Transcription:
The Future of Multiple Myeloma

Melanie Cole (Host):  Myeloma is a cancer for plasma cells which normally produces antibodies to help fight infection. Left untreated, myeloma can interfere with production of normal blood cells and cause serious complications in bones and kidneys. City of Hope is the only Southern California member of the Multiple Myeloma Research Consortium, a collaboration of research organizations focused on rapidly bringing the most promising multiple myeloma treatments directly to patients. My guest today is Dr. Amrita Krishnan. She is the Director of the Multiple Myeloma program at City of Hope. Welcome to the show, Dr. Krishnan. So tell us a little bit about what multiple myeloma is, and are there any symptoms that would signal a red flag and get someone in to see you?

Dr. Amrita Krishnan (Guest):  Well, thank you again very much for the opportunity to speak to you and your audience. So, myeloma is actually the second most common hematologic blood cancer in the United States. There are about 20,000 cases every year, and it’s a disease generally of older people, a median age of 72. Now, symptoms can vary. Some people in fact are completely asymptomatic and their myeloma is found often on routine blood work. Often they’re anemic or they have an elevated protein in their blood, or their kidney function may be abnormal. Other people sometimes presents more dramatically with severe bone pain, what we call a pathologic fracture—meaning a fracture that occurs just outside of normal trauma. Certainly, fractures in the back, what we call compression fractures, are often a presenting sign. Other people sometimes present with symptoms of kidney failure, fluid retention, severe nausea, vomiting, and severe blood chemistry abnormality.

Melanie:  So how do you diagnose multiple myeloma if someone is experiencing some of these symptoms? Or if they’re not, is this something that would be found on a routine physical, on a blood test?

Dr. Krishnan:  Well, a routine physical can certainly give you those hints, if a person is anemic or they have elevated protein. So a routine set of blood always looks at a total protein, and if that’s high, that may be a clue. Usually, that’s when patients are referred to hematologists or blood doctors to further figure this out. And then we do more specialized tests. We do something called the serum electrophoresis, which is a fancy way of saying we look at the protein and try and figure out is it an abnormal protein or is it just normal protein that your body makes, as you mentioned earlier, to fight infections. We then do I guess the hematologist’s favorite test, the bone marrow biopsy, where we look to see if the plasma cells that you have in your bone marrow are abnormally high in number. Because everyone actually has plasma cells that you also mentioned, but in myeloma you have too many, and the ones you have are abnormal. They make abnormal immunoglobulin, and often even just looking at them under the microscope they may in fact look more immature or more abnormal. Then we do a bunch of X-rays, something they call a skeletal survey, looking at the bones to see in fact if there are subtle changes in the bone, even before people have symptoms. That can also be suggestive of myeloma. And then we often collect urine samples as well to look for protein in the urine.

Melanie:  So what are some of the newest developments in treating multiple myeloma? What is the typical standard of treatment, and what is changing today?

Dr. Krishnan:  So that’s certainly a challenge in regards to the question of what is the standard of treatment. Because often, as patients will find, certainly they go out see a physician and they also get a second opinion, sometimes a third opinion. Many of the times, with active myeloma, those opinions may not agree. And what I tell patients is that doesn’t mean there’s a wrong answer. It just speaks to the multitude of choices to patients with myeloma now. And that’s patients from the beginning of their diagnosis to patients who have relapsed disease. So the general paradigm for patients who can tolerate it, the patients who are fit enough but we say they don’t have other what we call comorbidities, other factors playing into their health, we try and give three drugs for their initial therapy. And those three drugs generally fall into category: a category called a proteasome inhibitor, another category called the immunomodulatory agents, and then steroids.

Melanie:  And now, what is changing? Is there different research going on for multiple myeloma, things that are changing? Cancer seems to be changing all the time, Dr. Krishnan. So what’s changing for myeloma? 

