therapy, and that can take care of it.

Patricia:                      

How about this one? “Side effects can be managed by diet and lifestyle.”

Dr. Ghobrial:              

So, I am a big believer that exercise and good, healthy living helps you in general. It makes your mood better, it makes you feel stronger, it gives you that energy because of the fatigue from the side effects, it helps with the dexamethasone because dex is a steroid, so you’re gonna be hungry, you’re gonna be eating more, and the on-and-off makes you fatigued and tired.

So, absolutely, diet and good healthy living – I’m not saying you have to go into extreme starvation and things like that. We say in general, be good, healthy living; exercise if you can.

Patricia:                      

What do you hear from your patients about side effects and treatments that they may think is true?

Dr. Ghobrial:              

I think neuropathy is very important, and we underestimate the neuropathy, so if you have numbness or tingling, tell your doctor.

That comes from Velcade; it comes from thalidomide when we used to use thalidomide, but it can happen in many patients who have an underlying amyloidosis and we did not diagnose it yet, or it can just happen as you go on from myeloma, rarely. So, tell your doctor about this.

I think the fatigue is very important to know about it because people suddenly change their life, and they want to know about that. I think the rashes that can happen with many of the drugs are very important to know about so that you’re not surprised when you get the rash. We know, for example, Revlimid can cause itching of the scalp, and that’s something that if we don’t tell the patients and they start going like this, then there is a problem.

So, it’s small things, but we want to let them know. We usually tell the patients everything, to a point of just going through all the side effects. It’s better to be aware of it, and then, if you get or not, at least you were aware.

Patricia:                      

Sure. How does one distinguish treatment side effects from comorbidities like fatigue?

Dr. Ghobrial:              

I think that’s important, and again, talking to your doctor is very important. Keeping a diary on the side is very important because you may have had some of those problems, and that could be from myeloma before you even started the drugs, and making sure that we know what’s from myeloma, what’s from your thyroid issue, what’s from your lung problems if you have asthma or COPD, what’s your diabetes if you have that or your other medications, from what are you doing with those medications.

I think that’s why when you start therapy, we tell you, “Try not to take too many other medications that we don’t know about, herbal medicines and other things, because then we don’t know what are the side effects and what’s causing what.”

Patricia:                      

Sure. You mentioned neuropathy. Let’s talk a little bit about what that is.

Dr. Ghobrial:              

So, neuropathy can come in different ways, but the most common one is numbness and tingling that you have in your tips of toes and tips of your fingers, and that can happen from medications, as we said, or from the underlying myeloma or amyloidosis. It can be painful, and we’re careful that if you have this, tell your doctor because if it get worse and worse, it’s very hard for us to reverse neuropathy, so just always tell us because we can stop the drug, we can decrease the dose rather than having you go through it.

31:59

Patricia:                      

What about this one? “An MGUS diagnosis will lead to myeloma.”

Dr. Ghobrial:     

Great question. So, let’s talk about MGUS in general. In the general population, once you’re over the age of 50, there’s a three percent change of having MGUS incidentally found, and that’s known from the big studies from Dr. Robert Kyle. Any of us walking around probably may have MGUS, and we don’t know.

We started recently a big study called the PROMISE study where we actually screen for the first time to look for myeloma – or, for MGUS – and the reason for that is we said, “You go screening for mammography with breast cancer, you go screening with a colonoscopy for colon cancer; we don’t screen for myeloma, which is an easy blood cancer with a blood test. Let’s screen for it.” So, that’s available online – promisestudy.org.

The other thing that we said is if you have MGUS, your chance of progression is only one percent per year. That’s very important to know. So, that means that in 10 years, you have a 10% chance of progression to myeloma. In 20 years, you have a 20% chance. So, if you’re 70 or 80, you may have something else that happens before you even develop myeloma or before you are at risk of myeloma.

However, that doesn’t mean that you don’t have the chance. You have a very small chance; it’s a precursor to myeloma, but it’s one of the biggest precursors to myeloma, so we always tell you, “Please go see your doctor, please do follow up with us because the one thing that’s important is we catch it early before it happens.” So, it does not always go to myeloma, but if we live for another 100 years, it may actually progress to myeloma because of the 1% chance per year.

Patricia:                      

How about this one? “MGUS and smoldering myeloma are the same.”

Dr. Ghobrial:              

That’s not true. That’s a very important question. So, in general, MGUS is diagnosed as having less than 10% plasma cells and a small monoclonal protein, less than 3 grams, and you don’t have any organ damage.

Smoldering myeloma – and, the name says it; it’s almost myeloma, it has a higher chance of progressing to myeloma – in general, it’s about 10% per year, and usually, the bone marrow has more than 10% plasma cells. Now, you start telling me as a patient, “Well, if my bone marrow is nine percent, I’m MGUS, and if it’s 11%, I’m smoldering myeloma, that doesn’t make sense.” So, it’s correct. In general, those demarcations or numbers are more for us as physicians to talk to each other about what we’re calling rather than the patient themselves. The patient is a continuum.

So, you may move from MGUS to smoldering at a certain point, and it’s not really that extra percentage of bone marrow that moves you into the 10% risk. In general, again, smoldering myeloma, you have a higher chance of going to myeloma. So, I saw a patient recently who’s 30 who has smoldering myeloma. The chances of progressing to myeloma is 10% per year. In five years, you have a 50% chance.

You want to make sure that patient is followed up carefully, and you want to offer, potentially, clinical trials because we want to prevent progression. The hope in the future is you don’t want until you have lytic lesions, fractures in your bones, kidney failure, and then we treat. The hope is we treat you earlier and we can make a huge difference in that early intersection for myeloma.

Patricia:                      

It sounds like staying engaged with your care team is critical.

Dr. Ghobrial:              

Absolutely, and I would say myeloma is a specialty field. Come and see a myeloma expert, wherever it is, even for a one-time consult, because it’s really complicated and it’s not a common disease, so it’s not something easy for everyone to know what to do with MGUS, what to do with smoldering, what to do with overt myeloma. I relax for the first time. All of these things are important, and just like you go and see the best specialist in anything, I would say care about your myeloma in a very specific way, ask your doctor questions, go online and look it up, and always ask an expert if you want to have a second opinion.

