Mar 29, 2022

interviewer: For patients that were just diagnosed with multiple myeloma or have had a recurrence of the cancer, receiving the treatment that's appropriate for your situation requires an expert.

Dr. Aman Godara from Huntsman Cancer Institute is that expert. He's an expert at diagnosing and treating multiple myeloma, and we're going to get to some of those treatments and some information about clinical trials. But first, Dr. Godara, some context, what is multiple myeloma?

Dr. Godara: So multiple myeloma is a type of blood cancer, which occurs from the proliferation of plasma cells that are present in the bone marrow.

So patients who have multiple myeloma can have several complications as a result of this cancer. These complications usually involve weakening of the bones that can lead to fractures. These complications can cause low blood counts, high calcium levels, and sometimes can also affect the kidneys of patients who have multiple myeloma.

interviewer: And how does a person kind of come to realize that they have it? Are there some symptoms or signs that they notice?

Dr. Godara: Patients who are newly diagnosed with multiple myeloma, the way this disease comes to light is that these patients can have fractures very easily. So we see patients who have had a fracture recently and have a lesion that was weakening the bone there, a tumor that was weakening the bone there, that resulted in that fracture.

A lot of times, patients have low blood counts and when the testing is done to identify what the cause for the low blood counts is, that can also reveal a presence of multiple myeloma. This type of cancer produces a protein that we call the monoclonal protein that can be detectable in the blood or urine of the patients who have multiple myeloma.

And sometimes patients would also have kidney failure, and that's another population of patients when patients have kidney failure that we don't have a good explanation for. Those patients are also looked out for this disease to make sure that they don't have multiple myeloma.

interviewer: So a person would go to their primary care physician or perhaps an urgent care or emergency room because they fractured a bone. What are some of those other types of symptoms that have taken them to that first step?

Dr. Godara: So, a lot of times, patients have gone to an emergency department or to an urgent care center because they just had a fracture. And whenever patients have a fracture, they will have some imaging done of their bones, whether that is an X-ray, whether that's a CAT scan, and those things can also identify the tumors, the kind of weakening that this kind of cancer can do to the bones.

A lot of times patients end up into the hospital because they have very low blood counts, and that's also a sign and symptom of this disease.

interviewer: And how does physically having a low blood count manifest itself?

Dr. Godara: So patients who have low blood counts usually feel that they are getting tired easily with any work that they would normally do in their day-to-day life. Patients who have low blood counts could also have multiple infections one after another, and these infections usually are infections such as pneumonia. Patients who have low blood counts can also have increased bruising over their body. And these are all reasons that would lead to a diagnosis of multiple myeloma in a patient.

interviewer: And as far as the diagnosis goes, if somebody is experiencing these symptoms, they go to their primary care physician or the emergency room in the case of fractures. Is it pretty easy at that point to tell that that's what's causing these types of things when those typical tests are run?

Dr. Godara: Sometimes the answer could be a little bit complex. If somebody has a fracture and you see a tumor in their bone, the first thing that somebody should think about is that is this multiple myeloma?

But when patients have low blood counts or when patients have kidney failure, when they have come to see a doctor or they have come to an emergency department, then the answer is not really very straightforward. In that scenario, we have to look at different possibilities, different diagnoses, and ultimately confirm whether a patient has or does not have multiple myeloma.

interviewer: Tell me about the treatments for multiple myeloma. What are we talking about there?

Dr. Godara: Patients who have multiple myeloma and are just newly diagnosed with it, the way we treat these patients is a combination of three or four medicines together. And we have come a long way in the past 20 years in this regard. Twenty years ago, when patients would be diagnosed with this disease, they would receive chemotherapy as their initial treatment. But now, the treatment has become a lot more focused on the disease and the problem that causes this disease.

So the three or four drug combinations that we usually treat our patients with are medication combinations that work particularly well against this type of cancer. They have side-effects that are predictable and manageable in the hands of the clinician who is treating these patients.

interviewer: And from what I understand, multiple myeloma is not something that's ever cured. So, after a first round of treatments, they might be cancer-free for a while, but eventually, is there going to be a relapse?

