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Advice for Setting Myeloma Treatment Goals and Collaborating on Care Decisions

Advice for Setting Myeloma Treatment Goals and Collaborating on Care Decisions from Patient Empowerment Network on Vimeo.

This animated video defines common myeloma treatment goals, provides an overview of available myeloma therapies, and includes advice for making care decisions and the importance of being your own advocate.

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Transcript:

Bianca: 

Hi! I’m Bianca, a nurse specializing in myeloma. In this video, we’ll discuss myeloma therapy and explain how to work with your healthcare team so that you can choose a care plan best suited for YOUR myeloma. 

I’d also like to introduce you to Suzanne. Suzanne is a patient advocate living with myeloma.  

Suzanne: 

Thanks, Bianca. I’m happy to share my own experience and to talk about how I worked with my healthcare team to decide on a care plan. 

When my doctor and I were first considering my options, we started by setting treatment goals. Bianca, can you define treatment goals?  

Bianca: 

Sure! Each patient is unique, so it may vary by person. You should collaborate WITH your healthcare team to determine YOUR treatment goals. Common goals of myeloma treatment may include: 

  • Reducing and managing your symptoms. 
  • Slowing the progression of the disease. 
  • Inducing remission. 
  • And, helping you live longer while maintaining quality of life.

Suzanne: 

Thanks for explaining this. When I discussed treatment goals with my doctor, I pointed out that I still wanted to be able to play pickleball with my friends, and to care for my young grandchildren. We reviewed options that could allow me to stay as active as possible and manage my myeloma at the same time. 

Bianca: 

That’s a great point, Suzanne. It’s also important to remember that your treatment goals can change throughout the course of your myeloma. Discuss them regularly, not just with your care team but also your care partner – that can be a family member or even a close friend. 

Suzanne: 

That’s right. I discussed my care with my husband AND my adult children – it’s important to keep your support team in the loop.  

And it’s also essential to understand the treatment options available to you. Bianca, what are the types of therapy available to treat myeloma? 

Bianca: 

There are a number of different classes of therapy, which include: 

  • Proteasome inhibitors; 
  • Immunomodulatory therapies or IMiDs; 
  • Monoclonal antibodies; 
  • Stem cell transplants; 
  • There are also the new and recently approved therapies such as bispecific antibodies and CAR (Chimeric Antigen Receptor) T-cell therapy; 
  • And, of course, clinical trials.   

Clinical trials can be a good option for patients at any stage of disease, often giving patients early access to a viable and cutting-edge therapy. When considering treatment, you should ask your doctor if there is a clinical trial that may be right for you.  

Suzanne: 

Good point! When I was deciding on a therapy, my doctor and I, along with my husband, discussed the risks and benefits of each approach as well as the potential outcome of each option. My doctor also walked through the clinical trials that were available to me. 

Bianca, given all of the options, how do you decide which therapy is appropriate for a particular patient? 

Bianca: 

That’s a great question. As mentioned in our previous video, results of in-depth testing, which determine if a patient has low-risk or high-risk myeloma, can affect your choices. Other factors that impact treatment decisions may include: 

  • Your age, overall health, and any pre-existing conditions. 
  • Potential side effects of the treatment. 
  • Previous therapies that may have been used to treat your myeloma. 
  • The financial impact of a treatment plan. 
  • And the patient’s lifestyle and preference.  

Suzanne: 

That’s right. And, you shouldn’t hesitate to weigh in on what YOUR preference is. Do your own research so you understand each treatment approach, then work WITH your healthcare team to determine what might be best for you.  

Bianca: 

That’s excellent advice, Suzanne. So, when making treatment decisions, you should: 

  • Work with your healthcare team to understand your treatment goals. 
  • Talk with your doctor about all available treatment options. 
  • And, inquire about any clinical trials that may be right for you. 
  • Then, discuss the pros and cons of each option. 
  • Bring a care partner with you to appointments and take time post-visit to discuss the proposed plan and treatment options. 
  • And, always remember that you have a voice in your care. Speak up and ask questions. You are your own best advocate. 

Suzanne: 

Great advice, Bianca. Don’t forget to visit powerfulpatients.org/myeloma to learn more. Thank you for joining us!  

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Is Myeloma Research Examining Sequencing of CAR T and Bispecifics?

Is Myeloma Research Examining Sequencing of CAR T and Bispecifics? from Patient Empowerment Network on Vimeo.

Is the sequencing of CAR T-cell therapy and bispecific antibodies being examined in myeloma studies? Expert Dr. Ola Landgren from University of Miami Sylvester Comprehensive Cancer Center discusses what’s known about sequencing of CAR T and bispecifics and what needs further study in clinical trials.

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Transcript:

Lisa Hatfield:

So with both CAR T and some of the bispecifics approved, obviously if a patient comes in and they need something right away, they’ll take whatever is first available. But all things being equal, if a patient says, well, I can, I have both CAR T accessible and bispecifics accessible. There are some patients out there, I’ve spoken with some who are wondering, is there a benefit to sequencing one before the other, or are there any trials looking into that?

Dr. Ola Landgren:

There are studies that have allowed patients to go on treatment with one of these modalities. For example, the bispecific antibodies with the prior exposure to a CAR T-cell therapy. There are also trials with CAR T-cell therapy that has allowed patients who have been exposed to prior antibodies, either bispecifics or the conjugated antibody drug conjugates, Belantamab mafodotin. So if you look at those studies and see how the numbers compare, if you are not exposed or you are exposed, I think the data is not entirely clear-cut.

There is no definitive study. Some data suggests that maybe it’s not that different, but then there are some studies that suggest that if you go to the antibody first that maybe that would lower the efficacy of the CAR T cell. So some people have for that reason said the CAR T cell should be done first. To make it even more complicated, there are some studies that have then taken time into the equation. So that means that you could have the patient treated with the antibodies for BCMA and CD3, and the antibody is given successfully for a long time, for many years. And eventually, unfortunately, the antibody may stop working.

Now, if you switch back to back to a CAR T-cell therapy without any other therapy in between, some studies indicate that that’s less likely to be beneficial. But if you instead do another target, say you did GPRC5D/CD3, or you did a completely different therapy with small molecules or you did carfilzomib (Kyprolis), or you did venetoclax (Venclexta), or IMiDs, or different types of combinations that are out there, been around for a long time, and you get good mileage out of those combinations.

Now, if that stops working, if you now go to this other therapy, you go back to the CAR T cell, that will suggest that the results are not that different. So I think that there are aspects that we don’t fully understand. I personally believe, based on what I’ve seen, based on what I know from treating thousands of patients with myeloma for almost 30 years I’ve been a doctor, I think time is probably very, very important. So if you go back to back from one therapy to the other, that’s less likely to be beneficial. If you go from one therapy, and it stops working and go to the other drug with the same target.

But I would say it’s not that different from how we think about IMiDs or proteasome inhibitors. If you were to go single drug with a proteasome inhibitor and you switch to single drug with another proteasome inhibitor, or the same thing with an IMiD, that’s less likely to work versus if you went to something else in between. So we just need to generate more data and learn. Lastly, I want to say that in my experience, from all I see in my clinic at the current time, I think the choice that patients make is based on personal preference and to some degree also the situation of the patient. I saw a patient yesterday, 50 years old, who came from another country and has relocated to us here in Miami and asked, what are the options?

And we talked about CAR T cells, we talked about bispecifics. And considering all the different factors that CAR T cell would imply that we had to give some other combination therapy for two or three cycles while we harvest the CAR T cells and manufacture the CAR T cells and then plan for the admission and give it, and also that the patient was not really very happy about the side effects in the hospital with CAR T cell. That patient shows the bispecific, but I’ve also seen other patients in the same situation saying, I’d rather do these different steps for two or three months, I stay in the hospital, and then I enjoy being off therapy.

Actually, I saw another patient just a few days ago, a gentleman in his upper 70s who we had the same conversation, and he had picked the CAR T cells. And I saw him with his wife and he has been off treatment for two years doing excellent. So different patients make different decisions. And I think that is just how the field is evolving. So I think we should be open to individual patient’s priorities and what they want, and we should just offer everything. And of course, we can guide if a patient wants us to give direction, but I think presenting it and let patients be part of the decision-making, that’s the future of how medicine should be practiced.


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Myeloma Patient Expert Q&A: Dr. Ola Landgren

Myeloma Patient Expert Q&A: Dr. Ola Landgren from Patient Empowerment Network on Vimeo.

START HERE bridges the gap between expert and patient voices, empowering myeloma patients to feel comfortable asking precise questions of their healthcare team.

In this webinar, Dr. Ola Landgren delves into the emerging and exciting therapies and clinical trials for myeloma, discusses the latest options for relapsed disease, and explores the current landscape of managing and monitoring multiple myeloma. Watch as Dr. Landgren answers patient-submitted questions and discusses another hot topic: the utilization of artificial intelligence in multiple myeloma.

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Transcript:

Lisa Hatfield:

Hello, and welcome. My name is Lisa Hatfield, your host for this Patient Empowerment Network START HERE program where we bridge the expert and patient voice to enable you and me to feel comfortable asking questions of our healthcare teams. The world is complicated, but understanding your multiple myeloma doesn’t have to be. The goal of this program is to create actionable pathways for getting the most out of myeloma treatment and survivorship.

Today I am honored and really excited to be joined by Dr. Ola Landgren. Dr. Landgren is chief in the Division of Myeloma and the Department of Medicine, and also serves as director of the Sylvester Myeloma Institute at the University of Miami’s Miller School of Medicine. Dr. Landgren, it’s such a pleasure having you today.

Dr. Ola Landgren:

Thank you very much for having me. It’s really a great pleasure to be here today.

Lisa Hatfield:

So in this program, first, we’ll get a high level update from Dr. Landgren on what the latest myeloma news means for you and your family. And then we will launch into some questions that we’ve received from you. Dr. Landgren. We’re at a pivotal moment in the history of multiple myeloma. We’re experiencing an unprecedented wave of progress marked by significant increase in new treatment options and ongoing research. We are very honored to have your expertise to guide us in understanding these advancements and providing clarity around all the evolving landscape of myeloma care.

So before we get started, to you at home, would you please remember to download the program resource guide via the QR code. This is where you’ll find useful information to follow before the program and after. So we are ready to START HERE. Dr. Landgren, can you speak to the emerging and exciting myeloma therapies and trials right now?

Dr. Ola Landgren:

I’ll do my best. There are so many things to talk about, and I don’t think we have 10 hours, so I will have to shorten it. But I would say that the past 12 to 18 months, we have had three new drugs approved in the field of myeloma. These are the bispecific antibodies. The first out of those three was the BCMA-CD3 targeted drug teclistamab-cqyv (Tecvayli). And in the middle of 2023, we had both talquetamab-tgvs (Talvey), and elranatamab-bcmm (Elrexfio) approved. Talquetamab has another target is GPRC5D with CD3. And elranatamab is similar to teclistamab with the BCMA-CD3 targeted bispecific antibody. These are amazing drugs. They have been found in patients that have been heavily pretreated to result in about 60 percent or more percent of patients responding.

So overall response rates ranging from 60 percent to 80 percent in various trials. We have now these drugs approved, they’re still only approved as single drug and there are new trials going, combinations of two of these or these drugs with other drugs such as daratumumab (Darzalex) or IMiDs, such as lenalidomide (Revlimid) or pomalidomide (Pomalyst). So a lot of drug development is ongoing as we speak. We also have the CAR T cells that are reasonably new drugs. We, you think about everything new every week there’s a new drug, but they are very new CAR T cells.

We have had them for about three or so years, three-and-a-half years. And, the two drugs that are approved in that setting is, ide-cel (idecabtagene vicleucel) [Abecma]. That was the first and then cilta-cel (ciltacabtagene autoleucel) [Carvykti], that was the second. They both go after BCMA similar to the two antibodies I mentioned, teclistamab and elranatamab because they are CAR T cells, that indicates that they are cells.

They come from the same person who’s going to receive them back as treatment. So you collect the cells from the blood and you manufacture them into to CAR cells. So chimeric antigen receptor T cells, and then you give them back. There are several new CAR T-cells in development. There are other targets in development, GPRC5D, for example. There are additional other targets and there are also dual targeted cell therapies in development.

There are also allogeneic CAR T cells in development and that means that you could have a product off the shelf. So someone could donate cells, they could be manufactured into CAR T cells, and then you could give them to technically any person, so it doesn’t have to be the same person collecting and then manufacturing, giving them back. So that would shorten the time window for production.

And there are a lot of other details also that are important in this context. The whole manufacturing process that’s currently four to six weeks is being improved. There are some technologies that can make the CAR T cells in 48 hours, but the turnaround time is maybe one to two weeks with all the control steps, but that’s still a huge improvement. And then you have the antibody drug conjugate if you want.

So then you have the belantamab mafodotin (Blenrep). That actually was the first BCMA targeted therapy we had in myeloma. And then the drug was approved on an accelerated approval study. But when the randomized study was completed, it turned out that it was not better than the control arm. The company took it off the market. And now what’s happening is that there are two new trials, and one of them was just reported in the beginning of February of 2024.

The other one was around the ASH meeting in 2023. These two trials show that if you combine it with other drugs, the most recent one was with bortezomib-dexamethasone (Velcade-Decadron), that was superior with the belantamab mafodotin with bortezomib-dexamethasone versus daratumumab with bortezomib-dexamethasone. So I think we will probably see this drug coming back to the myeloma field. It is currently available as compassionate use, so physicians can prescribe it, but these trials will most likely, I would think, lead to FDA approvals with these combinations.

And lastly, I would say that other exciting trials, there are so many trials going on, but another thing that I think is interesting and exciting is also the use of antigens. And you can use mRNA and things like that. So these are like the vaccines. You can either, take a patients’ myeloma cells and look what they have on the surface, you can make more traditional vaccines or you can use more sophisticated newer technologies just like how the COVID vaccines were developed. And you can inject these sequences and then they will translate into spike proteins where the immune system could go after myeloma cells.

We don’t yet have a product like that in the myeloma field, but there are a lot of biotech and groups that are working to see. Moderna, was actually initially a cancer vaccine company and then COVID came and they turned into a COVID company, and now they’re be back again in the cancer field. So that’s a little bit of a summary of a lot of the exciting news that’s out there.