Patricia:                      

Sure. How about this one? “Myeloma is hereditary.”

Dr. Ghobrial:              

It’s a very good question. So, it’s not hereditary specifically. However, there is a 2x increased risk in family members, and that goes back to that PROMISE study.

We are screening people who have first-degree relatives with myeloma. So, what does it mean? Why do I have a higher risk if I have a family member with myeloma? I recently saw a patient who – the patient had myeloma, the mother had myeloma, and the grandmother had myeloma, and you’re thinking, “Okay, there is something we’re inheriting.”

So, we don’t know. There are some susceptibility genes that we could potentially be inheriting, germ line, and we’ve done something called “germ line,” which means you have it from Mom and Dad, that can increase your risk. It could be other factors come in and we’re still trying to understand all of these factors. What are the genes that can increase your risk? Is there an immune factor that can increase your risk, and can we identify those early in the family members?

Patricia:                      

What about preventing progression from smoldering? Is there anything patients can do?

Dr. Ghobrial:              

I would say enroll on the PCROWD. Study PCROWD is empowering patients themselves to go online. You can look it up – PCrowd with Dana-Farber – so, precursor crowdsourcing.

This is a study where anyone who has MGUS or smoldering myeloma can tell us about their data – so, their clinical information – tell us about their samples – so, give us their samples whenever they’re going to get their peripheral blood or their bone marrow – and by doing that, we can look at 1,000-3,000 people, put it all together, and hopefully give you very soon the answer of what causes progression, what are the specific markers genomically and immune that can predict progression, and can we target them?

Can we develop therapy for you specifically as a smoldering patient and not use the same drugs as myeloma, but target it for one specific patient for one specific operation?

Patricia:                      

When patients come into your office, they’re learning a lot of new things. Are there terms that are confusing to patients that you need to define for them?

Dr. Ghobrial:              

Absolutely. I think a lot of those terms are very hard. The words “complete remission” – was that a cure or not? It’s not.

We decrease all of your M spike, we decrease your plasma cells to zero, but it doesn’t mean that we’ve cured you. I think progression is very important. We use certain numbers. A 25% increase in your M spike or a 0.5-gram increase – even monoclonal protein is important to understand, that that’s the antibody that your plasma cells are secreting.

So, absolutely, there are so many words that could be very daunting for any patient to go through all of this. I think having an advocate with you – don’t go on your own because there’s so much information you’re getting that first time. I personally think if patients are recording us or taking notes, that’s perfectly fine because you go back and think about it, and you want to make sure that the information is clear.

So, it’s a lot of information to take in, especially if you’re not in the medical field, and I would encourage patients to ask questions, take notes, think about it a lot.

Patricia:                      

Tell me what an M spike is.

Dr. Ghobrial:    

So, an M spike – a monoclonal spike – is the protein – the antibodies. So, plasma cells are actually antibody-secreting cells, so they secrete the antibody, it goes in the blood, and when you have a lot of it from the same type of cell, they’re monoclonal, so they’re all the same IgG kappa – IgG kappa because they came all from that same kind of plasma cells.

And, when we run a specific gel, called serum protein electrophoresis, all of those antibodies will run in one area, and they will do a spike instead of going into a bigger area, where we call it polyclonal. So, that tiny little spike, which is a very high level of all of them coming together, we can measure it, and we can say, “Your monoclonal spike is 3 grams per deciliter.” If you don’t have all of them the same type of protein, they will just go around in one big area – big lump, basically, on that electrophoresis, and they will not come out as a spike. So, that’s monoclonal spike. 40:44

Patricia:                      

And, what are some reliable source of information for myeloma? The world wide web is vast.

Dr. Ghobrial:              

Yeah, and it’s unfortunate. So, there is so much information, and you can get lost, and you can also get misinformation. I think some of the big foundations are very important So, I would say the Multiple Myeloma Research Foundation, the International Myeloma Foundation, the Leukemia and Lymphoma Society, and of course, if you go to clinicaltrials.gov, you will find that information, and you’ll find a lot of the clinical trials. But again, ask your doctor. Ask the experts.

Patricia:

There are a lot of online forums – again, we talked about how vast the internet is. How can a patient identify misinformation online? What are some clues?

Dr. Ghobrial:              

That’s a hard one. I would say again, print it and take it to your doctor. Tell him, “Does that make sense? I’ve read this.” This is where you really need to do your research and go to the sites that you have confidence in so that you’re not lost in the middle of so much misinformation.

Patricia:                      

Do you have patients come in and say things to you that you just have to say, “Whoa, that’s just not accurate”?

Dr. Ghobrial:              

Yeah, but again, this is part of the discussion. I personally think every question is a good question. Even if it sounds completely ridiculous, ask it. That’s why we’re here. We’re here to tell you, “This is right, this is wrong, this one I don’t know, I’m not so sure,” and that’s okay. It’s part of the discussion.

Patricia:                      

Before we finish up, let’s get your take on the future of myeloma. What are you seeing on the horizon?

Dr. Ghobrial:              

Oh, a lot, and I hope I live long enough to see all of the amazing things. I truly think that we will cure myeloma. I think we should treat patients early. That’s an absolute change.

I think immunotherapy is coming in, CAR-T, bispecific antibodies. We will harness our immune system to kill myeloma, and I think there’s so much to be done there. I think precision medicine is very important. The first study is from MMRF [Multiple Myeloma Research Foundation] coming out now, genotyping, asking the questions “Which mutations do you have?”, and then putting them into different buckets so you can understand which disease should be treated with which drug.

We always say we know there is different subtypes of myeloma, then we treat you the same way, so let’s stop doing that, let’s do precision medicine, let’s individualize treatment specifically for you. So, I think that’s another big thing. So, in the future, there will be so many options. The hope is truly we’ll cure myeloma, we diagnose it early, we screen for it, we diagnose it early, and we prevent it from even causing one lytic lesion for a patient. 41:52

Patricia:                      

Dr. Ghobrial, let’s end by talking about why you’re so hopeful about the future of myeloma.