Dr. Godara: Once patients are diagnosed with multiple myeloma, they will initially receive a treatment that consists of three or four drugs combined together. And the initial attempt is to control the myeloma and put it into a remission. Once that happens, we have to decide upon the next steps for the patient.

And the next steps depend on how aggressive the myeloma was at that time of diagnosis, whether there were any high-risk features associated with the myeloma, and these are genetic changes usually that accompany the diagnosis of multiple myeloma.

So, based on that decision-making at that point of time, sometimes we choose and recommend our patients to undergo a technique called stem cell transplantation with high-dose chemotherapy, where patients receive a high dose of chemotherapy that otherwise would be toxic to their bone marrow, but in this technique, patients' stem cells are collected before they receive this chemotherapy so that we can overcome the side effect of that chemotherapy on the bone marrow.

And this is a treatment that has been well-established for patients with multiple myeloma for the last 30 years, and we still continue to use it, especially in patients who have any aggressive features associated with their myeloma or have high-risk myeloma when they presented at the time of their diagnosis.

So once patients have received their initial treatment and have received either a stem cell transplant or not, they would still continue some form of maintenance treatment, at least until a few years into their diagnosis. This is to confirm that the myeloma remains in remission and does not come back early.

interviewer: And generally, how long is it before the first remission might come back then?

Dr. Godara: So this will depend a lot on what the initial treatment for the patient was, and it will also depend on the risk-staging of multiple myeloma when it was diagnosed.

On an average, when we talk about a standard patient with multiple myeloma, the time that this disease could take to come back would be somewhere around four to six years after the treatment has been initially started. But patients who have some aggressive features associated with this type of cancer, their myeloma can come back within the first two or three years of their diagnosis.

interviewer: And for that patient that then has had their first or their second remission, what are the treatment protocols at that point? Do you change up the treatment or is it pretty much the same thing just again?

Dr. Godara: So patients who are experiencing their first or second relapse, we make a determination of what their initial treatments were and how long ago were those treatments done.

If there has been a long gap between the time that the patients received those last treatments, we can certainly use those treatment options again in the same combination as they were used initially.

But if a patient experiences a relapse while they are on one of those treatments, then in that case we usually tend to make some switches to their treatment combination and start off with a new regimen for those patients who have relapsed.

interviewer: And there's been a lot of development in those treatments over the past few years. Can you tell me a little bit about that?

Dr. Godara: There has been a lot of development in the field of multiple myeloma. And when we talk about that, we are not just talking about new treatments but more innovative ways of combining these treatments together that have become available in the past few years.

So when a patient is newly diagnosed, as I mentioned earlier, patients could receive a combination of three drugs or four drugs together. So there's been a lot of focus on whether one strategy is superior to another.

And there are certain populations of patients where one strategy has been proven to be superior than the others. So patients who are not very fit when they are diagnosed with this cancer, or are above the age of 70 or 75 years, those patients are not eligible to receive a stem cell transplant usually.

And in that scenario, we have information to the effect that if we use four treatments together, they serve to be better than three treatments together, not just in terms of the duration of response that these patients get out of that particular treatment, but also it can impact survival when we use four treatments together. Patients can have a longer survival compared to when they receive three drugs together.

So that's been one area, one aspect of this disease where there is currently a lot of focus identifying what works better and what combination works better than another.

When patients have relapsed, what makes a difference there is what type of relapse we are talking about. Patients who have had their first or second relapse, we have several different options that we can easily choose from to treat those patients and put the myeloma back into remission.

But one other aspect of this disease is that the way all this progress is happening is through the clinical trials.

There are clinical trials that are focusing on patients who are just diagnosed with multiple myeloma.

There are clinical trials that are focusing on patients who are experiencing their first or second relapse, from the time that they have been diagnosed.