Lisa Hatfield:

Thank you. And do you have any comments about the sequencing of some of these? So with both CAR T and some of the bispecifics approved, obviously if a patient comes in and they need something right away, they’ll take whatever is first available. But all things being equal, if a patient says, well, I can, I have both CAR T accessible and bispecifics accessible. There are some patients out there, I’ve spoken with some who are wondering, is there a benefit to sequencing one before the other, or are there any trials looking into that?

Dr. Ola Landgren:

There are studies that have allowed patients to go on treatment with one of these modalities. For example, the bispecific antibodies with the prior exposure to a CAR T-cell therapy. There are also trials with CAR T-cell therapy that has allowed patients who have been exposed to prior antibodies, either bispecifics or the conjugated antibody drug conjugates, Belantamab mafodotin. So if you look at those studies and see how the numbers compare, if you are not exposed or you are exposed, I think the data is not entirely clear-cut.

There is no definitive study. Some data suggests that maybe it’s not that different, but then there are some studies that suggest that if you go to the antibody first that maybe that would lower the efficacy of the CAR T cell. So some people have for that reason said the CAR T cell should be done first. To make it even more complicated, there are some studies that have then taken time into the equation. So that means that you could have the patient treated with the antibodies for BCMA and CD3, and the antibody is given successfully for a long time, for many years. And eventually, unfortunately, the antibody may stop working.

Now, if you switch back to back to a CAR T-cell therapy without any other therapy in between, some studies indicate that that’s less likely to be beneficial. But if you instead do another target, say you did GPRC5D/CD3, or you did a completely different therapy with small molecules or you did carfilzomib (Kyprolis), or you did venetoclax (Venclexta), or IMiDs, or different types of combinations that are out there, been around for a long time, and you get good mileage out of those combinations.

Now, if that stops working, if you now go to this other therapy, you go back to the CAR T cell, that will suggest that the results are not that different. So I think that there are aspects that we don’t fully understand. I personally believe, based on what I’ve seen, based on what I know from treating thousands of patients with myeloma for almost 30 years I’ve been a doctor, I think time is probably very, very important. So if you go back to back from one therapy to the other, that’s less likely to be beneficial. If you go from one therapy, and it stops working and go to the other drug with the same target.

But I would say it’s not that different from how we think about IMiDs or proteasome inhibitors. If you were to go single drug with a proteasome inhibitor and you switch to single drug with another proteasome inhibitor, or the same thing with an IMiD, that’s less likely to work versus if you went to something else in between. So we just need to generate more data and learn. Lastly, I want to say that in my experience, from all I see in my clinic at the current time, I think the choice that patients make is based on personal preference and to some degree also the situation of the patient. I saw a patient yesterday, 50 years old, who came from another country and has relocated to us here in Miami and asked, what are the options?

And we talked about CAR T cells, we talked about bispecifics. And considering all the different factors that CAR T cell would imply that we had to give some other combination therapy for two or three cycles while we harvest the CAR T cells and manufacture the CAR T cells and then plan for the admission and give it, and also that the patient was not really very happy about the side effects in the hospital with CAR T cell. That patient shows the bispecific, but I’ve also seen other patients in the same situation saying, I’d rather do these different steps for two or three months, I stay in the hospital, and then I enjoy being off therapy.

Actually, I saw another patient just a few days ago, a gentleman in his upper 70s who we had the same conversation, and he had picked the CAR T cells. And I saw him with his wife and he has been off treatment for two years doing excellent. So different patients make different decisions. And I think that is just how the field is evolving. So I think we should be open to individual patient’s priorities and what they want, and we should just offer everything. And of course, we can guide if a patient wants us to give direction, but I think presenting it and let patients be part of the decision-making, that’s the future of how medicine should be practiced.

Lisa Hatfield:

Thank you so much for that explanation. I’m going to segue into a comment that I always make to myeloma patients. As Dr. Landgren was explaining all of these treatment options, he is on top of all the latest and greatest news and therapies. I always recommend to myeloma patients newly diagnosed or otherwise to seek out at least one consult from a specialist. If you have difficulty accessing care, then a lot of places can do video conferencing, but even that one consult to see a myeloma specialist is so important in your care and treatment options. So I’ll just throw that out there, Dr. Landgren, as a myeloma specialist that you are, we appreciate your expertise in explaining that so well.

Dr. Ola Landgren:

I agree 100 percent with what you said, and I would like to add to that and say, going to a specialist center and it doesn’t have to be here, can really really help. It can be a lot of small things. There is data indicating that survival is longer for patients who have access to specialists. That has been published in the Journal of Clinical Oncology. The Mayo Clinic has published that, I think it was more than one year longer survival.

That by itself is, of course, very strong, but I also think that there are a lot of the small things like the different types of pre-medications, the drugs that are given around myeloma drugs. Could you decrease the dose of some of these drugs like the dexamethasone? Could you get rid of Benadryl if you give the antibodies? These may look as small things, but they can make a huge difference for quality of life.

We have a lot of people coming for second opinions, and we always say if you live closer to someone that you trust, you should go back and be treated there. You can always reach out to us. We are happy to be involved. You have us as a backup. We can be your quarterback if you ever need us. I think that is absolutely the best advice for every patient. Go and get feedback and if you’re not sure about the feedback you get, you could always have two different quarterbacks and you could ask them. I don’t think having 10 or 20 is going to help, but having one or two second opinions, I think is a good decision.

Lisa Hatfield:

That’s really helpful information, thank you, Dr. Landgren. So I think we’re going to shift a little bit to managing and monitoring multiple myeloma. Once you’ve had a patient go through the induction therapy, what kind of monitoring do you complete for your myeloma patients and in particular those who have reached a certain level response and are maybe on maintenance or continuous therapy, what type of tests do you do and how often regarding labs, imaging, bone marrow biopsies?

Dr. Ola Landgren:

There are a lot of different ways, obviously, of practicing medicine. So every center has developed models that they feel very comfortable doing. So I like details. I like to know things. I like to check things. I’m not excessive in ordering invasive tests, but I like to know. Also, I like to make sure the patient not only has good long-term clinical outcomes, but also good quality of life. And to me, I try to minimize the intrusiveness of what we do. So, for example, if I give a combination therapy where there is an injection or infusion, say week one, week two, week three, and then there is a week off. I recognize that if you do labs during that week off, you will have a better yield and understanding of how these three different injections or infusions actually have moved the disease forward and suppressed the disease.

But in my mind, I think that week off is a very important week off for the patient. So I would rather do testing the third day of the treatment at the treatment unit. So if it’s week one, week two, week three, I would draw the myeloma labs that same day. And that would give the patient six more days off from injection, infusion that third week and the whole fourth week off. So I would give the patient 13 days off.

Again, these are small things. These are things I’ve thought about a lot. I’ve practiced medicine for many years and I recognize that having time off like that, many patients travel, they go on vacation, they do different things. So I don’t want to just randomly put a blood test in the fourth week just because I want to check after week one, two, three, and then have the assessment.

I sort of underestimate the benefit of the therapy and then I start the next cycle, say back to back cycle two and cycle three and so forth. I would typically do blood tests once a month following these principles. I do baseline and I would do the last day of injection or infusion. For a newly diagnosed patient, you ask me, I would for baseline always do bone marrow biopsy and an aspirate. I would always do a PET-CT for every patient as my default. Sometimes we end up doing MRI. So that could be other things that are happening, but that is what we do for the majority of our patients.

After we have completed four to six cycles of treatment for patients that are candidates for consideration of transplant with chemotherapy with melphalan (Alkeran), we would usually do a biopsy after four to six cycles and we would use that to determine what’s the optimal mobilization protocol for stem cells. When we do that, we would run a MRD test.

We would run our in-house flow cytometry test that we developed when I used to work at Sloan Kettering and we have developed that here in Miami as well. We work closely with Sloan Kettering, and we have set up this assay in collaboration in the new 2.0 version. We will also send the aspirate for the clonoSEQ at Adaptive Biotech, which is the DNA-based sequencing for MRD. We would send the patient for collection of stem cells.

When the patient is back, we will continue treating. So if you say we do it after four cycles, we would collect, if we do it after five or six, then we collect. After that, we would typically resume therapy and for the majority of our patients, we actually give around eight cycles of therapy, and we have seen that you can deepen the response. You don’t increase the toxicity, but you deepen the response for the vast, vast majority of our patients. When we have used our best therapies, we have done it that way…

We have even published on this, over 70 percent of our patients are MRD negative, and many of those patients, when they come to cycle eight, they ask, do I have to do the transplant? And that is a controversial topic. But I think there are two large randomized trials that have shown the same thing, that there is no survival benefit with transplant. But you can also say that there is, in those two trials, a progression free survival benefit, meaning that the disease would stay way longer with transplant.

But many patients say, if I reach MRD-negative, both those two trials show that if you’re MRD-negative without transplant, or you’re MRD-negative with the transplant, PFS was actually the same. And given that there is no survival, overall survival benefit, why would I subject myself to go to that? Why don’t I keep the cells in the freezer and go right to maintenance? And we will have a conversation with every patient, they would meet our transplant team, they would meet our myeloma expert team.

And the individual patient will make decisions. I think over time, more and more patients have chosen to keep the cells in the freezer. For patients that are MRD-positive, we would counsel towards transplant, but there are patients that don’t want to do that, and we are not forcing any patients to do that. We would give patient maintenance, and on some of our trials, we use the standard of care, which is lenalidomide maintenance.

And we are also developing new approaches where we have done daratumumab added once a month with lenalidomide. We have gone one year, and we have started to do two years of that. And after that, we would stop daratumumab and just do lenalidomide maintenance. Lastly, to answer your question fully here, we would do a PET-CT in the bone marrow after the eight cycles as a repeat, and we would offer a patient to check on maintenance on an annual basis, and this is in accord with the NCCN guidelines. So a lot of details here, but you asked me how we do testing.

Lisa Hatfield:

Yes. And one of the questions that comes up, too, regarding bone marrow biopsy, so you talked about patients kind of through the process of myeloma treatment, perhaps they’ve reached a point where they’re going to be for a while. Do you see a need for continued bone marrow biopsy, say, annually, or is there some benefit to using the newer tests that are being investigated, like mass spec testing and some of the newer ones, I think the EuroFlow? Do you think that that can be used to test for bone marrow biopsy? And how will that be used to monitor the myeloma if a patient is doing relatively well, or do you still like to do bone marrow biopsies on a regular basis? And I know every specialist is different in how they’ll answer that question.

Dr. Ola Landgren:

So what’s known in the literature is that there is no study that definitively has compared annual biopsies with these blood-based tests that you mentioned, showing that they can replace the bone marrow. Those tests or those studies have not yet been published and shown in a convincing way that we have done. This is how it is. It’s still an open question. We don’t know the answer for sure. So our take has been to offer patients to repeat it on an annual basis for maybe two or three and sometimes up to five years. I don’t think we would do biopsies every year for five, 10, 15 or more years. At some point, you have to ask yourself, what are we trying to chase here?

But I think the data we’re looking at that we have published on this and others have also show that if you are MRD-negative after completion of the eight cycles with or without the transplant, the patient that are MRD-negative one year later, they are more likely to be free from progression 10 years later, compared to the ones where you only check once and you don’t know what happened one year later. And that is frankly because there is a small group of patients where MRD-negative could bounce back into positive.

So to check after completion after eight cycles and to check after one more year on maintenance, I think gives us more confidence in thinking about if we eventually could step down and maybe even stop the maintenance at the long term. There is no study that definitively has proven that, but the data suggests that being negative after eight and do another year and even if you do two years out, those are very strong indicators that the disease will stay away long term.

So that’s our justification for offering it, but we would never force any patient. And I also want to say that we have thought about for a long time, how we can contribute to the field and how we can advance the field for blood-based tests. So we are here in Miami, developing a lot of these technologies, and I have made a promise that we will make all these available for all patients that come here to Miami as part of our standard workup. Because they are not clinically validated tests, they will have to be reported for now as research tests, but we will share the information with individual patients.

So we have three different platforms for now. And we are working on the fourth one. So one of them is the mass spec with MALDI, where we can screen the blood with lasers. And we can increase the sensitivity by maybe hundred times compared to existing immunofixation assays. The second is something called clonotypic peptides, which is a more sophisticated way to run mass spec, which is probably up to thousand times more sensitive than immunofixation. And the third technology we are doing or setting up right now is circulating cells that we sequence.

And this is the Menarini technology that is approved for certain other solid tumors. I think for GI malignancies, it’s FDA cleared, but we are doing it in myeloma. We are also looking for free circulating DNA. We’re working with New York Genome Center to set those types of assays up. So my thinking is, if we can offer every patient that come here to do it, and many of those patients will do an annual biopsy, we actually will have the database that can answer the question you asked me, if it can replace. There is no other way that this can ever be answered.

But having a large database, we actually can compare on a patient level, how the bone marrow biopsy with flow cytometry and sequencing, how that behaves in relation to the blood base. How does it perform? Is any of these better? Can they replace each other? So I think if we do this for one or two years, we will have the answer to the question. That’s why I want to do it.

Lisa Hatifeld:

So that kind of leads to the next question that is really an exciting area. I know it’s not necessarily new, but newer is artificial intelligence.  And I know I was reading an article about one of, that you and your colleagues have worked on a newer project and I don’t know if you pronounce it IRMMa or not, but using these large databases to help predict I think, it’s the response of treatment in some patients. So can you talk about that a little bit and tell us about that development and what developments are exciting with artificial intelligence in cancer, in particular myeloma?

Dr. Ola Landgren:

Yeah. So you mentioned the study we just published. We published a model that we call IRMMa and that stands for individual risk prediction for patients with multiple myeloma. So what we were thinking was at the current time, all the existing models are pretty much providing the average patient’s predicted outcome. So think about it is like it’s a probability measure. So you say, if I take this about therapy, what’s the predicted average outcome for patients that take this therapy, say, five years later? So on average, say 70 percent of patients are free from progression. That sounds pretty good. The problem is that you don’t know if you are in the group, 70 percent group that didn’t progress or if you’re in the 30 percent that did progress.