Dr. Krishnan:  So that’s the great thing and the exciting thing for those of us in the myeloma field is that change, as you mentioned, is happening, and it’s happening so quickly. In cancer, this has been an incredible couple of years. For myeloma, several things—even this year, I think, we’re going to see—that are very exciting to us in the field. For example, use of what we call targeted therapy. So, monoclonal antibodies to myeloma are probably the newest thing on the block, where we target specific antigens on the myeloma cells so that the antibodies can attack those myeloma cells specifically. We’ve shown some very encouraging results with a different variety of antibodies for patients. The other thing that’s certainly moving forward and City of Hope is one of the leaders in this is this whole concept of immunotherapy. So, using your own immune system, but re-engineering it to make it smarter to fight myeloma. And we’re looking at a variety of ways, certainly T-cell therapy probably being one of the areas where we’ve been a big leader of research. We’ve now started to explore that in myeloma as well.

Melanie:  What advice do you have, Dr. Krishnan, for patients that are recently diagnosed with multiple myeloma? It’s a scary diagnosis. What do you tell them as the first thing that they should do?

Dr. Krishnan:   So I agree with you. Any cancer diagnosis is frightening, and myeloma I think even more so because when patients get on the Internet, they read that the disease is incurable, they read the median survival. And sometimes it can be shorter than certainly than what they ever thought. So I would first of all caution them to take it all into context that, as we talked about, the field is changing so quickly. So in fact, some of that stats in terms of survival is certainly also changing and for the better, very much so. The other thing I would say is, really, myeloma, while it is in the hematologic cancers as one of the top ones, it’s still a relatively rare cancer compared to breast cancer, lung cancer. So I would encourage them to come and see a myeloma specialist. Now, I reckon,especially California is a huge state, not everyone lives close to a myeloma center. But also, what we do is we work with physicians in the community. The patients come to see us and we sort of recommend a treatment algorithm, and then they go back to their treating physicians in their community and we work with them, follow along their progress, and we’re available for questions, et cetera. But I think that’s probably a very important part because certainly, part of the treatment of myeloma, for example, is stem cell transplant and figuring out where to put that into a patient. Treatment is part of our expertise. We have multiple clinical trials for patients who have relapsed disease as well, and in fact we also have clinical trials now for patients who have newly diagnosed myeloma. So I really would encourage them to come to a center, at least for a second opinion to see what their options are.

Melanie:  How does multiple myeloma affect bone health, and are these effects permanent? Do you give advice on building to maintain healthy bones during treatment?

Dr. Krishnan:  Myeloma certainly affects bones in the sense that the plasma cells send signals to the cells in the bone that leads to what we call abnormal bone turnover. So we’re constantly turning over our bones—building it up, breaking it down, building it up, breaking it down. But in myeloma, you break it down too much and you don’t build it up. And so, certainly the best way to prevent that is treat the myeloma, so get those plasma cells to stop sending those signals to the bone. But we have other what we call bone strengthening agents, the bisphosphonates you may have heard of zometa aredia, that we use in conjunction with our anti-myeloma therapy. And then other supportive care measures: vitamin D, calcium. Exercise is tolerated, certainly. All those things together are important in terms of bone health.

Melanie:  In just the last minute, if you would, Dr. Krishnan, give your best advice to the listeners about multiple myeloma, what you would really like them to know and why they should come to City of Hope for their cancer care.

Dr. Krishnan:  Certainly, we have been at the forefront of a lot of some of the new drugs for myeloma, and those drugs have had a huge impact in improving survival for people with myeloma. And we also are the leader and expert in stem cell transplantation, and we are certainly one of the leaders in myeloma for that as well. So we really offer the patients this comprehensive range of care. And that really starts from the newly diagnosed myeloma patients through patients undergoing transplants through patients with relapsed disease and patients with multiple relapses in advanced myeloma. So, we can offer all those treatments for a variety of patients. The nice thing is also our doctors are integrated, so the same doctor who you see at the beginning of your journey is the same doctor who will be your doctor if you need a stem cell transplant, the same doctor if your myeloma comes back. So that’s also very nice for patients. And I think the biggest issue is obviously our expertise and our access to many, many new drugs for myeloma that have clearly markedly improved survival for patients. And ultimately, I hope that someday we’re going to be able to use that word “cure,” and I strongly believe we’re getting closer and closer to that.

Melanie:  Thank you so much for such great information. You’re listening to City of Hope Radio, and for more information, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.