Dr. Ghobrial:              

Well, again, I trained – and, I said that 15 years ago – at Mayo Clinic, where we only had few drugs, when the survival of myeloma was three to five years, when we saw patients having severe fractures and severe pain, and now, we look at it, and it’s only 15 years in our lifetime, and we look at it that myeloma is a completely different disease.

We can diagnose it early – in fact, we’re thinking of screening them early – we can make a huge difference in all of the comorbidities, but the most important thing is we have so many amazing drugs that we’re using together to get an amazing, complete remission, MRD-negative disease, and then, in the next 5-10 years, I think we will change, again, immunotherapy with CAR-T. We will have precision medicine and immunotherapy to completely change how we treat myeloma. So, I am extremely hopeful and extremely excited for our patients.

Patricia:                      

So, how do you talk to your patients about this hope? I would imagine that when they come in, they’re pretty terrified about what’s going on.

Dr. Ghobrial:              

Absolutely. Again, the first thing is you want to say, “Yes, you have a cancer,” and that shocks you. That is a big thing. It makes a big difference in a patient. “I have cancer now” is an important part that you have to acknowledge.

And then, you go to the next step, and now, let’s talk about treatment. Let’s talk about survival. Let’s not say, “I will not see my kids grow up.” These are not things – again, we cannot predict. We’re not gonna play God, and we can never predict if someone will respond or not, but we know from the data that we have so far that we have amazing remissions and long-term survivors. I have many of my patients that I transplanted 15 years ago still alive, doing well. Again, I cannot say that myeloma is cured, but we have a good remission rate currently.

Patricia:                      

Dr. Ghobrial, thank you so much for taking the time today.

Dr. Ghobrial:              

Absolutely. Thank you.

Patricia:                      

And, thanks to our partners. To learn more about myeloma and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Patricia Murphy.

ASH 2019: Timely Myeloma Care Makes a World of Difference; Experts Prioritize Addressing Race-Associated Risks

Diverse Health Hub and the Patient Empowerment Network will partner to produce ongoing educational programs beginning in 2020. These programs identify demographic disparities found in existing diagnostic and treatment practices for multiple myeloma. Program content and educational resources will supply actionable and meaningful material tailored to healthcare providers, patients, and patient care teams. When patients feel heard and understood by their healthcare providers, they are more likely to participate in clinical trials and advocate confidently for treatment options. Our joint goal is to empower a targeted and unique population of myeloma patients to spark life-saving conversations with their providers. Be sure to sign up for PEN’s newsletters to learn more.


Onsite at ASH 2019, Diverse Health Hub interviewed prominent myeloma researchers, including questions from our members.

Is earlier effective treatment for a deeper response keeping myeloma at bay? Yes. According to new evidence around timing of treating myeloma presented at ASH 2019, immunotherapy drug daratumumab (DARZALEX) demonstrated it could repeatedly attack marker CD38 – a game changer. Dr. Sikander Ailawadhi sheds light on these new findings: “In the past the thought was that once the patient was treated by a drug that targets one particular marker that whole pathway or that mechanism of action is gone, but there was data presented at ASH, which we are all very encouraged about. Patients who have let’s say been treated with daratumumab (DARZALEX)—so one drug affecting that pathway – when they had disease progression at some point, they were treated with a brand-new drug going in for that pathway and the patients got very good deep responses.Watch the complete interview below.

  • Myeloma Treatment: Earlier effective treatment for a deeper response to keep disease quiet
  • New Drugs: 2020 to be a big year for myeloma, drug approval buzz
  • Encouraging Data: News at ASH 2019 reveals CD38 marker can be targeted repeatedly

Are disparities shortening the lifespan of a subset of myeloma patients? Yes. Several published papers indicate that the burden of disease was higher for a subset of myeloma patients as a result of socioeconomic status, age, race, lack of resources, access, and insurance type. Dr. Ailawadhi identifies the need for programs that educate both patients and providers to mitigate underlying disparities. Watch the complete interview below.

  • Access to Care: Significant number of minority patients unaware of medical record access
  • Burden of Disease: African Americans and Hispanics get treatment later than whites; costs tend to be higher for minority patients
  • Observation: More frequently diagnosed with myeloma later stage, at a younger age
  • Need: Educate patients, educate providers. Patients need to be their own advocates and direct the conversation with their providers in order to get to the right expert care

What role does education and awareness play in the diagnosis of ethnic myeloma patient populations? Despite advances in the treatment of multiple myeloma, Dr. Ajay Kumar Nooka identifies a gap between patient education and awareness of current therapeutic options. Dr. Nooka discusses how myeloma presents in various ethnic groups, and identifies disparities in access to initial treatment for African Americans and Hispanic populations. Nooka says, “education and awareness is the biggest gap we tend to see.” Watch the complete interview below.

  • Good news: “Really good time in myeloma, more therapeutic options”
  • Need Improvement: Education and awareness gaps still need to be filled; disparities among people of color, long road to diagnosis, delays and access to drugs
  • Clinical Trials: Lack of minority awareness and participation in clinical trials contributes to treatment disparity

About Diverse Health Hub:

Diverse Health Hub is a health equity education and awareness channel producing educational content for both patients and providers in order to bridge the gaps between healthcare practices and the needs of multicultural communities.  Diverse Health Hub works directly with a diverse patient and respected provider population in multiple therapeutic areas to promote cultural competence in healthcare. The organization believes access to these diverse perspectives cultivates culturally competent communities.

ASH 2019: Disparities Around Accessing Health Technology Revealed for a Subset of Myeloma Patients

In this Diverse Health Hub interview, Dr. Sikander Ailawadhi of Mayo Clinic, discusses disparities around access to care in multiple myeloma from the 61st American Society of Hematology (ASH) Meeting in Orlando, Florida.