And then we also have a lot of clinical trials focusing on patients who have received multiple different lines of therapy before and are running out of options when they suffer from a future relapse.

So some of the clinical trials that are ongoing right now are not just looking at some innovative treatment combination, but these treatments are innovative by themselves.

So there has been a lot of focus on immunotherapies in treating multiple myeloma. So one of the antibody treatments that we use in these combinations to treat multiple myeloma became available around seven years ago and has been a game-changer for the patients.

And these treatments are particularly focused on targeting the plasma cells that are causing this multiple myeloma, and at the same time, they don't have the toxicities or side-effects that we usually associate with cancer treatment.

Now, in just the last couple of years, we have had also some other immunotherapy treatments where we are harnessing the power of your own immune system to target multiple myeloma. Those treatments have shown us that they have efficacy and they work for patients who have had multiple different lines of therapy. Their toxicities are very unique and very different, but at the same time they are predictable toxicities that we have measures and steps we can take to mitigate that toxicity that comes along with these treatments.

interviewer: So if I'm understanding correctly, somebody who has had multiple myeloma a few years back and then it has come back will have a whole different selection of treatment options possible to them that might have fewer side-effects, might be more effective in treating the disease. Is that accurate?

Dr. Godara: So that's accurate to some extent, because as we start focusing more and more on the disease, and more and more on treatments that are not having any off-target effects, as a result, there is more efficacy and less toxicity.

So one of the questions that we are commonly asked when a patient has experienced a relapse is that when we do start a new treatment, what will be the duration of the treatment? And in this regard, there has been a lot of focus to developing treatments that are just a one-time treatment and do not require any continuous administration.

One of the newer treatments for patients with multiple myeloma is Car T-cell therapy where patients' own immune cells are engineered to fight this cancer. And this treatment is given as a single-dose treatment and has a toxicity that is predictable. It requires administration of this treatment in the hospital, but once the patients are out by a few days or a few weeks from this treatment, we don't anticipate any further toxicity related to this treatment.

Then there are also some similar treatments that are, again, harnessing your immune system to fight the cancer, which require a weekly or every other week administration that requires patients to come in every week or every other week to get these treatments.

But again, these are treatments that usually have toxicities that are more pronounced at the beginning when patients start these treatments, rather than toxicities that continue as long as those patients continue on those treatments.

interviewer: Multiple myeloma is a complicated disease that takes a lot of medical expertise from different specialties to manage. Tell me how, at Huntsman Cancer Institute, you're able to provide that to the patients.

Dr. Godara: So patients who have multiple myeloma usually require a multitude of services. Patients are sometimes sent to see an orthopedic surgeon because they have suffered a fracture. Patients are sometimes sent to a radiation doctor because they have a bone tumor that requires a radiation treatment. And sometimes the effect of this cancer on your wellbeing is so immense that patients have to participate in some wellness programs to get back to where they were before this diagnosis occurred. We provide a multitude of these services under the same roof at Huntsman Cancer institute.

At the same time, all the innovation that's occurring in the field of multiple myeloma, an opportunity to participate in that is through clinical trials. We provide clinical trial options for patients who are not just newly diagnosed with this cancer, but also patients who have had their first, second, or multiple relapses in the past. We give them an opportunity to participate in clinical trials for some of these innovative cancer treatments right at their doorstep.

interviewer: What is the value of somebody getting a second opinion that has had a multiple myeloma diagnosis or has relapsed?

Dr. Godara: So patients who have multiple myeloma, I strongly recommend them to see a specialist for their disease so that not only we can discuss what's the right combination of treatments to start off for their disease, but also patients who have had relapsed myeloma, the opportunity for them is to participate in clinical trials and bring some of these innovative treatments out to the front long before they are available as an option for treatment for these patients.

The ultimate goal here is that we want our patients to live longer, we want to minimize their toxicity, and at the same time maintain a quality of life that patients can enjoy their lives with.

For Patients