So where are you as an individual? So it’s almost like looking at the weather app on your phone. If it says it’s a 70 percent probability of sunshine and then you go outside and it’s raining, it’s because it didn’t say that it’s 100 percent probability of sunshine. So if you think about another situation would be, say, in a GYN clinic, if a woman were to come and ask the doctor, am I pregnant? Yes or no? You couldn’t say it’s 70 percent probability. You would say, yes, you’re pregnant or not pregnant.

So for myeloma, we have for a long time been living in these weather report systems where we say 70 percent or 30 percent. And we want to go in the other direction of the pregnancy test, where we actually can say for someone with this particular disease profile, with this treatment, this is where this is going to take us. We worked on this project for almost four years and we worked with a lot of other groups around the world that have a lot of data. And they have graciously agreed to collaborate with us and share their data sets. The beauty with this collaboration, there are many beauties of it, but one of them is that people don’t treat patients the same way.

And that actually has allowed us to say for patients that have a particular biological or genomic makeup, if you’re treated this way or that way or the other way or a fourth way and so forth, which of these different treatments would make patients have the longest progression and overall survival? So if you have a large database, you can actually ask those questions. So you can say that you profile individual patients in full detail and you put them in detailed buckets instead of grouping everybody together.

And now if you add a new case, if a new patient is being added and you say, which bucket would this individual fit? Well, this is the right biological bucket. You can then use this database to say out of all the different treatment options, which treatment option would last the longest, which would give the best overall survival? Other questions you could ask is also, for example, you have a patient with a certain biological workup or makeup. And you say, if I treat with these drugs, will the addition of, say, transplant, will that prolong progression for his survival?

And you can go into the database and the computer will then say, I have these many patients that have this genomic makeup and these many people that were treated with this treatment with transplant versus the same treatment without transplant. There was no difference in their progression or overall survival. So then the computer would say, it doesn’t add any clinical benefit, but there could be another makeup where the answer is opposite, but transplant actually would provide longer progression for his survival. I think the whole field of medicine is probably going to go more and more in this direction. So what we want to do is to expand the number of cases.

So we are asking other groups around the world, if they have data sets with thousands of patients, they could be added to this database and we could then have more and more detailed information on sub types of disease and more and more treatment. So it will be better as we train it with larger data sets. The model is built as an open interface so we can import new data. And that’s also important because the treatments will continue to change. So we, for example, say I have a patient that has this genetic makeup. I was thinking of using a bispecific antibody for the newly diagnosed setting.

How is that going to work? The computer will say, I don’t know, because we don’t have any patients like that in the database because that’s not the data, type of data that currently exists from larger studies. But let’s say in the future, if there were datasets like that, you could ask the computer and the computer will tell you what the database finds as the answer. But if you go for another combination, if that’s in the database, it would answer that too. That is where I think the field is going.

And lastly, I would say we are also using these types of technologies to evaluate the biopsies, the material. We work with the HealthTree Foundation on a large project where we are trying to use computational models to get out a lot of the biological data out of the biopsies and also to predict outcomes. So I think artificial intelligence is going to come in so many different areas in the myeloma field and probably in many, many other fields in medicine.

Lisa Hatfield:

Thank you so much, Dr. Landgren, for that broad overview of myeloma, especially relapsed and refractory myeloma. So it’s that time now where we answer questions we’ve received from you. Please remember that this is not a substitute for medical care. Always consult with your medical team. And we’re going to jump right into some questions that we’ve received from patients, Dr. Landgren, if you have a little bit of time to answer these questions for us.

Dr. Ola Landgren:

Of course.

Lisa Hatfield:

Okay. So broad questions. We try to make them broad so they apply to most people, but this patient is asking Dr. Landgren, what are the key biological processes driving disease, progression and evolution of multiple myeloma, and how can we target these processes to prevent disease relapse and improve long-term outcome?

Dr. Ola Landgren:

So that’s a very good question. So I think in a nutshell if you use genomics, which refers to the genetic changes that you can see in the plasma cells, there are certain features that the myeloma cells have. They have the copy number changes, that’s the gains and losses of chromosomes. You can find these if you do FISH and cytogenetics could be, for example, gain of chromosome 5 or gain of chromosome 7 or gain of chromosome 11. That would be part of the Hyperdiploidy disease, or you have loss of chromosome 13 or 13q deletions. We also refer to 17p deletion. These are copy number changes, they’re extra or loss of these chromosomes. But then you have also the structural variance where you have the translocations of chromosome 14, chromosome 14 harbors the IGH locus, which regulates the making of immunoglobulins.

Plasma cells make immunoglobulins. For reasons that are not entirely clear. The translocations in myeloma that include IgH, they are partnering up with oncogenes. There is a list of oncogenes, there’s MATH, there’s three MATHs, A, B, C. There’s FGFR3, MMSET, and there’s also Cyclin D1 that are on the list. So these are the different types of structural variants that you can see with FISH probes.

What people have understood less about are something called mutational signatures. And myeloma is made up by eight distinct mutational signatures that you can see in every single patient. And what that means is that you can, if you conduct whole genome sequencing and you look at all the base pairs, you can see there are certain number of combinations. C can be swapped for A and C can be swapped for G or C can be swapped for T, T can be A and T can be C and T can also be G.

Those are the combinations. So there are four different base pairs, but if you, because the DNA is double stranded, these are the only possibilities that mathematically that you can see. Now if you look for every base pair and you look on one base pair on the left and one on the right, we call that 5 and 3 prime, you look through triplicates, every of these base pairs can have these different swaps I mentioned. Mathematically, there are 96 different combinations that you can come up with. That’s it.

If you don’t go through the entire genome from left to right, you see that there are these recurrent eight signatures that are there in every patient. So although we don’t understand why they are and exactly how they function, the fact that you see them in every patient tells us that this has to have something to do with the biology of the disease. It must have a role in the control of the disease. We are starting to see that there is one signature that’s called APOBEC. That signature seems to be very important for resistance to treatments. And you can see that APOBEC can be more or less expressed.

And if APOBEC is very expressed, we see that there are lot of mutations in the cells. We have seen in patients with the chemotherapy that APOBEC can be very expressed. When we treat with four drug combinations, it can be very expressed. And what I’m saying, when I say it can be expressed, these are in the patients that relapse out of these therapies. We have also seen that in CAR T cells and bispecifics. So that makes me believe and our group believe that the cells use some form of what we call tumor intrinsic defense mechanism to protect themselves from whatever therapy we use.

It doesn’t matter if it’s immunotherapy, chemotherapy or small molecule therapy, there are some fundamental programs the cells can turn on. We need to understand that better and we are spending a lot of time trying to drill into this.

Lastly, I also want to say there was a fourth class of genomic events called complex events that you can see in myeloma, something called chromothripsis. That’s a very severe genomic lesion, is a ripple effect through the genome. There are a lot of havoc going on. And the first time we saw that, we thought this has to be something wrong with this sample. But when we look through more and more samples, we see that about a quarter of the patients actually have this chromothripsis.

So the bottom line is, it’s time to stop doing FISH, it’s time to do more advanced sequencing, ideally whole genome sequencing, but a step towards a whole genome could be to do whole exome sequencing. But there are companies saying that you can do whole genome sequencing for $1 in the future. So that’s really what needs to happen. We need to have better tools to better understand and then we can use this to better understand how to differentiate the therapy and have an individualized treatment. That’s what I talked about with the IRMA model.

Lisa Hatfield:

All right, well, thank you so much for that explanation. Dr. Landgren, can you speak to the advantages that bispecific antibodies offer over traditional therapies and how do you see their role in overcoming treatment resistance?

Dr. Ola Landgren:

Well, the bispecific antibodies is a novel way of engaging the immune system to go after the myeloma. So if you think about the other antibodies we have, we have three other antibodies. We have daratumumab, we have isatuximab (Sarclisa), we have elotuzumab (Empliciti), they are naked antibodies. They bind to the myeloma and on the backend of these antibodies, there is something called the FC receptor that attracts cells, NK cells, for example, also T cells, and they also attract, some of these antibodies also attract complement and they also by themselves send what’s called a death signal into the myeloma cell.

The bispecific antibodies are very different. They bind and they don’t send death signals, they don’t engage with the complement. What they do is that they have another arm sticking out that binds to the T cells. That’s a CD3 arm and there’s an open pocket. So when a T cell passes by, it grabs the T cell. And now you have a T cell linked to the antibody sitting next to the myeloma cell and the T cell will kill the myeloma. T cells can be very aggressive and kill the myeloma. You just hold them together, it’s like a matchmaker.

And if you think about how CAR T-cell therapy is designed, you take out the T cells, you manufacture them to have a special antenna receptor on their surface, and then you give them back again. And then they bind, this receptor binds to myeloma cells. So in the setting of a CAR T-cell therapy, the T-cell sits next to the myeloma cell, but that’s because the T cells were taken out of the body, manufactured to have this receptor that then finds the myeloma cell. But the bispecific antibody, that they don’t require the T cells to be taken out, to be modified this way.

You just use your existing T-cells in your body and these antibody just binds to the T cells and the myeloma cells in the body. So it’s sort of a little bit mimics what the CAR T cells do, but it does it in its own way within the cell, within the tissue in the body. You asked me for resistance mechanism and how they are better. Well, I think the best answer I can give you is to say that the overall response rate for the bispecific antibodies are very high. They are 60 to 80 percent single drug compared to the current trials. And if you look and see the trials that have led to approval for the other existing drugs, they were 20 or 30 percent.

So the overall response rate is much higher for the bispecifics than they were for the other existing drugs. We don’t really know exactly how to use them, I would say. What’s the optimal dosing schedule? We give them weekly, it may be every other week, and maybe monthly, eventually, I would think. And should they be combined with which drugs? That’s ongoing investigation. Other questions are, can they be stopped? Can you monitor patients off therapy for a long time? Will some patients never have the disease coming back? We hope so, but we don’t know. Or would it be patients could be off therapy for a long time, like with CAR T cell? Could that happen with the bispecifics? It’s possible.

And if you were to monitor with blood-based tests and you see that there is reappearing disease, would you then put patients back on the therapy? These are questions we…there are a lot of questions, we don’t have answers to all these, but that’s where I think the field is going. A lot of people, including us, are trying to investigate this.

Lisa Hatfield:

Okay, thank you. And we have a number of questions about MRD testing, so I’m going to try to combine those all together. Basically, what the questions are asking is how do you interpret MRD testing with regard to prognosis, treatment response, and maybe even like treatment, ongoing treatment? How do you use those results in your clinic or any comments you might have on the MRD test?

Dr. Ola Landgren:

So MRD tests have been around for quite some time. We have been pioneers pushing it. We have worked on it for over 15 years. We worked with the FDA to see if MRD could eventually become an endpoint for drug approval, that’s work in progress. The FDA will make those decisions. There are a lot of trials that use MRD as a secondary endpoint to see how it correlates with progression-free survival. And there actually are some trials that have been using it as a cool primary or primary endpoint in the absence of FDA’s decision to accept it. But that is probably going to change in the future. We will see.  What have we done in the clinic? Well, we have used it in the same way as we have done with PET-CTs and the regular blood work. So if you use SPEP IFE light chains and you see there is residual disease after you have delivered your planned treatment, people have used what’s called consolidation therapy.

So we have done the same with the MRD test. If there is someone who has a little bit of disease left, we have tried to see if we could make that patient MRD-negative. We have also used it as a tool to build more reassurance. I mentioned before for patients who get this new combination therapies, if they are not very keen on jumping right to chemotherapy with Melphalan and transplant, if they want to collect the cells and keep them in the freezer, using the MRD as a tool to guide for reassurance.

Looking at the randomized trial showing that MRD negativity with or without transplant seems to have the same progression-free survival and in the absence of overall survival, either way, that has been published. But we would always say to patients, there are no definitive studies that have shown that this is how it is. It’s still an area of investigation. So if a patient wants to sort of do everything by the traditional book, we would give every step in the therapy and not pay attention. But a lot of patients say, I would rather monitor, and if I have to do these more toxic therapies, I wouldn’t do it. But I will use MRD to build confidence in myself.

Lisa Hatfield:

Well, thank you so much, Dr. Landgren, these have been great questions, and I actually have another half sheet of questions that we don’t have time for, because that’s all the time that we have. Dr. Landgren, thank you so much, it’s been a pleasure talking with you today. So thank you for joining our Patient Empowerment Network START HERE program. This has been an excellent discussion. Thanks to all of you, for your questions and tuning in. My name is Lisa Hatfield. I’ll see you next time.

Dr. Ola Landgren:

Thank you very much for having me. Thank you.


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How Has CAR T-Cell Therapy Transformed Myeloma Care?

How Has CAR T-Cell Therapy Transformed Myeloma Care? from Patient Empowerment Network on Vimeo.

How has the emergence of CAR T-cell therapy impacted myeloma care? Expert Dr. Shambavi Richard explains which myeloma patient groups could benefit from CAR T-cell therapy and shares research updates from recent clinical studies. 

Dr. Shambavi Richard is Co-Lead Physician for the Myeloma CAR-T Programs at Mount Sinai Tisch Cancer Center. Learn more about Dr. Richard.

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Transcript:

Katherine:

Dr. Richard, how is CAR T-cell therapy impacting the landscape of myeloma care? 

Dr. Richard:

So, as I’d hinted or alluded to previously, prior to CAR T cells appearing on the horizon, we had very limited options for patients who had had the first several lines of therapy.  

So, once they had been exposed to two proteasome inhibitors, two iMiDs, and then anti-CD38 antibody which is the three major class of myeloma drugs, they are then called triple class exposed or penta-exposed depending on how many of these drugs they’ve been exposed to.   

We had a study called the MAMMOTH study back – this was published back in 2019 prior to the era of CAR T cells and other T-cell directed therapies. And at the time they had looked at patients who were triple class exposed, and who had been exposed to daratumumab were refractory to daratumumab as their last line of therapy. And what we saw was with their next line of therapy or whatever else was available at the time for patients such as these, their expected response rate was only about 30 percent or so, number one.  

Two, their outlook was very poor with a median progression-free survival which means that the amount of time that patients could go without the disease coming back, and that median progression-free survival was less than six months. And their expected even median overall survival was well under a year. So, that was what the landscape looked like when CAR T cells came onto the scene. For instance, the CART2 trials, which is one of the approved products which is cilta-cel which is what we have now, we actually saw for this same group of patients, the response rate was now 98 percent.  