About Diverse Health Hub:

Diverse Health Hub is a health equity education and awareness channel producing educational content for both patients and providers in order to bridge the gaps between healthcare practices and the needs of multicultural communities.  Diverse Health Hub works directly with a diverse patient and respected provider population in multiple therapeutic areas to promote cultural competence in healthcare. The organization believes access to these diverse perspectives cultivates culturally competent communities.

Related Programs:

Good News for Future of Myeloma Treatment, Still Addressing Race-Associated Risks

ASH 2019: Multiple Regimens, Deeper Responses in Multiple Myeloma Treatment

How to Make a Treatment Decision

Myeloma Patient Cafe®

Myeloma Patient Cafe® – How to Make a Treatment Decision from Patient Empowerment Network on Vimeo.

Five myeloma patients from around the country sat down to discuss their disease and how to make the best treatment decision for them.

See More From the The Myeloma Patient Cafe®


Transcript:

Cindy:

Hello everyone and welcome to the Patient Empowerment Network’s Myeloma Patient Café. My name is Cindy Chmielewski, and I’ll be hosting the program today. I was diagnosed with multiple myeloma way back in 2008. The Myeloma Patient Café is an opportunity for myeloma patients to get together and discuss their disease and also to share tips and information about myeloma.

Today’s topic is going to be how to make a treatment decision. But before we get into that discussion, I think it’ll be nice if we all go around and take a few minutes to introduce ourselves. We could say our name, where we’re from, and just a short history of our treatment journey. I’ll go first.

As you know, my name is Cindy. And I’m from Lawrenceville, New Jersey, and I was diagnosed with multiple myeloma back in 2008. When I was diagnosed, my myeloma was really tricky to begin with. My induction therapy stopped working for me just after a few cycles, and a stem cell transplant failed to put my myeloma into remission. So, I was very, very scared back then, and I retired from teaching.

But fortunately, a combination therapy was able to put my myeloma in what’s called a very good partial remission. But it took almost three years to get that maximum response. And right now, I’m staying in that very good partial remission with maintenance therapy.

Mike:

I was diagnosed in 2013 after having MGUS in 2009 and smoldering myeloma in 2010. My initial treatment was part of a clinical trial, and I had Revlimid, Velcade, and dex for three cycles, then a stem cell transplant, and then two more cycles of RVD and then maintenance therapy on Revlimid until 2018. I was really fortunate. I went into stringent complete remission and MRD negative. But then in July 2018, I began to relapse. So, I’ve started another treatment with Elotuzumab, Revlimid, and dex, and that’s been working pretty well recently.

Cindy:

Good. Thanks for that introduction. And Alan, would you like to share a little bit about your story?

Alan:

Sure, I was diagnosed in 2016. I was very far along, and the myeloma was very advanced. And when I was first diagnosed, I was put in the hospital and nearly died in the hospital because of some pain meds they gave me. It just shut down my digestive system. But anyway, everything happened really fast because it was so advanced. I really didn’t have much time to make decisions. We found it because my L5 vertebra had collapsed. I found out I had fractures in every vertebra, clusters of fractures in my ribs, 147 lesions on my bones, and 60 percent of the cells in my marrow were cancerous.

Like I said, it was so advanced I really didn’t have much time to make plans, but I went through two rounds of VDT-PACE. I went to a myeloma clinic that specialized in multiple myeloma. I did two rounds of VDT-PACE, then tandem stem cell transplants, then 16 rounds of Darzalex or daratumumab. Then they told me I was in remission and then went on maintenance treatments. I did Ninlaro and dex and – oh, Revlimid. That’s what it was. I did that for about seven or eight months. And my blood counts were just staying so low that they finally took me off that. My white count would never get over about 1.5 to 2. So, then I went back on the Darzalex, and that’s what I’m on now. I’m in stringent remission.

Cindy:

Good to hear that. You had some journey there. And Connie, can you tell us a little about your story?

Connie:

I was diagnosed January 3rd of 2010 after I fractured my sternum in a race. A gal was pacing me, and I thought I had a sports injury and just had too much fun sprinting. But it took about nine months before they finally realized that I’d fractured my sternum that day, and then I got diagnosed with the multiple myeloma.

Cindy:

And Josine, how about you?

Josine:

Hi. I was diagnosed actually five years ago this past month, Columbus Day weekend 2014, with 32 compressed fractures in my spine and my ribs from – I thought it was from lifting a box of legal documents at work in Manhattan, but it wasn’t. It was the myeloma pushing out because I had – 95 percent of the plasma cells were cancerous. Fast forward three months later I had a stem cell transplant, never went into remission. I’m on a triplet now of Revlimid, Ninlaro, and dex, and it brought my M-spike down to 0.2, which when I started out, I was at 8.0. So, life is good.

Cindy:

So, now let’s talk about how we make treatment decisions. And Mike, I’m gonna go back to you. When you were in smoldering myeloma, you had that opportunity to either watch and wait or to go on a clinical trial. What made you decide clinical trial? What was part of that decision-making process?

Mike:

When I was in smoldering myeloma, I wasn’t really offered a clinical trial. It was when things switched from smoldering to active myeloma. And what made me decide to do the clinical trial is a couple of things. One, my background is that I am a scientist, an engineer. So, I’ve been interested in the science behind treating multiple myeloma and other cancers and wanting to do my little part to try to help advance the science through participating in a clinical trial. So, that was one factor.

The second factor is that I felt like I’d get really good treatment period, but I’d get the very best treatment if I was in a clinical trial. And it turns out that I was monitored much more frequently while I was in the clinical trial than I would’ve been otherwise. And that ended up over time giving me, I think, some peace of mind. So, I’m really glad that I did participate in the clinical trial.

Cindy:

Good. Anyone else participate in a clinical trial or had that option brought up to them? No?

Alan:

I did not.

Cindy:

No. Did your doctors ever ask if you were interested? Or was that never brought to your attention?

Alan:

It was never brought to my attention.

Cindy:

Josine, did the doctor ever ask you?

