Myeloma Monthly

How Aggressive Is Your Myeloma?

Dr. Berenson

Hi, I’m Jim Berenson from the Institute for Myeloma & Bone Cancer Research.

I’d like to discuss how you can tell how good or bad your myeloma is. That’s a very good question and very complicated to answer. There are so many facets to this, especially as we get more and more information from testing that we didn’t have available until just a few years ago — protein testing, genetic testing, along with proteins and genes we didn’t even know existed until just a few years ago. All of these are helping to determine what stage your myeloma is in. But also, importantly, this is a rapidly changing field as new drugs become available. So, the data we may have generated to predict outcomes from the old chemotherapy and steroids may not be relevant in the era of new antibody therapies and more targeted treatments. So just because there was a marker that said you were going to do poorly from data generated even a few years ago, it may not be relevant with all the new treatments that are being used today to treat myeloma.

But in general, we want to know several things:

  1. How are you feeling?
    1. What’s your quality of life? Are you active or are you bedridden? These are very extreme differences and certainly predict outcomes. Some of that “bedriddenness,” if you will, may not only be related to the myeloma, but also to other things which have nothing to do with myeloma but will determine your outcome in a negative way if you’re not active. Staying active is important!
  2. There’s a variety of things that myeloma does itself.
    1. Do you have poor blood counts because the myeloma is covering your bone marrow? That can predict a fairly difficult disease course and overall outcome for you. Or if your blood count is normal, it’s likely easier for you to be treated with drugs that may negatively impact your blood counts.
    2. How is your kidney function? If your kidney function is poor at the start, this used to be an incredibly negative factor. Not anymore! The good news is that we have a lot of new treatments to deal with this. Unfortunately, many doctors treat everybody alike. You can’t do that now. You need to be more aggressive to reverse kidney disease quickly because unfortunately, if you don’t, the patient can end up on permanent dialysis and that is not a very good thing for your quality of life.
    3. How are your bones doing? Do you have a lot of bone disease, holes in your bones and fractures? That certainly can impact negatively your quality of life and how long you live.

So, there are a lot of factors that come into play that are myeloma and non-myeloma related factors that indicate how good or bad your myeloma is. However, even more important is how good or bad you are going to do with the treatment for your myeloma. That’s what it’s really about.


Myeloma Monthly – Myeloma Bone Disease

Dr. Berenson

Hi, I’m Jim Berenson from the Institute of Myeloma & Bone Cancer Research.

I’d like to discuss with you today Myeloma Bone Disease. Bone-related problems are the most important thing that happens to a myeloma patient clinically. Why? Because the bone marrow where myeloma resides is right next to bone, and often, the bone marrow itself when crowded with myeloma cells causes a negative impact on bone strength. And how does that occur? It occurs because there are types of cells called osteoclasts in the bone marrow that are like Pac-Men that gobble up bones. So what does that do? It weakens the bones, so patients have fractures. The bones can expand from the myeloma pushing on them so patients experience bone pain. All of this often leads to the requirement for pain medication, surgery and sometimes radiation treatments. And sometimes the spinal cord can be impacted by crushing the vertebral bodies or myeloma tumors in the back. That can lead to more serious problems like paraplegia which is paralysis of the legs.

So how do we stop that from happening? Well, there are multiple ways we can do that, easy ways such as maintaining your Vitamin D levels. It is important to have your doctor check that. You should be taking supplemental Vitamin D and calcium. Although calcium levels can be higher in severe bone disease from leeching calcium out of bone, most patients actually require supplemental calcium. So, the use of calcium and Vitamin D are most helpful in maintaining bone strength. Second, there are drugs we use today to help prevent bone loss. First, we had intravenously administered bisphosphonates. In earlier days, it was Aredia or pamidronate, and more recently over the last 20 years it’s been Zometa or zoledronic acid. A monthly infusion makes bones stronger. How do these drugs work? They eliminate the Pac-Men, stopping them from gobbling up bones. So, the bones are stronger and less likely to fracture. We also now have available a newer drug for myeloma bone disease called XGEVA (or denosumab), an antibody that reduces the number of osteoclasts, so there is less bone loss resulting in stronger bones. So, one can use either of these types of drugs, the bisphosphonates or XGEVA. However, the latter is markedly more expensive and doesn’t work any better than the bisphosphonates. Importantly, XGEVA doesn’t cause kidney problems which can sometimes occur from administration of either Aredia or Zometa. So, for patients who have kidney problems, we now have an option to treat their bone disease, we have XGEVA.

In addition, it’s important for the myeloma itself to be treated. Eliminating the myeloma cells in the bone marrow prevents them from stimulating the Pac-Men and their ability to gobble up bones. Thus, we have a multi-pronged approach in myeloma patients to prevent bone loss, fractures, and bone pain. We have Vitamin D. We have calcium. We have drugs like bisphosphonates and XGEVA and we have treatment for the myeloma itself. As a result of this multi-pronged approach, bony complications have been markedly reduced among myeloma patients over the last two decades.