Deep responses were 83 percent. And we now have the final readout of their median progression-free survival which is almost three years. So, you can see a significant difference.  

Under six months, media progression-free survival to three years. And over 50 percent of the patients were living over three years. So, that’s kind of where we are at. I mean so it was no small improvement. This considerably kind of almost reset the bar and has given a new lease of hope and life to patients who had advance myeloma. And one of the things we say in myeloma is although we don’t, as yet, say that myeloma’s curable, we are working towards that. But we are also giving options for other treatments, other research to be effective in patients just by keeping them around longer.  

Katherine:

Have there been any recent research developments involving CAR T-cell therapy that patients should know about? 

Dr. Richard:

Absolutely. So, much as I have highlighted all the hope and the optimism and the good things about this, the fact is we’re still not curing people with these therapies.  

So, we called this a plateau in the survival curve which means that if we achieve that plateau, that means the disease is probably not coming back, and we have essentially the definition of cured. But we’re not seeing that. We’re still seeing a downslope in the survival curves of myeloma which means that patients are still relapsing in spite of these excellent therapies.

So, there’s a lot of research going on into why are patients still relapsing? Is it because they’re losing the antigen which the CAR T cells are recognizing? Is it because the CAR T cells are no longer effective even though the antigen is still present? Is it because there’s a considerable lag time between the patients being freezed or collected, the cells being collected for the genetic modification in the lab to the time when the patients can actually receive these cells? And that can be anywhere between four to eight weeks.  

So, during this time period, patients with advanced myeloma may not remain static with their disease. The disease is progressing. They’re getting worse. They may not be candidates for these kinds of therapies. So, one of the areas of research is how can we speed up this process, this manufacture process? How can we make it much more available? Because they’re limited by the manufacturing facilities, their abilities to have these viral vectors, to be able to transduce these cells and genetically modify.

So, can we take them off of those kinds of things? Can we automate this? Can we improve these manufacturing platforms? So, a lot of different things are being tested. And then as I’d also mentioned earlier, right now they’re approved for advance myeloma, but what if we can bring them up earlier? Are patients actually going to get cured by that? Are they going to have a much better progression-free survival with that versus waiting until they’re very advanced? So, these are all many, many things that are being looked at.   

In addition, a lot of these CAR T products, these approved products, all them are all recognizing one antigen on the myeloma cell. Now there are products are being looked at that are dual target antigen recognition ability. So, that’s another thing. So, maybe if the CAR T cells are missing one of the antigens, and they’re not able to use that to kill the myeloma cell, maybe the other antigen can pick up the slack. So, these are various things that are being looked at. 

Understanding the Basics of CAR T-Cell Therapy

Understanding the Basics of CAR T-Cell Therapy from Patient Empowerment Network on Vimeo.

CAR T-cell therapy is an exciting new option to treat multiple myeloma, but what patient type is this therapy right for? Expert Dr. Shambavi Richard defines CAR T-cell therapy and explains the eligibility requirements.

Dr. Shambavi Richard is Co-Lead Physician for the Myeloma CAR-T Programs at Mount Sinai Tisch Cancer Center. Learn more about Dr. Richard.

See More from The Care Partner Toolkit: CAR T-Cell Therapy

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Transcript:

Katherine:

Let’s begin with the basics of CAR T-cell therapy. What is it? And maybe, actually, we could start with what CAR is short for.  

Dr. Richard:

So, CAR stands for chimeric antigen receptors, so CAR T cell is a chimeric antigen receptor T-cell therapy. What that means is T cells, which is one of the cells for immune system are actually come from the patient. They’re expanded and activated in a manufacturing facility. And there they undergo genetic modification to form the CAR T cells. And what’s special about the CAR T cells is that they have the capacity to recognize myeloma cells and are efficient killers of the myeloma cells.  

Katherine:

Who might this approach be right for? What determines eligibility? 

Dr. Richard:

So, interestingly enough, today as we speak, CAR T cells may be eligible for many, many different kinds of – in the phases, many different phases of the myeloma journey. When they were initially tested, as most new therapies are, they were tested on patients who had very advanced myeloma, really were not candidates or did not have great options for any other kinds of therapy. And when they got tested in these groups of patients, they really had stellar results that far outstripped anything else that we had as options for patients in those advanced stages of myeloma.

So, the approval for CAR T cells as they stand today for myeloma is for advanced myeloma with patients who have had four or more lines of therapy and have had exposure to pretty much the major three classes of therapies for myeloma which includes proteasome inhibitors, imides, and anti-CD38 antibody therapy.  

But having said that, now CAR T cells are being moved into earlier lines of therapy are now being tested in these in various clinical trials. And even for newly diagnosed myeloma patients to see if they are as good as autologous transplants. Are they better than autologous transplants? And so on and so forth. So, really that’s what I mean by saying for now CAR T cells are appropriate for anyone if they are candidates for clinical trials. But in terms of approved indications for CAR T therapy, those are for advanced myeloma patients who have had at least four lines of therapy. 

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Making Treatment Decisions | Understanding Common Myeloma Therapies

Making Treatment Decisions | Understanding Common Myeloma Therapies from Patient Empowerment Network on Vimeo.

What are common myeloma therapies, and when are they used? Dr. Ashley Rosko outlines the factors that impact treatment decisions and reviews available therapies including stem cell transplant, proteasome inhibitors, immunomodulatory therapies, and monoclonal antibodies.

Dr. Ashley Rosko is Medical Director of the Oncogeriatric Program at the Ohio State University Comprehensive Cancer Center – The James. Learn more about Dr. Rosko.

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Advances in Myeloma Treatment: CAR T-Cell Therapy and Bispecific Antibodies

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Transcript:

Katherine:

We know that multiple myeloma patients have a number of options and that many available therapies are used in combination. 

So, I’d like you to walk us through the options that are available. 

Dr. Rosko:

So, I’m going to start by how the best way that I can frame out when we talk about newly diagnosed versus patients when they have relapse. So, there are therapies that are available for patients that are FDA-approved when they are newly diagnosed with the cancer, and there are therapies that are approved only when a cancer has acted up again or relapsed. 

So, I’ll kind of frame it from patients who are newly diagnosed. And then, I also will talk more about relapsed therapies and what we’re able to offer to patients. So, in first, when we talk about treatment options, we frame treatment based on a couple things. So, one is, we talk extensively about the disease biology. So, that plays an important role in how we decide which treatment the patient should get. 

And then, the second part about how – I would probably say there’s about four main parts. And so, disease biology is one, and another thing has to do with the patient characteristics. In terms of the patient’s overall health prior to developing cancer, and also how the cancer has impacted their health in terms of everyday activities. Whether or not a person has really slowed down quickly, whether they’ve been in the hospital, and how it’s impacting their organs. Because that plays a role in terms of what we’re able to give patients.  

If a patient has advanced kidney failure, which can sometimes happen, or if you have to focus more on protecting their bones and if there’s concern about fractures and things like that. And then independent of patient characteristics in terms of overall health, the last part I talk to patients about is their own preferences. It’s a hard thing to talk about, shared decision-making in a cancer that most people have never heard about, but there is certainly – when we talk about options and there are, it’s important to talk about shared decision-making in terms of what’s most important to them and where they – and most patients will say, “Well, I just want the best medicine.”  

And I say to them, “Well, you know, we have lots of options, and that’s the best thing about it, but we also want to be cognizant of the real world, of giving best options,” and for example, Many of my patients – so, I’m at The Ohio State University, I’m here. And a lot of patients travel. I have a lot of older patients that I care for, and they’re very independent with travel. And I want to make sure that whatever therapies we’re getting for them, that we can do this in such a way that maintains their lifestyle.  

So, the beginning part of a treatment, it is broadly described as – when we talk about someone who was diagnosed with this, it’s this thing called induction. So, induction is when we give anywhere from two to four medications to be able to control their cancer and put it into remission. And we know that the cancer is in remission because, like we started out the conversation with Dr. Cottini, myeloma makes proteins. Oftentimes, it makes proteins, those proteins are not nutrition proteins but are cancer proteins that we can track in the blood. 

So, we can check them every month and to make sure that the patients are having a really good response, and as such, we’re able to define that they’re responding to their treatment. Because they have a beginning stage in induction, which they’re given treatment, and then the goal is to put patients put in remission.  

Depending on the overall health of the patient, a standard of care for most patients diagnosed with multiple myeloma is to undergo an autologous stem cell transplant. An autologous stem cell transplant is not a transplant in which you’re getting cells from your brother or sister and they’re being donated to you. They are your own stem cells. We get them out of you when your bone marrow is free of disease, and then we would admit you to the hospital for a more intensive therapy and give them back. 

That is often the standard of care for patients newly diagnosed with multiple myeloma, and it is recommended for most patients. Some patients get – I like to think of it as a stem cell transplant not at the time of their initial diagnosis, but later on at the time of relapse, or some patients are not candidates for a transplant or elect not to have a transplant. And all of these options are very personalized to the patient. It’s very hard to say that this is exactly what we do. 

Because it’s a strategy where it requires a lot of shared decision-making to make sure that we’re getting good disease control, good quality of life, and deep, deep remissions for our patients. So, then, if a patient gets a transplant, there’s a period of recovery, and then patients go on a pill most often, a maintenance pill that they stay on for indefinitely. 

Myeloma is also a cancer which has perpetual therapy. Very different than many other cancers, where there’s a beginning and an end, myeloma for the most part is perpetual therapy, where you get some form of therapy at higher dosages versus lower dosages over a period of time.   

So, I’m going to talk broadly about the classes of drugs that we have and how we use them to be able to define therapy. 

So, the first class of drugs are called proteasome inhibitors. Just like many other cancers, we use different types of drugs to be able to target different aspects of a cancer cell’s growth cycle.  

So, very similar to how we do other drugs, these are very specific to the cancer cell, and they’re very targeted. So, unlike some of our other kind of classic chemotherapies, many of these medicines that I’m going to talk about are very targeted at the cancer cells without causing too many other problems. 

So, proteasome inhibitors include drugs like bortezomib (Velcade), which is given as a shot, carfilzomib (Kyprolis), which is given as an IV, or ixazomib (Ninlaro), which is given as a pill. They have different indications, but they’re the same class of drugs.  

The next class of drugs is called immunomodulatory drugs, or iMiDs. This includes things like lenalidomide (Revlimid), pomalidomide (Pomalyst). Those are the most common, and then we sometimes use the drug that the original iMiD drug, which is called thalidomide (Contergan). 

These are all pills that patients take, and so that’s oftentimes very nice for patients to be able to provide therapy at home, very well-tolerated. The next class of drugs are called monoclonal antibodies. On a cancerous cell, there is a marker. 

And so, we use monoclonal antibodies to be able to target the marker on the cancer cell. What that means is very specific. To that cancer cell, so, the most common target is the CD38, that’s a marker on one of the cancer cells. And we use a drug called daratumumab (Darzalex), that can be given as an IV or a subcutaneous agent, or another drug called isatuximab (Sarclisa). We also have other markers on the plasma cell. There’s a marker called SLAMF7, which we have other drugs called elotuzumab (Empliciti), which is often used for patients more in the relapse setting. 

How Do Myeloma Test Results Influence Prognosis and Care?

How Do Myeloma Test Results Influence Prognosis and Care? from Patient Empowerment Network on Vimeo.

Key testing is important for understanding myeloma, but how do results impact care and treatment? Myeloma experts Drs. Ashley Rosko and Francesco Cottini discuss how test results can affect care options and encourage patients to discuss results with their healthcare team.

Dr. Ashley Rosko is Medical Director of the Oncogeriatric Program at the Ohio State University Comprehensive Cancer Center – The James. Learn more about Dr. Rosko.
 
Dr. Francesca Cottini is Assistant Professor in the Division of Hematology at the Ohio State University Comprehensive Cancer Center. Learn more about Dr. Cottini.

See More From INSIST! Myeloma

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Making Treatment Decisions | Understanding Common Myeloma Therapies


Transcript:

Katherine:

Dr. Rosko, what do the results of these tests tell you about prognosis? 

Dr. Rosko:

Yeah, I think this is a really important question. And, in my experience, when we encounter a patient newly diagnosed with myeloma, it is like drinking from a firehose in terms of the amount of information that we are reviewing and the amount of information that we are discussing with the patient and with their family. And oftentimes, we talk about this piece of these cytogenetic abnormalities, and we talk about – but I really encourage your patients and anyone who is listening in today to really take a deeper dive. 

Because sometimes it’s helpful as, one, you’re navigating a new cancer diagnosis, but that’s challenging in and of itself. And then, two, talking about a cancer, multiple myeloma, that is – most people don’t know so much about multiple myeloma, unlike breast or colon or lung cancer, and so I really encourage patients and their caregivers. And a lot of times this happens, where we’ll go over all the cytogenetic abnormalities, we’ll talk about how it plays a role in their overall treatment trajectory, and their prognosis, but also good just to circle back and say. 

Settling into what this diagnosis is, oftentimes, people on first time treatment. And then even sometimes months or even years into their diagnosis, they stop and they come back and they say, “Can we talk about this FISH data?  

Can we talk about what changes that I had within the DNA? What does this mean?” And that’s not uncommon at all.  

So, I really feel like for many people that are on the call here today, I think it’s important to say it’s okay to go back to your physician and say, “I’m learning more about this, now that I’m more familiar with what this diagnosis is, can we talk about these FISH changes, or can we talk about the stage of my cancer?” Because I think it’s oftentimes an overwhelming period of time to have a new cancer diagnosis. And I also want to just give permission to everyone on the call that it’s okay to go back and ask questions, even if it’s been months or years.  

So, having high-risk mutation can upstage a cancer and in the absence of high-risk mutations can downstage a cancer. So, what that really means is saying, “These biologic changes that are happening in the cancer cells give a sense of what we anticipate that the trajectory is going to be when someone is diagnosed.” 

Now, it’s imperfect. I feel like cancer just generally is unpredictable, and there are many things that we try as clinicians. And especially with the experience that we have, to say, “This is what we anticipate the course will be like you, in terms of response, in terms of the cancer being quiet.” As you all know, multiple myeloma is not a curable cancer right now. And for all patients, when they’re diagnosed, they’re often able to get disease control and be able for that cancer to be put in remission. And we do focus on remission. 

