The Latest Myeloma News from the American Society of Hematology Meeting

Andrew Schorr:

So, here's a question from Russell in Waverly, Pennsylvania, and he says, 'Why are there so many varied opinions on the treatment of multiple myeloma and conflicting ones as well?' He's not just talking about some of the cancer fighting treatments that we've talked about now, such as Revlimid and Velcade and thalidomide and melphalan and prednisone, you know all this that we try to understand as patients, transplant or no transplant, but also even drugs to help, the bisphosphonates and others related to bone complications. Dr. Lonial, and I'll from all, I imagine that if you put your scientists in a room and you have a lot to argue about, but for us as patients, why isn't there more clarity yet?

Dr. Lonial:

I think it's because over the past 20 years we've not had a lot of really effective therapies until the last four or five, and I think that that's the reality is we're now struggling to try and determine how best to use all these new tools that we have, the many developing tools that are in the pipeline and that don't have a lot of large randomized phase-III data. I think it's not like lymphoma where there's one quick and simple answer because there's nothing else that's been proven any better than that one quick and simple answer, the CHOP for myeloma, if you will. We don't have that in myeloma, and I think that's what we're really struggling to do, and so for instance, the three-drug combination that you mentioned earlier, the combination of lenalidomide with bortezomib and dexamethasone that Paul Richardson presented both in the newly diagnosed and the relapsed refractory patients at ASH. We're participating in both of those trials with him actually, and I've been struck by how well tolerated those regimens are and how deep and quick the responses are. It's really quite striking, and my thoughts, my hopes are that that kind of a regimen using the most active drugs we have, like we do in CLL, like we do in lymphoma, like we do in many other diseases, we'll form the backbone of some consensus regimen some time in the next few years, but we just don't have enough data to really say that at this point.

Andrew Schorr:

Dr. Berenson, so you have strong opinions, and I know you have arguments with the other doctors in the field. Would you agree with what Dr. Lonial said that we still need yet some more definitive trials, or where are we? It looks like some of the data presented at ASH, like for instance this VMP, the VISTA trial, a phase-III trial, I think it was 1600 patients, that seemed to be a pretty rigorous trial.

Dr. Berenson:

Yes, I would agree with you. I think that was a very well run, very well designed trial. I personally use Velcade at a lower dose and use the melphalan on a four-week schedule with a lower dose and give the Velcade only four days a month because I do believe in our phase-II trial, which we presented at ASH over the weekend. We see less neuropathy and a better tolerated regimen, but I think in general the combinations of these newer agents with the tried and true is very important. One of the problems with myeloma is its rarity. Compared to breast, prostate, and lung, this is a relatively uncommon cancer, so the ability to conduct large, randomized trials quickly is not so easy, and in addition differences that are said to be really monumental and important in breast cancer, for example, the role of chemotherapy up front in which the difference is truly in terms of absolute percentage advantages are in the single digits. In myeloma we have to show bigger differences because we can't do these giant trials. I would say, however, really importantly for patients, don't give up the ship if what you try the first time doesn't work. I really believe that heartily. As I like to quote my daughter's principal at the school, he was talking about education, "There's a smorgasbord of new opportunities." Boy is that ever true in myeloma. So, I really want patients to get the message that this is a chronic disease, and there is really a rare patient that if you do get therapy and it doesn't work one way that you won't try something else and it will work great and be well tolerated. There are just so many options today. That's really the positive message.

Andrew Schorr:

It sure is. Brian Durie, so there you chair the Medical Advisory Board of the International Myeloma Foundation, and I'll give out that hotline number in a minute because what a wonderful service you provide for people one-to-one. Do you think we're moving; Sagar said, we've got a little ways to go for a consensus yet, but boy we have a lot to talk about, but for those of us, you know, we can say it's like; I always feel like Rodney King, you know it was the day after the riots in Los Angeles; can't you all get along? So, that's really what we want. We want this clarity. Do you see it coming some day soon?

Dr. Durie:

Absolutely. I think that we're getting closer, and it's just a matter of time. I think it's good news. I think there are lots of options, but we are limited by the fact that the outcome that we're looking for is a long outcome. We're expecting patients with myeloma to live for 10 years, to live maybe 15 or 20 years. So, you can't know if these new regimens are going to do that kind of a job for many years to come, but we have some very good hallmarks right now. For example, the IFM presented their transplant follow-up from their 99 trial, so that a study that was started in the late 1990s, and they have a 7-year survival in the 80-85% range so that in these single and double transplant protocols, in excess of 80% of their patients are doing well at seven years. Now, with the novel agents, we have patients doing well at two years, three years, and four years, but what we don't know is without transplant are those patients going to continue well at seven years, 10 year, and beyond 10 years? It's just going to take us time to see what will be the benefit with these novel agents with and without transplant. It may be that the answer will be novel agents plus maybe one transplant or maybe some new vaccine that we come up with, but it's going to take time to know so that the options are there. The advice is so important, and one of the things that I feel strongly about for the International Myeloma Foundation is that we can try to help people sort through what might be best for each one of them depending on their situation. Sagar Lonial mentioned that if you have abnormal chromosomes or some poor risk features, it may be that one option is better for you versus others maybe including Velcade as part of the combination.

Within all of this, we need to balance the short term benefit with the toxicity and expectation of long-term benefit, so good news, but it's going to take still time to sort out.

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Page last updated on November 22, 2013