Josine:

No, no. I would definitely be up for it, but it never came up in conversation.

Cindy:

How about you Connie?

Connie:

My numbers are very, very gradually going up like myeloma likes to do. And so, we have – looking ahead to a relapse at some point, my specialist brought up clinical trials and that we could discuss them and look them over and decide at that point.

Cindy:

Good. And while I’m talking to you, I think I read in your biography that you chose not to go ahead and have a stem cell transplant. Is that correct?

Connie:

That’s correct.

Cindy:

And can you talk about – a little bit why – what went through your head to make that decision?

Connie:

I think at that particular time the result of quality of life or overall length of life were very similar in terms of whether you had a stem cell transplant or in my case with standard risk myeloma. And I might at that time could’ve – everything that we had talked about and looked at with the research – maybe buy six more months of overall life – of survival. And I have to admit I was a little bit skeptical about – I guess I’d say killing off your immune system and how that might come back or not come back. And with standard risk, I decided to go up to Mayo Clinic and have them collect my stem cells as an insurance policy of sorts and then see how my myeloma progressed.

Cindy:

And at that time, were you in a complete remission when you were making the choice of whether or not to have a stem cell transplant?

Connie:

No, I wasn’t. I know the standard of care, and that was explained to me – was to have a stem cell transplant. But when I looked at the numbers with my specialist and my local oncologist, Revlimid was seeing some very good results. So, it really looked very similar to me. I thought with a deeper response up front we might get an overall better response, but I decided to – at my age – just to see how it would progress.

Cindy:

And that’s why this is such a crazy disease because everyone has a different presentation and yeah. And, I think, Alan, you were a little bit different. You had double transplants? Was that tandem transplants?

Alan:

That’s correct, about 60 days apart.

Cindy:

Can you talk about how you decided and why you decided to have such an aggressive line of therapy?

Alan:

Well, I think part of it comes to my personality type. I’m a business owner, and I’ve been fairly successful in life by surrounding myself with people that know way more than I do and letting them do their jobs. As I said in the beginning, things happened so fast with us we didn’t have much time to make decisions. And we were sent to a myeloma center. They specialize in multiple myeloma, and I feel like it’s probably the best in the world. But, of course, I guess everybody feels that way about where they’re treated, but my doctor was one of the top people in the world that specialized in multiple myeloma. He’s a clinical research scientist. And he told me how bad it was, and he said we’ve gotta treat it aggressively. But if we do, we feel like we can get you in remission.

And, you know, I really – when I first met him, he introduced himself by his first name, and I liked him, and I trusted him. And I had done a little bit of research on him, and I had just decided to do what he said. And it really made it – in many ways, it was easier for me because my situation was so bad that – and I know there are people that have had way worse than I have. But it was urgent that we make decisions. I didn’t really have a lot of time to think about it. So, I just surrounded myself with really good people and did what they said.

Probably the only decision I’ve really had to make is between my first transplant and my second. And like I said, they were only about 60 days apart. I did really well recovering from my first transplant. They released me to go home 14 days after my transplant, which they said was fairly unusual. The day I got home, I got C. diff And I was brutally ill, and then I got the flu. And then I got C. diff, and then I got the flu again. So, basically out of a two-month break, I was sick for a month.

Cindy:

Oh my gosh.

Alan:

And when I went back, he told me – he said, “Look, I know you’ve had a hard time. So, we can go one of three ways. Your test results were very good, so we can either let you go home for a couple weeks to recover.” Of course, he knew I had to run a business too while I was going through all that. And he said, “Or, we can do a reduced dose of melphalan, or we can just give you the full dose.” And I’m an idiot, and I said just give me the full dose. So, that also says a lot about my personality card.

But anyway – so, I don’t have any regrets. It’s taken me a long time to get back on feet, but I live a pretty normal life. About four or five weeks after I got home from my second stem cell transplant, I made arrangements to continue a family tradition of going fishing with my dad and my sons in South Louisiana. And I looked like a ghost honestly, but I’ve forced myself to do a lot of things I didn’t feel like doing so that I could recover.

Cindy:

Josine, can you talk about your initial treatment and if you were part of that decision-making process?

Josine:

Sure.

Cindy:

I know that initial treatment shocks us, and many of us are really, really sick. So, we’re really not part of it, but talk a little bit about your experience.

Josine:

Yeah. I was totally out of it at that point when I was first diagnosed because I was on morphine for 10 days, and I lost 10 days of my life. So, I never had anyone say that I had this cancer or discuss any treatments me. So, I was at their mercy. They gave me bendamustine and CyBorD – no. Yeah, CyBorD and bendamustine in the hospital. And I had, like I said, no recollection of any of it at all. My husband was there to make all those decisions at that time.

Cindy:

So, now, unfortunately, we have myeloma. And myeloma is one of those diseases of relapse and remission right now, although I’m very hopeful that we’ll be curing some people very soon. No one’s saying that they have a cure for myeloma. So, there’s a possibility that we will relapse in the future. Hopefully, the really, really, really distant future, but there’s that possibility. So, when we’re thinking about treatments, what do you think are some of the things that you consider when making that treatment option?

Mike:

In my case, Cindy, last year – last July, my oncologist gave me eight different options. And we went through the list, the pros and cons of each of those eight options, and finally together decided on the Elotuzumab, Revlimid, and dex. And it was very important to me to sort of understand what his thinking was and why he liked this option versus that option and so forth. Part of it had to do with how effective we thought things would be given my myeloma and my history with myeloma. Part of it had to do with side effects that we wanted to avoid. I have peripheral neuropathy left over from Velcade. So, that sort of ruled out Velcade. But anyway, it’s great that we had so many different options to be able to choose from. I’m fortunate enough to be in that position now. And it made me feel good to be able to go through those options one by one with my myeloma specialist.

Cindy:

Some of the things you considered is what your specialist was thinking, why he picked a treatment; but you also considered some side effects from previous treatments when selecting your new treatment, which makes a lot of sense. If you already had neuropathy, trying a treatment that is known to cause neuropathy might not be the best choice.