I think that’s also something that I talk to my patients about. Even though we can’t cure it, we can certainly control it, and that’s a big part of what we do. So, when we get good disease control, we’ll talk more about next therapies, but that is how Dr. Cottini – Dr. Cottini is a wonderful scientific investigator and knows all of the latest and greatest when it comes to different mutations that are identified within cancer cells. We partner very closely with her in terms of  scientific investigation and how the mutations that were newly identified, too, play a role in terms of response to treatment, and how we’re able to best treat them. 

Katherine:

Thank you for that. Dr. Cottini, do you have anything to add as far as what type of questions patients should ask their healthcare team about test results?  

Dr. Cottini:

I mean, I think Dr. Rosko already pointed out the most important things. So, multiple myeloma is a rare disease, and it’s not as intuitive to understand as breast cancer, lung cancer, prostate cancer. 

So, it’s really important as a patient to understand which tests are we ordering. Why are we ordering? How do we monitor the disease? Because that’s one of the most important questions the patient asks, because for different types of solid tumor, we get imaging, and we know that the tumor is growing or not. Where, for us, we look at the markers I had described previously. And sometimes, we maybe see small changes in the markers that are very concerning and worrisome for the patient, but sometimes they are not. So, I think asking questions about the testing and how we treat them and monitor the disease is a very important part of being a good applique for itself.  

Accessing Personalized Myeloma Treatment | What Patients Should Know

Accessing Personalized Myeloma Treatment | What Patients Should Know from Patient Empowerment Network on Vimeo.

Myeloma experts Dr. Francesca Cottini and Dr. Ashley Rosko provide an overview of the latest advances in essential testing for myeloma and explain how results could affect care and treatment decisions. Drs. Cottini and Rosko also review available myeloma therapies and their hopes for the future of patient care.

Dr. Francesca Cottini is Assistant Professor in the Division of Hematology at the Ohio State University Comprehensive Cancer Center. Learn more about Dr. Cottini.

Dr. Ashley Rosko is Medical Director of the Oncogeriatric Program at the Ohio State University Comprehensive Cancer Center – The James. Learn more about Dr. Rosko.

Download Resource Guide

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How Does Essential Testing Affect Myeloma Care and Treatment?


Transcript:

Katherine:

Hello and welcome. I’m Katherine Banwell, your host for today’s program. Today we’re going to discuss how to access personalized care for your myeloma and why it’s vital to insist on essential testing.  Before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you. Let’s meet our guests for today. I’ll start with Dr. Ashley Rosko. Dr. Rosko, welcome. Would you please introduce yourself? 

Dr. Rosko:

Hi everyone. My name is Ashley Rosko. I’m an associate professor at the division of hematology at The Ohio State University. 

I’m also the medical director of the oncogeriatric program here at The James and one of the myeloma physicians here at Ohio State. 

Katherine:

Thank you. Also with us is Dr. Francesca Cottini. Dr. Cottini, would you please introduce yourself to the audience? 

Dr. Cottini:

Sure. My name is Francesca Cottini. I am an assistant professor in the divisions of hematology at The Ohio State University. I see patients with multiple myeloma, and I also run my own lab where I focus on multiple myeloma basic research. 

Katherine:

Thank you both for taking the time out of your busy schedules to join us today.  

It’s no secret that it’s important for patients to take an active role in their care and treatment decisions, and I’m sure many viewers here today are doing just that. So, Dr. Rosko, let’s start with this question: Why do you think it’s essential that patients advocate for themselves and insist on better care?  

Dr. Rosko:

Yeah, so I think when it comes to uncommon diseases like multiple myeloma –  

Although we’re talking a lot about it here today, myeloma is an uncommon cancer, and when it comes to rare cancers, it’s really important for you to get care at either a comprehensive cancer center or a place where there is expertise specifically in multiple myeloma. 

And the reason why that’s so important, it’s recommended through the NCCN guidelines and other standing guidelines is because myeloma is a very – it’s a shifting and changing landscape when it comes to both treatment regimens, diagnosis, and there’s a lot of moving parts and pieces.

Such as, there is an uncommon cancer that when diagnosed, we do recommend that patients and with their caregivers and with their families and support be able to seek expertise care for these uncommon cancers. We work often in collaboration with our community team, but we would not be able to care for myeloma if it were not for our community partners. 

And so, it’s really, really important for patients oftentimes, when there’s been such a diagnosis, they can come to a comprehensive cancer center for a consultation or to be able to get a second opinion oftentimes. And then continue to get care locally. It really provides this overall guidance on the management and diagnosis of uncommon plasma cell disorders, and we’re happy to do that. 

Katherine:

Thank you for that. It’s helpful as we begin our discussion. Part of accessing more personalized care starts with test results. Dr. Cottini, what testing should take place following a myeloma diagnosis?  

Dr. Cottini:

So, once somebody is diagnosed with multiple myeloma, there are different types of tests that we need to get. Some are blood tests, some are urine tests, some are bone marrow tests, and others are just different types of imaging. So, the reason for all these tests is because multiple myeloma can kind of go everywhere and can cause the damage to different types of organs. 

So, if we look at blood tests, usually you would see that you get the complete blood count, so we can count the number of red blood cells, white blood cells, and platelets. And then we’ll look at kidney function, through a chemistry profile, calcium levels, multiple myeloma can affect bone cells can affect kidneys. And then, you will see some more sophisticated tests that are really important for the diagnosis of multiple myeloma but also for monitoring and seeing if you’re actually responding to the treatment or you are progressing. 

These two tests that you can see are kind of difficult to say, but very important and needs to be remembered. So, one is called serum protein electrophoresis with immunofixation. And the other one is free light chain assays. 

And the practicum with these two tests is we can identify the specific marker of the multiple myeloma cells and it is either something monoclonal protein or M-protein or kappa light chain numbers. And as I said before, these numbers can be monitored. So, in response to the treatment, they should go down. And then, unfortunately, if we see progression, they might go up again. 

And then, urine tests can also give the same type of numbers. Usually, we have our patient keep the urine for 24 hours, for a day, and we can see if there’s monoclonal proteins or light chains there, too. Then there is a least favorite test of all of them that is the bone marrow testing. So, this is very important for us, because it’s where most of the myeloma cells stay. So, we need to have a look at the bone marrow.  

We need like a piece of the bone and some of the liquid tissue to look at specific characteristics of the myeloma. And then, I said before, the myeloma can go to bones, so we need to kind of get some imaging of the bones. These are usually a set of X-rays – it’s called skeletal survey – to see if there is any area that is abnormal or at risk of fractures.   

Then, we are also looking at PET scan, which is a more sophisticated test that is based on sugar consumption. We know that myeloma cells and all cancers enjoy sugar, so with the PET scan, we can see visually where the myeloma cells are in the body.

Katherine:

What is cytogenetics? 

Dr. Cottini:

So, this is a really interesting question. So, cytogenetics, or FISH tests, are tests that practical tests allow us to look at the chromosomes of the multiple myeloma. 

So, everybody has 46 chromosomes, right? Multiple myeloma cells can have more of them or less of them. So, they can have – some myeloma cells have 17 chromosomes instead of 46. So, cytogenetics in the karyotype counts how many chromosomes there are. And then, there is another type of test that is called FISH test, or fluorescence in situ hybridization – I get all the difficult names – that practically look at specific area of chromosome. It can tell us if some areas of chromosomes are lost. That’s what you can read as deletions, or practically missing pieces of chromosomes.  

Or there are extra pieces of chromosomes. These are the amplification gains. Or if there are different pieces of chromosomes that stick together. And these are the translocational chromosomes. And all of these data are important for deciding for knowing how aggressive or difficult to treat the myeloma. 

Katherine:

Dr. Rosko, in many other cancers, we’ve been hearing about targeted therapies and immunotherapies. In some cases, a specific mutation or chromosomal abnormality may indicate that a particular treatment may be effective. Are we there yet in multiple myeloma care? 

Dr. Rosko:

Yeah, so, myeloma care is always a little bit different. So, myeloma, being a blood cancer, is different than other solid tumors and how we treat it is also a bit different. So, unlike solid tumors, in which we look at the size of a cancer and then if it’s in different places in the body. In multiple myeloma, it being a blood cancer, just by definition it’s throughout the body. So, we have to be able to estimate or stage cancers differently or stage myeloma differently. And it is based upon the cytogenetics that Dr. Cottini just outlined to you.  

So, to get back to your question, Katherine, I didn’t forget about, how do we define treatment, how are some of these therapies being defined specifically and personalized for persons with multiple myeloma? And we do do that. And it is based a lot upon the DNA of those cancer cells and whether or not they’ve acquired what I would call a standard-risk changes or whether or not they’ve acquired a biology that makes them tend to act more aggressively. Now, again, these DNA differences – not all cancers follow the book, and not all therapies are unique to these. 

But what it does help us to do as clinicians to say, “Well, we have standard risk mutations within these cancer cells, and then we can define oftentimes how many drugs a patient gets when they’re newly diagnosed. Just like many other cancers, our treatments for multiple myeloma can be a combination of pills or shots. And then, if patients carry mutations that tend to act more aggressively, we tend to be very aggressive with their upfront therapy. For many patients, we’d receive three medications. Patients with more aggressive disease biology may receive four medications. 

And it’s very unique upon many characteristics. It’s not only based upon the cancer cells’ DNA but also the health of the patient. The health of the patient really defines also the ability to tolerate treatment. So, many patients are – myeloma has a lot of heterogeneity to it, where some patients with myeloma can’t believe that they could possibly have this cancer. 

You know, it’s really kind of picked up subtly, with blood abnormalities. And then some patients with myeloma come into the hospital very very sick, with having kidney damage or having infection. And it runs the gambit between being asymptomatic really and having patients coming in quite unwell. That also influences our treatment decisions. So, when we think about the question about whether we have different immunotherapies or targeted therapies based upon the genetic changes within the myeloma cancer cells, the answer is yes, we do shape therapy that’s tailored around the type of abnormalities within the cancer cells. 

But unlike some cancers, where if the cancer cells carry a specific marker, we give a specific drug, that’s not quite where we’re at with multiple myeloma, in terms that providing therapy is saying, “If you carry this mutation, this is what you should get.” 

So, it’s a very long answer to say to you that we do personalize therapy based upon changes within the DNA, but we also base it upon how fit the patient is and how their health was prior to developing cancer. 

Katherine:

Thank you for that. Dr. Cottini, what mutations or abnormalities are you looking for? 

Dr. Cottini:

So, as Dr. Rosko said, and as I quickly previously mentioned, so there are different types of DNA tests that we can do. One is this FISH test, and that’s a standard test. It’s usually done practically everywhere. And it practically tells us if there are specific deletions or changes. 

And we don’t really have yet a specific medication that we know works for specific abnormalities. But all this information is important to decide, as Dr. Rosko said, number of drugs, and maybe that can be helpful in the future when hopefully thanks to the research, we will be able to say, “Based on this abnormality, you would benefit more from this type of treatment.”  

There are other types of tests. One is called DNA testing, so we look at the mutation. So, really to point to small changes of a particular gene. This is done not routinely, but I think it can still give lots of good information. And there are lots of genes that are normally myeloma, that has potential drugs that have been studied, those with multiple myeloma and any other type of cancer. 

Katherine:

Yeah. Dr. Rosko, what do the results of these tests tell you about prognosis? 

Dr. Rosko:

Yeah, I think this is a really important question. And, in my experience, when we encounter a patient newly diagnosed with myeloma, it is like drinking from a firehose in terms of the amount of information that we are reviewing and the amount of information that we are discussing with the patient and with their family. And oftentimes, we talk about this piece of these cytogenetic abnormalities, and we talk about – but I really encourage your patients and anyone who is listening in today to really take a deeper dive. 

Because sometimes it’s helpful as, one, you’re navigating a new cancer diagnosis, but that’s challenging in and of itself. And then, two, talking about a cancer, multiple myeloma, that is – most people don’t know so much about multiple myeloma, unlike breast or colon or lung cancer, and so I really encourage patients and their caregivers. And a lot of times this happens, where we’ll go over all the cytogenetic abnormalities, we’ll talk about how it plays a role in their overall treatment trajectory, and their prognosis, but also good just to circle back and say. 

Settling into what this diagnosis is, oftentimes, people on first time treatment. And then even sometimes months or even years into their diagnosis, they stop and they come back and they say, “Can we talk about this FISH data? Can we talk about what changes that I had within the DNA? What does this mean?” And that’s not uncommon at all.  

So, I really feel like for many people that are on the call here today, I think it’s important to say it’s okay to go back to your physician and say, “I’m learning more about this, now that I’m more familiar with what this diagnosis is, can we talk about these FISH changes, or can we talk about the stage of my cancer?” Because I think it’s oftentimes an overwhelming period of time to have a new cancer diagnosis. And I also want to just give permission to everyone on the call that it’s okay to go back and ask questions, even if it’s been months or years.  

So, having high-risk mutation can upstage a cancer and in the absence of high-risk mutations can downstage a cancer. So, what that really means is saying, “These biologic changes that are happening in the cancer cells give a sense of what we anticipate that the trajectory is going to be when someone is diagnosed.” 

Now, it’s imperfect. I feel like cancer just generally is unpredictable and there are many things that we try as clinicians. And especially with the experience that we have, to say, “This is what we anticipate the course will be like you, in terms of response, in terms of the cancer being quiet.” As you all know, multiple myeloma is not a curable cancer right now. And for all patients, when they’re diagnosed, they’re often able to get disease control and be able for that cancer to be put in remission. And we do focus on remission. 

I think that’s also something that I talk to my patients about. Even though we can’t cure it, we can certainly control it, and that’s a big part of what we do. So, when we get good disease control, we’ll talk more about next therapies, but that is how Dr. Cottini – Dr. Cottini is a wonderful scientific investigator and knows all of the latest and greatest when it comes to different mutations that are identified within cancer cells. We partner very closely with her in terms of  scientific investigation and how the mutations that were newly identified, too, play a role in terms of response to treatment, and how we’re able to best treat them.  

