Optimizing Therapy for Patients With Multiple Myeloma



Rafat Abonour, MD: My name is Rafat Abonour. I’m a hematologist at IU [Indiana University] Health, and I’m the director of the multiple myeloma, Waldenström macroglobulinemia, and primary amyloidosis programs.

We optimize treatment based on the principle of the treatment of multiple myeloma; every patient with multiple myeloma should undergo induction treatment, intensification, and maintenance. Induction treatment is evolving. We have several novel drugs and we use them in combination. We need to use the right combination upfront because that will provide the best reductions in the volume of the disease. Following that, we offer stem cell transplantation, which we think is very important.

Why do we do induction with combination therapy? Why do we do a stem cell transplant early in the course after induction treatment? We do this to provide the best chance to eradicate all of the subclones in the patients.

When you have a myeloma patient, they don’t have 1 type of myeloma. Within each patient there are several clones, and they respond differently. Some clones respond to drug A but not drug B. And so the goal is to try to eradicate all of the clones. What happens is if you leave behind a few of the aggressive clones that were controlled by the larger clones that were there, the patient will relapse with very ugly myeloma that is very hard to control, especially in what we call high-risk myeloma.

These are the 20% of patients who will relapse within 2 years from diagnosis. These cases are very hard to treat. For that reason, the best thing is to get the patient into a complete remission—not just complete remission, but get the patient into an MRD [minimal residual disease]-negative state. If you look at the bone marrow and you try to find a single myeloma cell at 1 in 1 million total cells and you don’t find it, that’s called MRD-negative. Today, data suggest that if you get an MRD-negative state after the best treatment you provide them, these patients will have a very long remission and very long survival. Our goal here at IU Health is that every patient should achieve a complete remission. Every patient should achieve an MRD-negative state.

When I started working in multiple myeloma we used to tell patients, “Listen, you’re probably going to live 2 or 3 years.” That was 20 years ago. Now patients are living much longer. We have patients who we treated 15 years ago who are still in remission. And they’re still living. Why are they still living? Because they are in remission. So if you want your patients to live longer, you need to keep the disease from coming back quickly. The longer they’re in remission, the longer they’re going to live.

That should be the goal of therapy today, because we have very good drugs. We have stem cell transplant. You use them together. You get more patients into complete remission. You get more patients into an MRD-negative state. What will happen is that it will take them much longer to relapse, or hopefully they never will. So the last thing, remission, is going to happen when you have a MRD-negative state.

Multiple myeloma is a heterogenous disease, and each patient is unique. Our approach is to customize treatment for each patient. The goal is to achieve MRD-negativity in each patient we see. You have the high-risk patient. You have intermediate-risk patients, and standard-risk patients. We will look at every patient and try to determine the best treatment for them, to try to provide them with lasting remission. We don’t have a 1-size-fits-all strategy, but we want to make sure that every patient has a chance to get a complete remission here.

When a patient is diagnosed with multiple myeloma, the referring physician always has this thought in mind: “What do we do?” They know what is the best induction treatment. The timing of stem cell transplantation is still a question. Some people don’t think stem cell transplantation is important. What we need to do is understand that today, when you do induction treatment followed by stem cell transplant early in the course of the disease, in the first year of diagnosis, that’s when you provide your patient the chance for the best progression-free survival and improve their overall survival.

So our approach has been a collaborative approach. The referring physician will say, “I have a newly diagnosed multiple myeloma patient. I’m going to induce them with this combination.” We agree that’s a very good approach. After 2 cycles, we will see the patient to make sure the patient is responding to the treatment and to make sure the patient is getting ready for the stem cell transplant. They may have an issue. They may not have had their colonoscopy. So we need to get the ball rolling early, so after 3, 4 cycles they are ready to proceed with stem cell transplant.

We have 5 physicians specialized in multiple myeloma here at IU Health, and we have nurse practitioners. We have a very robust stem cell processing laboratory and a stem cell collection lab. We have an excellent unit that’s staffed with nurses who have been doing this for many years. So when we tell our patients that their chance of surviving transplant is more than 95%, we mean it. We have all of the elements that it takes to make sure that we’re providing safe drugs, safe follow-ups, close monitoring. So that’s our team.

I don’t know if I can do anything else. I love the interaction with the patients. I love the patients. I hate myeloma. My passion is to really take care of these patients, and my most important passion is to get rid of the myeloma while providing them the quality of life they deserve.

Transcript Edited for Clarity

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