Mike:

Exactly.

Cindy:

Yes. Anybody else – things that they considered in the past when making a treatment decision or think they would be considering in the future for future treatment decisions?

Alan:

I had to make the decision about going on maintenance. And I have a lot of friends with multiple myeloma, and some of them chose not to do maintenance. I guess, once again, it goes to my personality type. The first thing I asked my specialist was, “If you were me, what would you do?” Nobody knows better than he does. And why would you do that. And he told me, and then the other side of it is – going back to my personality, I’m more likely to do the most aggressive thing to go ahead and get it over with. And that’s kind of why I decided I should finish my maintenance. They originally scheduled three years of maintenance for me. And I should finish that in January or February of next year.

Cindy:

So, it was trusting your specialist but asking why he chose that treatment.

Alan:

That’s correct.

Cindy:

But your personality is – go for the gusto there.

Alan:

Yes. And the other side of it is that right now I’m an 18-year-old in the body of a 70-year-old. I’m actually 52, but I figure I can handle the more aggressive treatments right now than maybe I could 10 years from now. I’ve got kids. I’ve got a grandson. And I figure if it means me doing the most aggressive things so I can be with them longer, I don’t mind doing that.

Cindy:

And Connie, I think one of your considerations was quality of life. I heard you talk about quality of life when you made that decision about not having your stem cell transplant right up front, harvesting your cells, keeping them in the fridge just in case you need it. Can you talk a little bit more about that?

Connie:

Yeah. I looked at having the stem cells available, so I could have a stem cell transplant if I needed one. And I wanted to continue to compete with the race walking. So, that was a small part of it. Also, I with my oncologist – this last appointment he mentioned that if my numbers continue to just go very slowly up that maybe the next appointment that we would discuss some options. He did mention that he liked – maybe for my particular situation – adding daratumumab. And we would be looking probably at a two- or three-agent combination. I’m, unfortunately, not able to tolerate the dex. So, I’m not sure how important a factor that is for trying to enter a clinical trial. I’ve noticed most of them do use dex because of the synergy there. So, that’s a bit of a concern for me as well.

Cindy:

I know you are not on your induction therapy now. You had some treatment decisions to make. Can you talk a little bit about what you thought about when going through those?

Josine:

Oh, sure. When the famous 100-day visit to the hospital – after you have your stem cell transplant; my specialist asked me if I wanted to go on consolidation or right onto maintenance. And I guess I was kind of like Alan. I’m like – I wanna do this consolidation first because I wanna do as much as I can to get to where I have to be and then start the maintenance. The only thing is I was on Velcade for those eight weeks, and there was no change at all in any of my numbers. So, then I was on Rev only for a year and a half.

And after that, the light chains went up, and I had new lesions. And my specialist had suggested adding Ninlaro and dex. And I had known that – well, he had told me. I didn’t know it then – that Ninlaro and Velcade were in the same class. And I was questioning him. I said, “Why would I go on that if the Velcade did nothing for me. And he said, “Well, working as a triplet it’ll work better.” And it really did. So, I’m grateful for that, but I was very confused at the time.

Cindy:

You mentioned the words consolidation and maintenance. Can you explain what the difference between consolidation and maintenance therapy is?

Josine:

Sure, consolidation is something that you do right before a maintenance program. It’s just eight weeks. They’re gonna try something to bring the numbers down even lower because, obviously, the stem cell transplant wasn’t as magical as they thought it would be for me at that time. So, I opted to do that just to give it a little boost to see if something else would work. And then the maintenance – I know Alan said he’ll be on it for three years. I think I’m gonna be on it indefinitely. I didn’t get an end date on mine.

Cindy:

And usually consolidation is more of a full dose of whatever treatment that you’re choosing to use as consolidation, whereas maintenance is usually a reduced dose or a reduced scheduling.

Mike:

One thing my myeloma specialist has said to me recently is that the line between consolidation and maintenance is kind of blurring now, and more patients are on sort of maybe in between consolidation and maintenance where you’re on treatment with more than one agent for an extended period of time. He’s told me I’m gonna be on something forever and ever for the rest of my life. So, it’s sort of hard to say whether it’s consolidation or whether it’s maintenance. It all just sort of blurs at this point.

Cindy:

Yeah, it’s hard to make that distinction. When does the consolidation end and the maintenance begin? At what dose level?

Alan:

That also shows how different we all are, and I’m in some different Facebook groups and support groups and things. And I see people asking what are the – how does the treatment progress, and what are the side effects of this drug and that drug. But we’re all different. And that’s the thing that is so important, even though there are some general guidelines – even in our treatments. I was classified as low risk. They got me into remission pretty quickly. So, things could change; but as of right now, there isn’t an end date to my maintenance treatments. I know people that didn’t do any maintenance. And then I also know people that probably won’t ever stop. And we were all treated at the same place.

Cindy:

It is very different from person to person, from treatment to treatment and even within yourself. Sometimes, you respond very quickly to one treatment and very slowly to another. So, that’s one of the benefits of being seen by a myeloma specialist, someone who only treats myeloma. Is everyone here being seen by a myeloma specialist?

Mike:

Yes.

Alan:

Yes.

Cindy:

Actually, I see two myeloma specialists – one and one for a second opinion, but I really do get my treatment locally. So, I’m very fortunate that all three of my doctors communicate with each other and work well with each other. So, let’s think about – if we had to make a treatment decision in the future and you were given two options, what kind of information would you like to know about each of those options before you make that decision?

I knew early on – one of the considerations I thought of after my stem cell transplant didn’t work was, I was still working at the time, and I was a teacher. And being a teacher, it was hard to take off from school to go to an infusion center to get my treatment. Or if I had to go several times a week, that just was not something possible. And I was trying to continue to teach.

So, one of things that I was considering back then was how the treatment was given. And one of the treatments that I chose was an oral treatment because that allowed me to continue to be employed. Eventually, I did retire. And that wasn’t as much of a concern, but back then, when I was still working and knew that it would be a conflict, that was something that came into my decision-making process. Anybody else?