Katherine:

Thank you for that. Dr. Cottini, do you have anything to add as far as what type of questions patients should ask their healthcare team about test results?  

Dr. Cottini:

I mean, I think Dr. Rosko already pointed out the most important things. So, multiple myeloma is a rare disease, and it’s not as intuitive to understand as breast cancer, lung cancer, prostate cancer. 

So, it’s really important as a patient to understand which tests are we ordering. Why are we ordering? How do we monitor the disease? Because that’s one of the most important questions the patient asks, because for different types of solid tumor, we get imaging, and we know that the tumor is growing or not. Where, for us, we look at the markers I had described previously. And sometimes, we maybe see small changes in the markers that are very concerning and worrisome for the patient, but sometimes they are not. So, I think asking questions about the testing and how we treat them and monitor the disease is a very important part of being a good applique for itself. 

Katherine:

Thank you. Dr. Rosko, I’d like to move on to treatment. We know that multiple myeloma patients have a number of options and that many available therapies are used in combination. 

So, I’d like you to walk us through the options that are available. 

Dr. Rosko:

So, I’m going to start by how the best way that I can frame out when we talk about newly diagnosed versus patients when they have relapse. So, there are therapies that are available for patients that are FDA-approved when they are newly diagnosed with the cancer, and there are therapies that are approved only when a cancer has acted up again or relapsed. 

So, I’ll kind of frame it from patients who are newly diagnosed. And then, I also will talk more about relapsed therapies and what we’re able to offer to patients. So, in first, when we talk about treatment options, we frame treatment based on a couple things. So, one is, we talk extensively about the disease biology. So, that plays an important role in how we decide which treatment the patient should get.  

And then, the second part about how – I would probably say there’s about four main parts. And so, disease biology is one, and another thing has to do with the patient characteristics. In terms of the patient’s overall health prior to developing cancer, and also how the cancer has impacted their health in terms of everyday activities. Whether or not a person has really slowed down quickly, whether they’ve been in the hospital, and how it’s impacting their organs. Because that plays a role in terms of what we’re able to give patients.  

If a patient has advanced kidney failure, which can sometimes happen, or if you have to focus more on protecting their bones and if there’s concern about fractures and things like that. And then independent of patient characteristics in terms of overall health, the last part I talk to patients about is their own preferences. It’s a hard thing to talk about, shared decision-making in a cancer that most people have never heard about, but there is certainly – when we talk about options and there are, it’s important to talk about shared decision-making in terms of what’s most important to them and where they – and most patients will say, “Well, I just want the best medicine.” 

And I say to them, “Well, you know, we have lots of options, and that’s the best thing about it, but we also want to be cognizant of the real world, of giving best options,” and for example, Many of my patients – so, I’m at The Ohio State University, I’m here. And a lot of patients travel. I have a lot of older patients that I care for, and they’re very independent with travel. And I want to make sure that whatever therapies we’re getting for them, that we can do this in such a way that maintains their lifestyle.  

So, the beginning part of a treatment, it is broadly described as – when we talk about someone who was diagnosed with this, it’s this thing called induction. So, induction is when we give anywhere from two to four medications to be able to control their cancer and put it into remission. And we know that the cancer is in remission because, like we started out the conversation with Dr. Cottini, myeloma makes proteins. Oftentimes, it makes proteins, those proteins are not nutrition proteins but are cancer proteins that we can track in the blood. 

So, we can check them every month and to make sure that the patients are having a really good response, and as such, we’re able to define that they’re responding to their treatment. Because they have a beginning stage in induction, which they’re given treatment, and then the goal is to put patients put in remission. 

Depending on the overall health of the patient, a standard of care for most patients diagnosed with multiple myeloma is to undergo an autologous stem cell transplant. An autologous stem cell transplant is not a transplant in which you’re getting cells from your brother or sister and they’re being donated to you. They are your own stem cells. We get them out of you when your bone marrow is free of disease, and then we would admit you to the hospital for a more intensive therapy and give them back.  

That is often the standard of care for patients newly diagnosed with multiple myeloma and it is recommended for most patients. Some patients get – I like to think of it as a stem cell transplant not at the time of their initial diagnosis, but later on at the time of relapse or some patients are not candidates for a transplant or elect not to have a transplant. And all of these options are very personalized to the patient. It’s very hard to say that this is exactly what we do. 

Because it’s a strategy where it requires a lot of shared decision-making to make sure that we’re getting good disease control, good quality of life, and deep, deep remissions for our patients. So, then, if a patient gets a transplant, there’s a period of recovery, and then patients go on a pill most often, a maintenance pill that they stay on for indefinitely. 

Myeloma is also a cancer which has perpetual therapy. Very different than many other cancers, where there’s a beginning and an end, myeloma for the most part is perpetual therapy, where you get some form of therapy at higher dosages versus lower dosages over a period of time.  

So, I’m going to talk broadly about the classes of drugs that we have and how we use them to be able to define therapy. 

So, the first class of drugs are called proteasome inhibitors. Just like many other cancers, we use different types of drugs to be able to target different aspects of a cancer cell’s growth cycle.  

So, very similar to how we do other drugs, these are very specific to the cancer cell, and they’re very targeted. So, unlike some of our other kind of classic chemotherapies, many of these medicines that I’m going to talk about are very targeted at the cancer cells without causing too many other problems. 

So, proteasome inhibitors include drugs like bortezomib (Velcade), which is given as a shot, carfilzomib (Kyprolis), which is given as an IV, or ixazomib (Ninlaro), which is given as a pill. They have different indications, but they’re the same class of drugs.  

The next class of drugs is called immunomodulatory drugs, or iMiDs. This includes things like lenalidomide (Revlimid), pomalidomide (Pomalyst). Those are the most common, and then we sometimes use the drug that the original iMiD drug, which is called thalidomide (Contergan). 

These are all pills that patients take, and so that’s oftentimes very nice for patients to be able to provide therapy at home, very well-tolerated. The next class of drugs are called monoclonal antibodies. On a cancerous cell, there is a marker. 

And so, we use monoclonal antibodies to be able to target the marker on the cancer cell. What that means is very specific. To that cancer cell, so, the most common target is the CD38, that’s a marker on one of the cancer cells. And we use a drug called daratumumab (Darzalex), that can be given as an IV or a subcutaneous agent, or another drug called isatuximab (Sarclisa). We also have other markers on the plasma cell. There’s a marker called SLAMF7, which we have other drugs called elotuzumab (Empliciti), which is often used for patients more in the relapse setting.  

Katherine:

Dr. Cottini, I’m wondering if you could briefly go over CAR T-cell therapy and bispecific antibodies. 

Dr. Cottini:

Yes, of course. So, these are all our new therapeutic approaches for patients. And these are types of treatments that are given to patients that already went through their induction, they went into remission, maybe they had a bone marrow transplant. And then, after a couple of years or months, unfortunately the disease came back, and they need the new and different treatment options. So, these two strategies, CAR T and bispecific antibodies, really rely on the T-cells, on the immune cells of the patient.  

And they all focus and target a specific marker on the plasma cells, but they work a little bit differently. So, the bispecific antibodies – and we have different antibodies.  

Some are approved by the FDA, some are just in clinical trials trials. They practically recognize something that is on the plasma cells, on the myeloma cells, that can be BCMA, GPRC5D, or other targets. So, at the same time that I am able to get close by the T cells, the immune cells, and in this way, practically there is both the antibodies and also the immune cells which is activating and getting rid of the cancer cells. 

So, these are infusions. Often, they’re done initially in the hospital and then in the outpatient setting. Sometimes it’s even every week, every other week or so.  

CAR T are different strategies, and it’s a very smart way of trying to get rid of the cancer cells. So, practically, these are T cells.  

So, these are immune cells from you, from the patient. And they are practically taken and then brought to a very specific and clean facilities where these T cells are modified in order to be able to recognize the cancer cells.  

And then these cancer cells are sent back to us and then practically they are given into the veins to patient, and then there is this kind of reaction of these T cells, which are very peppy and aggressive to be able to kill all the remaining cancer cells. So, these are all the new strategies. 

Obviously, we are kind of like in the early process, but these are very promising therapies I think we’ll be maybe moved up front even with diagnosis in the next 10, 20 years, we don’t know. 

Katherine:

I want to thank you both so much for your thoughtful responses. And as we close out the program, I’d like to get a final comment from each of you. What are you excited about in myeloma research, and why should patients be hopeful? Dr. Cottini?  

Dr. Cottini:

So, I think that especially if we look back especially at where myeloma was 20 or 30 years, I think we have made so many progresses, and there is really hope for our patients. I’m very passionate about research. That’s what I do. That’s why I read paper, I publish paper, and I think that it’s the heterogeneity of our disease is huge, and it’s difficult to tackle. But we as researchers, as physicians are the ones that can look at these changes, and find new therapies for our patients. So, I think that research is the way to go to be able to finally cure our patients. 

Katherine:

Dr. Rosko? 

Dr. Rosko:

Yeah, I mean I go Dr. Cottini’s sentiments. The multiplying therapies for myeloma really provides our ability to prescribe and make myeloma more of a chronic illness for our patients. I think it’s really important to allow patients to get really good targeted therapy personalized to them. Of course, we all are looking forward here to deep remissions. We want to be able to do that in such a way where we have good quality life for our patients. 

I think, importantly, as part of this program does here, we have to create access. So, most of myeloma is treated in the community, and most myeloma is diagnosed in older adults. And I really think how important it is, we talk about clinical trials, and being able to get our patients on to clinical trials, and to be able to get more knowledge about the disease process of pathogenesis, which I think is just really pivotal. 

So, I’m excited about personalizing therapy to the individual’s health and really being able to increase access to all of these novel therapies that we have. For patients, often at specialized cancer centers, but I’m really interested in how we can increase reach and access for all of these advances in myeloma research to every patient no matter where they’re at. 

Katherine:

Well, thank you both for joining us today. And thank you to all of our partners. To learn more about myeloma and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell. Thanks for being with us.  

Myeloma Combination Therapy | What Patients Should Know

Myeloma Combination Therapy | What Patients Should Know from Patient Empowerment Network on Vimeo.

Expert Dr. Jeffrey Matous shares an overview of myeloma treatment classes, why combination therapy can be effective, and the importance of clinical trials in patient care and moving research forward.

Dr. Jeffrey Matous is a myeloma specialist at the Colorado Blood Cancer Institute and the assistant chair in myeloma research for Sarah Cannon Research Institute. Learn more about Dr. Matous.

See More from Evolve Myeloma

Related Resources:

Questions and Considerations When Making Myeloma Treatment Decisions

Should You Push for a Stronger Myeloma Treatment at Relapse

Transcript:

Katherine:

There are several treatment classes for myeloma, such as immunomodulatory therapy and proteasome inhibitors, for example, and they’re often used together. So, what is a combination therapy and why is it used so frequently for myeloma?  

Dr. Jeffrey Matous:

Absolutely, so with learned over the years in myeloma that combining different types of drugs that work in different ways, we call those classes, so different classes of drugs, combining them together is the optimal treatment for myeloma.  

And back in the day, we used to use two drugs. Then, we learned that three drugs are better than two drugs, and now, we have data that four drugs are better than three drugs. And so, we bring in drugs from all kinds of different categories for our patients. And we even know that for the non-transplant-eligible patients, for the older patients, for example, that combining drugs from different classes is really, really important to get the best outcomes. And in general, the three classes that we use – the four classes that we use when we’re treating myeloma patients initially include the immunomodulatory drugs, and examples of those are lenalidomide, also called Revlimid. pomalidomide, also called Pomalyst. Thalidomide’s (Thalomid) an older drug, but we still occasionally use it.  

And then, we have the proteasome inhibitors. Examples of those are bortezomib (Velcade), carfilzomib (Kyprolis), and to a much lesser extent, there’s one called ixazomib (Ninlaro). And these days, we know that CD38 antibodies are really important and really getting their foothold into the initial treatment of myeloma.  

Examples of CD38 antibodies are daratumumab (Darzalex) or isatuximab. And then, usually, we combine these treatments with steroid medicines to sort of increase the effectiveness of the regimens. That’s how – those are the classes that we use when we’re treating myeloma. 

Katherine:

Okay and have you learned about adding one treatment to another to another through clinical trials or is trial and error? 

Dr. Jeffrey Matous:

Absolutely. We would not be where we are right now without the conduct of clinical trials. I always tell my patients by the time something’s approved in myeloma, and we had things approved in 2022, the field is already moving past that in clinical trials. It’s unbelievable. So, I’ll give you an example. When daratumumab, one of these antibodies, got approved by the FDA, already when it got approved by the FDA, we knew through clinical trials that were being conducted that combining it with other types of medicines was far more potent. 

And we have countless examples of this, so yeah. Absolutely, so every treatment that we use in myeloma, we discovered and developed through a clinical trial. And I always encourage my patients strongly to consider clinical trials, and then, we have to explain, because when patients hear clinical trials, and I could be deviating a little bit here, Katherine.  

They often think about experimentation and testing things that are unproven. In myeloma, we occasionally do that, but far and away, the overwhelming majority of our clinical trials are testing agents that we know are effective. We’re just trying to figure out what the best combination is and make sure that it’s safe for patients. 

What Should You Know About Emerging Myeloma Treatment Options? Resource Guide

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What Should You Know About Emerging Myeloma Treatment Options?

What Should You Know About Emerging Myeloma Treatment Options? from Patient Empowerment Network on Vimeo.

With myeloma treatment and research advancing quickly, it’s important to stay up-to-date on the latest therapies. Myeloma expert Dr. Jeffrey Matous reviews new and emerging myeloma treatment approaches, how these therapies work, as well as the potential risks and benefits of each option. Dr. Matous also shares resources for learning about myeloma and how to access better care.

Dr. Jeffrey Matous is a myeloma specialist at the Colorado Blood Cancer Institute and the assistant chair in myeloma research for Sarah Cannon Research Institute. Learn more about Dr. Matous.

Download Resource Guide

See More from Evolve Myeloma

Related Resources:

What Are the Phases of Myeloma Treatment

What Is CAR T-Cell Therapy for Myeloma?

Tools for Choosing Myeloma Therapy

Transcript:

Katherine:

Hello, and welcome. I’m Katherine Banwell, your host for today’s program. Today’s webinar is about advances in myeloma treatment and how emerging therapies may affect your care decisions.  