Myeloma Monthly – Immune Therapy

Dr. James Berenson and the Institute for Myeloma & Bone Cancer Research proudly introduces a new series of videos called “Myeloma Monthly”. These videos about Myeloma, are designed to be a helpful, informative tool for our patients and their family and friends. The videos will cover topics such as new treatments for this disease, new drug breakthroughs, questions you should ask, support for caregivers and much more.

To celebrate March as “National Myeloma Month” we are launching our first video titled “Immune Therapy” on March 1. To watch the video please click on the following link: www.imbcr.org/mmimunetherapy

Immune therapy has been used for a number of years to treat a variety of cancers including breast and lymphoma. In general, the immune system is harnessed to get rid of bacteria, viruses, and toxins, as well as poisons. In our case, we want to use and harness the immune system to get rid of the myeloma.

Immune therapy can take on several forms. Most commonly, it takes on the form of using antibodies or proteins that naturally occur to get rid of the body’s toxins, bacteria, and viruses. In this case, the antibodies target proteins on the myeloma cell to harness the immune system to get rid of the myeloma.

We have two recent additions to our armamentarium to treat myeloma which are antibodies: elotuzumab and daratumumab. These have proven quite effective – not as effective alone as when combined with other treatments.

Now we have coming on board a number of more specific treatments including the use of T-cells as cellular therapy to actually harness the immune system to get rid of the myeloma. They target a protein known as BCMA. This is expressed at very high levels in myeloma and not much in other cells in the body. Thus, when the immune system is harnessed, the myeloma is eliminated without a lot of cross damage on normal cells.

In addition, besides just the antibodies themselves targeting BCMA, there are now antibodies with toxins connected that also target both the BCMA on the myeloma cell and the immune T-cells. So, we bring both the effector cells (the T-cells that are capable of killing the myeloma) to the BCMA that is on the myeloma cells together to improve their myeloma-eliminating effects.

So, now there are a variety of different techniques that are being used to treat myeloma today with the immune system and the hope is that these will be more specific and not have all the side effects of the non-specific treatments we’ve had up until now.

Hi, I’m Jim Berenson from the Institute of Myeloma & Bone Cancer Research.

I’d like to discuss with you today Myeloma Bone Disease. Bone-related problems are the most important thing that happens to a myeloma patient clinically. Why? Because the bone marrow where myeloma resides is right next to bone, and often, the bone marrow itself when crowded with myeloma cells causes a negative impact on bone strength. And how does that occur? It occurs because there are types of cells called osteoclasts in the bone marrow that are like Pac-Men that gobble up bones. So what does that do? It weakens the bones, so patients have fractures. The bones can expand from the myeloma pushing on them so patients experience bone pain. All of this often leads to the requirement for pain medication, surgery and sometimes radiation treatments. And sometimes the spinal cord can be impacted by crushing the vertebral bodies or myeloma tumors in the back. That can lead to more serious problems like paraplegia which is paralysis of the legs.

So how do we stop that from happening? Well, there are multiple ways we can do that, easy ways such as maintaining your Vitamin D levels. It is important to have your doctor check that. You should be taking supplemental Vitamin D and calcium. Although calcium levels can be higher in severe bone disease from leeching calcium out of bone, most patients actually require supplemental calcium. So, the use of calcium and Vitamin D are most helpful in maintaining bone strength. Second, there are drugs we use today to help prevent bone loss. First, we had intravenously administered bisphosphonates. In earlier days, it was Aredia or pamidronate, and more recently over the last 20 years it’s been Zometa or zoledronic acid. A monthly infusion makes bones stronger. How do these drugs work? They eliminate the Pac-Men, stopping them from gobbling up bones. So, the bones are stronger and less likely to fracture. We also now have available a newer drug for myeloma bone disease called XGEVA (or denosumab), an antibody that reduces the number of osteoclasts, so there is less bone loss resulting in stronger bones. So, one can use either of these types of drugs, the bisphosphonates or XGEVA. However, the latter is markedly more expensive and doesn’t work any better than the bisphosphonates. Importantly, XGEVA doesn’t cause kidney problems which can sometimes occur from administration of either Aredia or Zometa. So, for patients who have kidney problems, we now have an option to treat their bone disease, we have XGEVA.

In addition, it’s important for the myeloma itself to be treated. Eliminating the myeloma cells in the bone marrow prevents them from stimulating the Pac-Men and their ability to gobble up bones. Thus, we have a multi-pronged approach in myeloma patients to prevent bone loss, fractures, and bone pain. We have Vitamin D. We have calcium. We have drugs like bisphosphonates and XGEVA and we have treatment for the myeloma itself. As a result of this multi-pronged approach, bony complications have been markedly reduced among myeloma patients over the last two decades.