Alan:

I would have to say for me the side effects probably would be the least important. I think I can probably endure a lot at this point in my life if it’s just temporary. I do have three businesses, and that would come into play as far as how treatments would go. My primary business as a financial advisor – I can pretty much do that from anywhere. In fact, even when I was going through my stem cell transplants, I always had my laptop with me. But since then, in the last year or year and a half or so, I’ve started two more businesses, and that would definitely come into play.

Cindy:

Does that – you were saying –

Alan:

And the other thing is I’d wanna know what the track record is, you know? Do we have a long-term track record?

Cindy:

So, you’re saying side effects for you would be least. But track record – are you talking more about the efficacy of the drug, how well it works compared to other drugs? What do you mean by track record?

Alan:

I would wanna know – I would be more willing to trust something that had a long-term track record of success than something new that we really just don’t know that much about. And that conversation actually came up with my doctor because there are a lot of new drugs out on the market right now. And he did tell me. He said, “Some of myeloma specialists are kind of getting away from the older drugs that we know work and going to these newer drugs.” He said, “I like to combine the two.” And that’s basically what he did. For my consolidation round, instead of doing a lower-dosed VDT-PACE of Velcade, dex, and thalidomide like they had historically done – for my consolidation round, they put me on the daratumumab. And I did 16 weeks of that, one treatment a week for eight weeks and every other week for eight weeks, and then I went on my maintenance.

Cindy:

Any other things that you would wanna consider or information you would want to know about a treatment before you make that decision?

Mike:

I think we’re getting close to the point where it’s gonna be important to understand a lot about the molecular basis of your particular form of multiple myeloma in order to be able to personalize the treatment. So, what particular mutations are driving your or my myeloma at this particular point? Because we know that changes over time, and what drugs are most effective against those mutations? I don’t know if we’re exactly at this point yet, but I think we’re getting close to that. So, when I relapse again, that’s something that I’m gonna be talking with my doctor about – exactly what mutations have I got and what are the best drugs against those mutations?

Alan:

I do agree with that, and I know the Myeloma Institute where I was treated they do genetic studies on every patient. I’m sure they do that in other facilities also. And I definitely agree that that’s where they’re trying to go. And hopefully, they’ll be there soon.

Cindy:

Finding a treatment that’s aimed at one of the mutations you have – the goal of precision medicine. That’s pretty exciting. Any other things that you might want to consider? How do find out about new treatments? There’s so many new treatments first that are FDA-approved and available. But there are also a lot of treatments and clinical trials. I know when I was newly diagnosed, I had no idea what was available to treat multiple myeloma. I didn’t even know if I had a choice of treatments. I just blindly followed my doctor’s orders. My doctor told me what he thought was best, and I said yes.

But now I know there are so many treatments. How do you find out information about them so that you can have that engaged discussion with your doctor?

Josine:

Selinexor – the newest one that was approved – one of the gentlemen in our support group has been on it for eight months on a trial. So, we watched him go from literally look like he’s dying to dancing the jig. It’s awesome. So, knowing people who are on that particular drug or whatever and then inquiring about it because I know Krissy is starting with that as well. That’s how we learn. And we just learn everything from the IMF. I learn on online and from our support group. Deena is an amazing support group leader.

Cindy:

Great. So, you learn information through your in-person support group –

Josine:

Yes.

Cindy:

– and through talking to someone else who’s been on that treatment. Other ways we could gather information about treatment options? Alan, do they talk about treatment options in some of your online support groups?

Alan:

They do. I see a lot of information about that. I’m an administrator on a Facebook group for a particular drug. So, I see a lot of people making comments about different treatment options that they’re doing and their success.

I probably don’t put as much research into this as a lot of people do. I’ve battled the fight of not becoming my disease is what I call it. You can’t overwhelm yourself with information. I’m a big picture guy anyway. I’m not an engineer type-like. My wife is. Her dad was a retired engineer. So, she wants all the little details. I just want the big picture. When I go in, they do my test. I just wanna know good or bad. That’s all I wanna know. I would have to say that talking to people that have the disease and their experiences probably has a bigger impact on me than anything. Because I believe that sometimes studies can be skewed, and I like personal knowledge.

Cindy:

Anybody else? Anyone actually go to the studies and read the studies or abstracts of the studies or ask their doctors about studies?

Mike:

I do.

Cindy:

I thought you would sneak up. You’re in my support group. I know you talk about those studies, so do I. Go ahead. Talk a little bit more Mike.

Mike:

I am the detail guy on that. So, I do read the studies. I’m on the institutional review board for the cancer center that I’m treated at. So, I get to see some of the trials even before they start. I’m fascinated by the disease and the science. If I take off my patient hat and put on my scientist hat, multiple myeloma is a really, really interesting disease. It’s a complex disease. It’s a complicated disease. And there’s a lot that we can learn about cancer in general by using multiple myeloma as a model cancer.

So, it’s fascinating to me to talk with my doctor about the research; and fortunately, he puts up with my dumb questions for the most part. So, to me, I just enjoy kind of understanding as much as I can about it. It gives me a sense of power. And maybe that’s an illusion, but it still helps. The more that I know, the more comfortable I feel about things. So, I do a lot of reading about it and keeping up with webcasts and so forth that are put on various foundations. And there are lots and lots of opportunities to learn. There’s a lot more to learn than I have time for, but it’s an interesting disease.

Alan:

Mike, you and I are exact opposites, and we’d make a great team. You know that, right?

Cindy:

Right.

Mike:

Yeah, even though we’re wearing similar shirts.

Cindy:

I’m glad we have such a varied panel today. It’s good having many different perspectives. Any other ways we educate ourselves about treatment options that are coming up?

Alan:

I wanna add also that I try to participate in events like this. I do quite a bit of public speaking. I’ve been asked to be a PACE ambassador for one of the pharmaceutical companies. So, I travel around, and I get multiple myeloma specialists all over the country. So, I’ve learned a lot through those conversations. And I think it’s important for us to do things like this to give back. We all know how scary it is when we’re first diagnosed. And if we can do something like this or help somebody that’s newly diagnosed, I mean we’ve done a great thing.