Before we get into discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you. Well, let’s meet our guest today. Joining me is Dr. Jeffrey Matous. Dr. Matous, welcome. Would you please introduce yourself? 

Dr. Matous:

Thank you very much, Katherine. I’m Dr. Jeff Matous, and I am physician at the Colorado Blood Cancer Institute, and also, the Assistant Chair in Myeloma Research for Sarah Cannon Research Institute here in Colorado. 

Katherine:

Thank you so much for taking the time to join us today. 

Dr. Matous:

It’s a pleasure. 

Katherine:

Before we get into our discussion, would you share with the audience how the field of myeloma has changed over the course of your career? 

Dr. Matous:

It’s unbelievable. I mean, I started treating myeloma back in the days of VAD, vincristine (Oncovin), doxorubicin (Adriamycin), dexamethasone (Decadron) 96-hour pumps with 40 pounds of dexamethasone that we put into patients, and wow. We didn’t have much else. We didn’t know how long to treat people, and then, in the 2000s, we have the revolution of all the new therapies, and it just keeps going and going and going. It really is an exciting to be in this field. 

Katherine:

Yeah. Let’s begin by sharing some advice for navigating myeloma care on a basic level. First, what testing should take place following a myeloma diagnosis? 

Dr. Matous:

Well, I think even before that, Katherine, I always tell my patients that an educated patient, like the people that are on this webinar, are the best patients, and so, when I meet a patient for the first time, we spend a lot of time educating patients even before we delve into a lot of the testing. 

And I refer them to excellent resources out there. Examples of these are the International Myeloma Foundation, or the Multiple Myeloma Research Foundation.  

There are others, of course, and so I really encourage my patients. In fact, I usually show them how to navigate these sites. And then, we get into testing, and testing in myeloma is multifaceted, because myeloma can affect patients in so many different ways. For example, it involves radiology studies to look for bone disease, urine work to see if the kidneys are affected by myeloma, a lot of blood work, and then, we also do a lot of testing to make sure that we understand the whole health of the patient, because that comes into play so much when we’re making treatment decisions in myeloma. 

Katherine:

Yeah. What factors impact treatment decisions? 

Dr. Matous:

Well, there are so many. One of the key ones is fitness, and fitness is a term that myeloma doctors use and rely on tremendously. 

And fitness, more or less, falls into a couple different categories. It’s more complex than that, obviously, but generally speaking, it’s too old or too frail, or young and vigorous and I stress to my patients that vigorous or frail is not determined by chronological age. It’s determined by your physiologic age. That’s really critical, so determining what your patient’s overall fitness is, is really important in myeloma. And then, we have to assess the risk of myeloma. I think we’ll talk about this a little bit later, because not all myeloma is the same and we treat myelomas differently depending on risk, certainly. And then, patient preference is a huge part, because there are so many ways to treat myeloma these days that we explore options with the patients and sometimes patients have pretty strong opinions about, you know, one type of treatment or the other, for example. 

Katherine:

What advice do you have for patients and caregivers related to working with their healthcare team in choosing a therapy? 

Dr. Matous:

Yeah. I think the big thing is to do some research on your own, but really, ask questions when you see your physician. I mean, ask questions about, for example, what are my treatment options? Are there clinical trials that might be available to me? What’s on the cutting edge in myeloma? What are the standard therapies? What are the pros and cons? And a question I often counsel patients to ask when they’re seeking other opinions is if you had 100 people like me and you treated them this way, how many would do well and how many would not do so well, and prognosis, and so forth. And then, the other thing I think is really important sometimes is gauging how experienced your physician is in treating myeloma, because we actually have data that shows that patients who are treated in myeloma centers actually fair a little better than those who are not. 

Involving a myeloma expert in your care doesn’t necessarily mean you have to get your care at that center. It just means you may want a myeloma expert on your team. Pretty much every doctor I know welcomes a myeloma person on their team, because the field is so rapidly evolving. It’s really hard to keep up with for a lot of people. 

Katherine:

Yeah. That’s great advice, Dr. Matous. Thank you. Stem cell transplant is often considered for myeloma patients. Can you talk about who this treatment option might be appropriate for? 

Dr. Matous:

Absolutely, so we’ve known for decades that, what I call high-dose chemotherapy, also called stem cell transplant, is a very effective and very potent treatment of myeloma and we’ve shown that time and time again in clinical trials, including some recent ones that are published just in 2022.  

And so, high-dose chemotherapy and stem cell transplant is not for everyone. You have to be fit enough to undergo it, and this is not age determined. It’s fitness determined. And then, a lot of people live a long way from centers that perform high-dose chemotherapy and stem cell transplants. 

If patients have to travel hundreds of miles, then sometimes that comes into play. Hey, I just can’t do this. I can’t get the time off, and uproot, and bring a caregiver, and travel 300 miles to get this care, so sometimes that comes into play. Physician bias definitely comes into play. We know that some physicians are stronger proponents of high-dose chemotherapy and stem cell transplant, and I fall into that category, but we have other physicians that may not even bring it up as an option to their patients. We know, for example, that African Americans and other minorities are notoriously under-referred for high-dose chemotherapy and stem cell transplant. A lot of decisions go into that, and again, this is one of those situations where if you’re transplant-eligible, that means you’re young and vigorous, and on paper, a candidate. You want to go, at the very minimum, consult with physicians that do high-dose chemotherapy and stem cell transplant and hear about that option. 

Katherine:

Yeah. You mentioned high-risk myeloma earlier. How do you determine if a patient is high risk or low risk? 

Dr. Matous:

Absolutely, so this is not uniformly agreed upon among myeloma doctors, but in general, we assess risk based on a few different things. One is called staging, and we stage myeloma unlike any other cancer, so it’s not staged like breast cancer, or lung cancer, or prostate cancer. It’s staged according to something called R-ISS, RISS, and you get, basically, a one, two, or a three.  

Those are your stages, and in general, if your stage three, you have higher risk disease, but even more than that, we’re beginning to understand how myeloma cells misbehave at the genetic level, and we know that there are certain genetic findings inside the myeloma cell that can convey higher risk features. It’s important to stress to patients that these are not genetic findings that they were born with or can pass on through hereditary. 

These are findings that occurred during the life of the patient that occurred by chance and developed inside that cell that turned into myeloma, and those are the genetic changes that we’re talking about. And we know that certain of these genetic changes confer higher risk disease. And in general, Katherine, if I see 100 people with myeloma, about 85 of the 100 will fall into what I call a standard risk category and about 15 percent will fall into what we call the high-risk category. 

Katherine:

Okay. That’s really good to know. Thank you. There are several treatment classes for myeloma, such as immunomodulatory therapy and proteasome inhibitors, for example. And they’re often used together.  

So, what is a combination therapy and why is it used so frequently for myeloma?  

Dr. Matous:

Absolutely, so with learned over the years in myeloma that combining different types of drugs that work in different ways, we call those classes, so different classes of drugs, combining them together is the optimal treatment for myeloma. 

And back in the day, we used to use two drugs. Then, we learned that three drugs are better than two drugs, and now, we have data that four drugs are better than three drugs. And so, we bring in drugs from all kinds of different categories for our patients. And we even know that for the non-transplant-eligible patients, for the older patients, for example, that combining drugs from different classes is really, really important to get the best outcomes. And in general, the three classes that we use – the four classes that we use when we’re treating myeloma patients initially include the immunomodulatory drugs, and examples of those are lenalidomide, also called Revlimid. pomalidomide, also called Pomalyst.  

Thalidomide’s (Thalomid) an older drug, but we still occasionally use it.  

And then, we have the proteasome inhibitors. Examples of those are bortezomib (Velcade), carfilzomib (Kyprolis), and to a much lesser extent, there’s one called ixazomib (Ninlaro). And these days, we know that CD38 antibodies are really important and really getting their foothold into the initial treatment of myeloma.  

Examples of CD38 antibodies are daratumumab (Darzalex) or isatuximab. And then, usually, we combine these treatments with steroid medicines to sort of increase the effectiveness of the regiments. That’s how – those are the classes that we use when we’re treating myeloma. 

Katherine:

Okay and have you learned about adding one treatment to another to another through clinical trials or is trial and error? 

Dr. Matous:

Absolutely. We would not be where we are right now without the conduct of clinical trials. I always tell my patients by the time something’s approved in myeloma, and we had things approved in 2022, the field is already moving past that in clinical trials. It’s unbelievable. So, I’ll give you an example. When daratumumab, one of these antibodies, got approved by the FDA, already when it got approved by the FDA, we knew through clinical trials that were being conducted that combining it with other types of medicines was far more potent. 

And we have countless examples of this, so yeah. Absolutely, so every treatment that we use in myeloma, we discovered and developed through a clinical trial. And I always encourage my patients strongly to consider clinical trials, and then, we have to explain, because when patients hear clinical trials, and I could be deviating a little bit here, Katherine.  

They often think about experimentation and testing things that are unproven. In myeloma, we occasionally do that, but far and away, the overwhelming majority of our clinical trials are testing agents that we know are effective. We’re just trying to figure out what the best combination is and make sure that it’s safe for patients. 

Katherine:

Yeah. Dr. Matous, some of our viewers may have already been through some therapy at some level. Let’s dive into new and emerging treatment. CAR T-cell therapy has been approved for myeloma patients and it’s certainly a hot topic right now. Can you tell us about this treatment and who it might be right for? 

Dr. Matous:

Absolutely, so these T-cell therapies in myeloma are really exciting, and basically, how they work is T cells are cells that normally, in our body, they’re part of our immune system. When they see something foreign, usually, it’s a foreign infection or some kind. T cells go into kill mode and take out the foreign invader, and they’re supposed to do this with cells that are thinking about turning into cancer, but for various reasons, cancer cells can escape the T cells, and then, kind of brainwash the new system to say, hey. It’s okay if we coexist with you. No big deal. We’ll just hang out together. Okay? And that’s not okay. And so, in CAR T-cell therapy, what we do is we take the patient’s T cells.  

We remove them from the blood with a procedure called apheresis, which is a machine that many patients might be familiar with through their stem cell collections. 

It’s the same machine. And we collect these T cells. Then, they go to a laboratory where they are genetically modified in the laboratory using very sophisticated techniques to become myeloma killers. And we tell – we educate the T cells to become myeloma killers. We grow them up in sufficient numbers, and then, we return them to the patient. We just, basically, put them back in the patient’s bloodstream in the vein and they go and they are really effective at killing myeloma cells. And that’s CAR T-cell therapy, so it’s an amazing immune therapy. It’s way more complicated than I laid out, of course, but that’s the general thought behind it. 

Katherine:

What are the risks of this therapy? 

Dr. Matous:

Absolutely, so we have a lot of patients who come and ask about CAR T-cell therapy and think that it’s the same thing as getting daratumumab in the clinic or carfilzomib in the clinic.  

Get it and you’re on your way. Far from that, and so, CAR T-cell therapy has a lot of risks. The risks fall into a few different categories. The first risk is called CRS, which doesn’t stand for what you think it stands for. It stands for Cytokine Release Syndrome. This occurs when the T cells recognize the myeloma cell and kill it, and when they do this, a lot of substances get released in the body that can cause a lot of symptoms, like fever, or low blood pressure, or low oxygen, and this requires specialized management to shepherd people through this.  

This almost always occurs in about the first week of the treatment after the patients receive the CAR-T cells. In addition, patients who receive CAR-T cells can have what’s called neurologic toxicity that falls into many different categories. It can be something as simple as a headache, or a transient or temporary difficulty, you know, saying words or being confused, or in the most severe situation, even a seizure. 

This requires a lot of close monitoring for neuro toxicity. In addition, we know that patients that get CAR T-cell therapy are, for quite a while after they receive the CAR-T cells, an increased risk for infection. It’s very suppressing of the immune system, immunosuppressive. And lastly, a lot of our patients who go through CAR T-cell therapy have low blood counts for a long time and they have to be monitored for this, might need transfusions, or some different therapies. It’s a complicated therapy for sure. 

Katherine:

Yeah, so what questions should patients be asking their doctor when considering CAR T-cell therapy? 

Dr. Matous:

I think the first thing, of course, is am I a candidate, because the commercially approved CAR-T cells, there are very specific criteria for who’s a candidate, who could receive it. Okay, and then, you want to know, one, if you’re a candidate. Two, what the risks and benefits are. 

Three, are there alternatives besides CAR T-cell therapy. Is it too early or too late to do this? Should we think about maybe another clinical trial or one of the T-cell redirecting antibodies, for example? You want to ask those questions for sure. These treatments are tremendously expensive, of course, and so that may come into play, as well. You want to know what the experience of the center is with CAR T-cell therapy, I think, and then, you also want to know are there clinical research studies for which you might be eligible to have CAR-T cells, not just commercially available ones, because we have two that are commercially available right now, and we have scores of CAR T-cell treatments that are still in clinical trial. [22:32] 

Katherine:

Yeah. Well, thank you for that, Dr. Matous. 

I know many viewers will appreciate all of this information. Let’s switch gears now to another therapy we’ve been hearing about; bispecific antibodies. One has been recently approved for myeloma, teclistamab, so let’s start with what are bispecific antibodies and who might they be right for? 

Dr. Matous:

And strap on your seatbelt, because there’s a whole bunch of them coming, I think, for approval. So, the T-cell redirecting antibodies, it’s a different strategy for trying to get your T cells, the patient’s T cells, to attack the myeloma cells. And in CAR T-cell therapy, it’s a single infusion. That’s the treatment. And the bispecific antibodies that I often call T-cell redirecting antibodies, because they redirect the T cells to the myeloma cell, these are given over a continuous period and it might as long as you tolerate it, as long as it’s working. It might be for a year. And they are given either under the skin as a subcutaneous injection, or in the vein. 

And there are many, many different of these T-cell redirecting antibodies, the bispecific antibodies. How they work, I just do this with my patients. I hold up my hand and I say the bispecific antibodies have two hooks on them, and one hook recognizes the T cell and latches onto the T cell, and the other hook latches onto the myeloma cell. And then, what it does, it brings the T cell in proximity to the myeloma cell. Then, the T cell says “Oh, aha. I’m supposed to kill this myeloma cell,” and usually does it. Now, the part that connects the T cell and these bispecific antibodies is always the same. It’s CD3. However, the part that sticks on the myeloma cell, there are different targets, and you referred to teclistamab (Tecvayli), which was approved by the FDA, and that attaches to something on the outside of a myeloma cell called BCMA, BCMA. 