Cindy:

Right. I agree with you 100 percent. Being a retired teacher, it’s in me to help educate others because I really truly believe that knowledge is power. And there has to be just a variety of ways, whether it’s through teleconferences or online support groups or in-person support groups or mentoring, there’s just so many ways that you give back and help someone.

Alan:

To me, the first of the unknown is worse than the actual treatments.

Cindy:

Exactly. And being able to talk to someone who’s been in your shoes is the absolute best.

Alan:

Do you mind if I share something with you real quick?

Cindy:

Go ahead.

Alan:

I mentioned that I went fishing four or five weeks after my second stem cell transplant. While I was there, I got a phone call from one of my clients, and one of her good friends had just been diagnosed with multiple myeloma. And he was gonna be treated where I was. And I was able to – she wanted me to talk to him. So, I called him. I shared my story. I told him how bad I was. And he said, “Well, I’m nothing like that. They caught mine early.” But I said, “Well, you understand my situation was serious.” I said, “I’d like to tell you where I am now. He said, “Okay.” I said I’m in South Louisiana fishing with my dad and my sons.” And he said, “You’re kidding!” I said, “No, I caught a 30-pound fish last night. I’ll send you a picture in a minute.” And just to hear the change in his voice, the tone of his voice, to give him that encouragement that everything was gonna be okay –

Cindy:

Right.

Alan:

– was an amazing feeling. About a year and a half later, I was fishing again in South Louisiana. And I only go a few times a year at most. And I got a phone call, similar situation – a single dad with a 13-year-old daughter. And I got to share my story with them. I got her – I got them on speakerphone so they could both hear me. My daughter was 14 when I was diagnosed. I will never forget that – being able to talk to them and encourage them because we all know how important your attitude plays a part in our recovery.

Cindy:

Exactly. Thank you so much for sharing that very personal story. And I’m sure we all have a similar story of a way that we spoke to someone and probably made a difference at that point in their journey. So, we’re coming to the end of our program. What are some things that you know now that you wished you’d knew then about making treatment decisions? Anything that you know now that you wished you knew in the past?

Connie:

I think one of the things I’ve learned is not to self-diagnose. I think when – it took nine months to get my myeloma diagnosis. I had broken a rib previously. And so, after that race, I thought I had just broken another rib. And it got better and went away. And a couple of months later when I turned over in bed, it felt like a knife going through me and took my breath away. And then another two months went by. I thought – well, I just re-broke it. Another two months went by and same thing, turned on my side in bed at night, and it went another knife through me.

So, I just even competed in some other races that summer. And I didn’t quite feel like I could go as fast as I wanted to or I might really do some serious damage. And that’s when I knew I needed to see a doctor. And I did, and I got bronchitis. And they first treated me and checked out everything for heart and didn’t find anything. And then, when I got the bronchitis, I went back to the doctor. And that’s when they decided to send me to a specialist, and he just touched my sternum and realized it was deformed and said he didn’t even wanna touch it until he got some images. And that’s when he – after the images that he got, he referred me to the West Michigan Cancer Center for further diagnosis.

Cindy:

Josine, any final words of wisdom?

Josine:

Well, like Connie was saying about self-diagnosis. I thought I hurt my back at work. If I had only heard the words multiple myeloma in life growing up, which I never heard of it until diagnosis, I think it would’ve been less painful a journey to say the least. Well, you know, it’s all part of everybody’s journey. And we’re here today, and every day’s a gift.

Alan:

As far as things I wish I would’ve known; I wish I would’ve known how hard the battle would be after the major treatments. It took me a long time to bounce back. My immune system just wasn’t very good. I kept pushing myself probably harder than I should have, but it goes back to the same thing – is do things that you don’t feel like doing. Push yourself to do the things – there are days when I don’t feel like getting up out of bed, even today. For the last week and a half, I’ve been fighting a cold. I actually – Thursday before last, me and my oldest son took our four-wheel drives to an off-road event and camped out for the weekend. Of course, I got sick the day we got there. But we had a great time and made some great memories, and the price was well worth it.

And that’s kind of the attitude that I have. I know that there’s a price to be paid at times for the things that I do, but every day is just a blessing. Every day is an opportunity to have a positive impact on somebody else’s life, and every day is a day to make memories with my family and my friends and the people I love. And put your focus there.

Cindy:

Wonderful words.

Alan:

The way that I put it in my talks is – we will find in life whatever we look for. If we look for reasons to be sad and upset and depressed, we will find those. If we look for reasons to smile and be happy, we will find those also.

Cindy:

That’s true. Very good. I could listen to your words of advice all day long, but we don’t have all day. So, how about Mike. Do you have any final words of wisdom? Advice?

Mike:

I guess the thing that comes to my mind that I know now that I didn’t know at the beginning – there’s so much. I didn’t know anything. But I realize now that I’m not alone. I felt very alone at first, but I’m not alone, and I’m not alone in lots of different senses. One sense is that there are other patients and other folks who are going through multiple myeloma just like I am. And so, a forum like this is really important to be participating in. I believe participating in in-person support groups is important, online support groups.

So, just realizing that you’re not alone is a key thing. And another way that I’m not alone is I have a wonderful team of doctors and nurses and healthcare professionals working to make me as well as I can be. And then I also am very blessed to have great friends and family. So, just knowing that I’m not alone is a key, key thing.

Cindy:

I like that. I’m not alone. Very good. Well, we’ve come to the end of our time. I think we learned a lot of great information between each other, and I’m hoping that it’s gonna be very beneficial to the myeloma community. So, to our audience, thank you for joining us for this Patient Empowerment Network programming, Myeloma Patient Café. I am

Cindy Chmielewski. And remember that this fifth -grade teacher says, “Knowledge is power and is your best medicine of all.” Thank you very much for joining us.


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