But we know that other bispecific antibodies that can attach to different markers or antigens on the outside of the myeloma cell and affect the same change, and so, I think these are going to be coming fast and furious. 

Katherine:

Who’s this class of treatment right for? 

Dr. Matous:

I think – well, again, the FDA approval right now is for people who have seen pretty much everything. You know, you’ve had a lot of treatments. You’ve seen all the different classes of the myeloma drugs, but in our clinical research trials right now, we’re testing these as an initial therapy, in second-line therapy, after stem cell transplants. They’re being tested pretty much in every scenario right now in clinical trials, so right now, it’s when you’ve exhausted the normal treatments and you’re considering CAR T-cell therapy, or you’re considering getting treated with a drug called selinexor (Xpovio), or looking at another clinical trial. That’s when it’s the time to ask about the bispecific antibodies. 

Katherine:

What are the risks and benefits of this therapy?  

Dr. Matous:

The risks are pretty similar to the risks from CAR T-cell therapy, so Cytokine Release Syndrome. That usually occurs during the first week. Neurologic toxicity is, I think, less frequent with the bispecific antibodies, but infections and low blood counts definitely a concern with these bispecific antibodies, requires a lot of monitoring without any doubt.  

Now, the other thing about the bispecific antibodies, there’s, right now, they’ve been in the realm of the larger centers, so myeloma centers is where people have been getting these bispecific antibodies, but there’s absolutely no question in my mind that these bispecific antibodies are going to be available through almost every general hematology, oncology practitioner’s office, but not for a while. The docs that aren’t used to giving these medicines are a little – they’re being quite cautious rolling them out in their practices right now. There are still a lot of questions as these roll out, and so, right now, I think teclistamab is still largely unavailable outside myeloma centers, but that’s going to change, I think, even over 2023 and definitely into 2024. 

Katherine:

Okay. That’s really good news. For patients who want to know more about bispecifics, what questions should they be asking their healthcare team? 

Dr. Matous:

Again, the same thing is – the same questions. Well, teclistamab is approved by the FDA. What other bispecifics are there? What about combinations? What about clinical trials? And then, that’s what you want to ask for sure. Then, how often do I need to come in the office? With teclistamab, the answer is weekly.  

If they say for how long, it’s until it quits working or you have side effects, and then you can’t take it anymore. That’s the way the FDA label is. And so, it’s a big commitment to go on these treatments, but they’re effective. You ask me about the effectiveness of these drugs and, essentially, all the studies with these different bispecifics, including teclistamab, have been studied initially in people who have seen every myeloma treatment. They’ve had an average of about six different myeloma treatments. 

They’ve seen all the drugs. They’re not working anymore. They’re in trouble. They’re in a pinch, and roughly, seven out of ten people have dramatic responses to these bispecifics when they’re treated, which we’ve never had anything like this at all in the myeloma world. 

Katherine:

Wow. Do the side effects go away at some point? 

Dr. Matous:

The side effects are completely manageable. Yeah and you can – by and large, you can adjust the bispecific, either the schedule or different things, to make these completely tolerable for patients. 

Katherine:

Okay. 

Dr. Matous:

Very few patients on our trials, with these bispecifics, who we have not been able to manage and, pretty much, handle all the – any side effect that occurs. 

Katherine:

Okay. That’s good. Are there other emerging myeloma therapies that patients should know about? 

Dr. Matous:

There are a bunch of other therapies. Looking at in myeloma, for sure, and a lot of these other therapies are – they’re exploring the same pathway where the proteasome inhibitors work, but in a little different way. 

And proteasome inhibitors, again, just to refresh your memory, are  Velcade or bortezomib, Kyprolis or carfilzomib, and there are different drugs that work in this area that are being explored. And also, for the immunomodulatory drugs, there are different what are called cell mod or cell-modifying drugs that are being developed. Also, at our recent hematology meeting last December where all the blood doctors get together, there was a lot of research presented looking at using different cells for attacking the myeloma, for bringing back an old friend, interferon, to fight the myeloma through a new sophisticated way. The field is just really going at breakneck speed right now. 

Katherine:

Where do clinical trials fit into myeloma care? 

Dr. Matous:

I’m biased, Katherine. I think in every step of your myeloma journey you should ask about a clinical trial, because clinical trials might be appropriate as initial therapy, second-line therapy, third-line therapy, post-transplant maintenance therapy. There are clinical trials available, pretty much, at every phase of myeloma care, and so, I think it’s important that you here about your clinical trial options when you’re talking with your physician. Now, for some folks, it’s going to be hard to get on a clinical trial. You might be a long way from a center that does very many clinical trials, but you should always, always ask about it and there are many resources for researching clinical trials that are out there, right? One example is you can call The Leukemia & Lymphoma Society and they have counselors on the phone that can guide you toward clinical trials. You can go to clinicaltrials.gov. You’re paying for it. Might as well use it and search clinical trials there. It’s a pretty easy site to use, as well. 

My answer is at every phase of your journey, whenever you’re considering a treatment or a new treatment for myeloma, you want to know what your clinical trial options are. 

Katherine:

How can patients and care partners stay informed about the latest myeloma research? You mentioned a couple of websites. Are there others? 

Dr. Matous:

There are. There are a bunch of these that are out there, right? There’s the Myeloma Crowd. There’s – you know, this webinar. The Leukemia & Lymphoma Society in the Rocky Mountain area, we have, every year, a blood cancer conference that we put on free for patients through The Leukemia & Lymphoma Society that reviews new goings on in the field of myeloma, so there’s a lot of information out there and just a little bit of effort on the web. You can find great resources. Again, the ones I mentioned earlier I think are my top ones. Particularly, the IMF, the International Myeloma Foundation, because the physicians who run that and the people who run that, they made sure that everything that’s on there is entirely believable. 

Katherine:

Yeah. Okay. Let’s get to a few audience questions that we received before the webinar. Kendall writes, “I’m in the maintenance stage following initial diagnosis and treatment. At first relapse, is it appropriate to push for stronger treatment in hopes of a cure?” 

Dr. Matous:

Yeah, so the answer to that has changed. The answer is yes, and so, the – it used to be said in myeloma that your best treatment was your first treatment. Then, if you relapsed, that the treatments didn’t work as well, and the remissions did not last as long. Throw it out, so now, we get multiple chances to get really deep remissions in patients, and we should be every bit as greedy when we’re treating relapsed disease, at least initially, as we are when we treat disease at the very beginning. We know, for example, that there are many second-line therapies. I’ll just throw out some examples – daratumumab, pomalidomide dex, daratumumab Revlimid dex, daratumumab Velcade dex.  

Not to mention, the T-cell therapies that can put patients in remissions that are so deep that we can’t even find myeloma cells using very sophisticated molecular techniques, so be greedy. 

Katherine:

Yeah. Okay. Good advice. PEN community member, Greg, sent in this question. “Can you discuss any future or potential changes to using stem cell transplant for myeloma patients?” How would you counsel patients who do not want to pursue a transplant as a treatment option? 

Dr. Matous:

So, for stem cell transplant in myeloma, for years, it’s been the standard of care for suitable patients. And every couple years, I liken this to that game we used to play called King of the Hill growing up where stem cell transplants, King of the Hill, and everyone tries to knock stem cell transplant off the hill. And so far, it really hasn’t happened. And so, transplants still, I think, an important part of the overall care for suitable patients. 

For patients who are eligible and safe enough to undergo transplant. However, not all – now, will this be challenged in the future? And the answer is – I think the next challenger, and this will be a serious challenger, will be CAR T-cell therapy. And so, we have to figure out if CAR T-cell therapy or the bispecific antibodies are safe enough to give at the beginning and as effective as stem cell transplant and what the long-term side effects, how they might differ, as well, so that question is going to be tackled in the myeloma word, but it’s going to be several years until we have an answer there, for sure.  

So, for my patients who are otherwise candidates for stem cell transplant, but who don’t want to do it, usually, I’ll say, “You may change your mind in the future. In myeloma, it’s important to keep all your options open and you should at least discuss with the transplant center collecting and freezing away your stem cells for a rainy day to keep that option open to you.” So, even you’re thinking of not doing it, it might be a good idea, it probably is a good idea, to harvest and store your stem cells at a transplant center. 

And then, if you’re not going to do transplant up front, they key is to stay on prolonged maintenance therapy.  

We know that that’s one of the keys for making survival as long as possible in patients who don’t do a transplant is to continue on ongoing maintenance therapy as long as possible. Don’t curtail your therapy just because you’re not doing a transplant. 

Katherine:

Right. Okay. Well, thanks for that, Dr. Matous.  

Those were all great questions. Please continue to send them in to questtion@powerfulpatients.org and we’ll work to get them answered on future programs.  

So, Dr. Matous, as we close out the program, we’ve definitely learned that the field of myeloma is advancing very quickly. Would you share with us why you’re hopeful? 

Dr. Matous:

Yeah. It’s because for – I’ve been doing this quite a while and I always used to tell my patients if you just hang around. 

If you stay in the game, something else is going to come that we don’t even know what it is right now that’s going to impact your life, your quality of your life, the longevity of your life, and be a good treatment for you. And so far, that’s been the case. And right now, with the T-cell therapies, I’m really, really excited about how they can impact the cure of our patients. I also think that the basic research that’s going on in myeloma right now, and this is done by the real smart scientists, not the clinicians like me, but the really smart people that work in the laboratory. Learning how myeloma cells misbehave at very amazing levels, and when we learn that, it almost always results in a treatment that benefits our patients.  

And so, I think that we have every reason to be optimistic for our patients with myeloma, because of all the treatments that are coming out that we know about, that we know are around the corner, and for those that we don’t even have an idea what they are yet. 

Katherine:

Yeah. Well, it seems like there’s a lot to be hopeful about in myeloma care. Dr. Matous, thank you so much for joining us today. It’s been a pleasure. 

Dr. Matous:

Well, the pleasure’s been mine. I love talking to myeloma patients and I would just encourage you to keep getting all the information you can. The field’s moving really fast. Just keep up with it and don’t lose hope. 

Katherine:

Yeah. And thank you to all of our partners. To learn more about myeloma and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Katherine Banwell. Thanks for joining us.  

Is There Financial Assistance for Myeloma Patients?

Is There Financial Assistance for Myeloma Patients? from Patient Empowerment Network on Vimeo.

Can myeloma patients access financial assistance for their care? Expert Dr. Benjamin Derman shares information about available support and resources to reduce the financial burden on patients.

Dr. Benjamin Derman is a hematologist and oncologist specializing in multiple myeloma at the University of Chicago Medicine Comprehensive Cancer Center. Learn more about Dr. Derman.

See More from Engaging in Myeloma Treatment Decisions

Related Resources:

The Role of a Myeloma Specialist on Your Care Team

How Can You Engage in Your Myeloma Treatment Decisions? Resource Guide

Expert Advice for Newly Diagnosed Myeloma Patients

Transcript:

Katherine:

One final question for you. Jennifer asks, “Many new medications for treatment were mentioned. And I’m sure these could be expensive. What are the options to make these available financially for patients who need them?”  

Dr. Derman:

That’s a really good question, and one that we don’t yet have great answers to. As a physician, I don’t receive compensation based on the drugs that I prescribe. And so, I do know – I often have a good sense of what these drugs cost. A lot of the costs that are passed along to patients typically revolve around oral therapies. Even patients who are on Medicare, or sometimes especially patients who are on Medicare. And looking at some of the policy changes that seem to be coming down the pike that include capping Medicare out of pocket costs for medications will be a huge benefit to our myeloma patients.  

It’s important to familiarize yourself with different organizations and the financial support that may be available. Just to name a few, and you’re not limited to these, but The Leukemia & Lymphoma Society does a really great job in providing financial support to patients. But there are definitely other programs that can be contacted for this.  

And also, a lot of the pharmaceutical companies will actually have patient assistance programs as well. Sometimes it’s as simple as asking your provider, and typically they will have their team look into this for you. But we’re fortunate to have a team of pharmacists and my nurses as well who are used to doing this kind of thing. So, it’s important to look into those as well.

How Can Myeloma Patients Cope With Fatigue?

How Can Myeloma Patients Cope With Fatigue? from Patient Empowerment Network on Vimeo.

Fatigue can have a big impact on daily life for people with myeloma, so how can this common symptom be managed? Expert Dr. Benjamin Derman shares insights about why fatigue occurs, advice about treatment timing, and recommended adjustments to optimize energy levels.

Dr. Benjamin Derman is a hematologist and oncologist specializing in multiple myeloma at the University of Chicago Medicine Comprehensive Cancer Center. Learn more about Dr. Derman.

See More from Engaging in Myeloma Treatment Decisions

Related Resources:

What Factors Affect Myeloma Treatment Decisions

How Is a Myeloma Patient in Active Treatment Monitored?

Expert Advice for Newly Diagnosed Myeloma Patients

Transcript:

Katherine:

Craig sent in this question prior to the program. “My primary side effect is fatigue.” And you just mentioned that. “What advice do you have for planning activities through the day?”  

Dr. Derman:

So, this is a very common side effect that we see. In part, it can be from the disease itself. And if that’s the case, it’s going to get better as treatment works. In other cases, it’s due to the treatment itself. And sometimes there are controllable aspects. If it’s a pill, let’s say, where you can control the timing of when you take it. I often tell patients, “Take the drug at night. Because if it makes you tired, at least you’re going to be going to sleep at that point.” 

I do think making sure that you have a good night’s sleep is important. I think making sure that you keep your day-night cycles. So, even if you feel fatigued and you’re at home, it’s not good to be having the windows closed and not being exposed to the outdoors at all. You need light during the day. That’s a normal human need. We do the same thing when patients are in the hospital, and it’s very easy to get your day and night cycles messed up.  

And the other thing too is planning periods of the day when you know that your activity level is going to be, or your energy level is going to be higher, and planning your activities around those times. I think those are at least some important things that we can do.