With a five-year survival rate of only 50.7%, multiple myeloma remains difficult to treat. In this interview with i3 Health, Carol Ann Huff, MD, Medical Director for the Johns Hopkins Kimmel Cancer Center, explores the challenges and research advances of myeloma treatment. She also gives advice on helping patients to find assistance with the prohibitive costs of treatment and on handling the difficulties involved in treating patients at smaller community cancer centers, including patients who live in rural areas.
What are some of the most challenging aspects of managing multiple myeloma?
Carol Ann Huff, MD: One the most challenging aspects of multiple myeloma is when we have a patient who has high-risk genetics. Unfortunately, even with all of the advances that we have made, high-risk disease is still high risk, and their survival is significantly shorter than patients who lack those genetic features. That's probably our biggest challenge. In addition, many patients begin treatment with concomitant or comorbid illnesses from fractures and bone pain as well as symptoms of their disease, so educating and orienting patients to all of their care and getting their families on board are also challenges that we have.
What questions do you commonly encounter from patients or caregivers about their treatment, and how do you counsel them?
Dr. Huff: The questions that people have vary with where they are in the process. In the beginning, people don't know the disease. They don't know a lot about it, where it came from, how they got it, what they can do, what the treatments are, and what the side effects are. I think that most patients are very motivated, and they want to do whatever they can do to help themselves get better in the process. Answering their questions is a multidisciplinary approach that entails not only explaining the treatments but also involving our social workers and physical therapists and nutritionists, who all try and help people grow stronger.
Unfortunately—or fortunately—treatment is generally lifelong, so that's an adjustment for patients: not just starting on treatment but facing the prospect of maintenance therapy. However, when you explain that the maintenance therapy significantly prolongs survival and enables better quality of life, most people are accepting of that process.
Another issue, which actually relates back to the first question, is managing the cost of the care and the copayments: one of the challenges we find is just the extraordinarily high cost of caring for multiple myeloma. That cost is divided between insurance coverage and out-of-pocket expenses, and although two therapies may be covered in terms of their overall costs, the amount that a given patient has to pay can vary dramatically between an oral regimen and one that's given in the infusion center. So some of the questions that come up from patients and families are assistance with managing cost. Thankfully, there are many assistance programs that are out there, and we have a very robust collaboration with our pharmacy and our social workers to help get patients plugged into these programs. I would always encourage patients who aren't necessarily being cared for at a myeloma center to explore those options because what I often find is that when patients come to us, they haven't been able to connect with assistance foundations and things to help them.
Do you find that in smaller cancer centers or more rural spaces, treatment is more challenging?
Dr. Huff: Well, there's cost, but there's also the logistical challenge of just getting people in. When I talk to colleagues who care for patients that come quite a distance, they find that it's harder to give infusion or injection regimens, so there's a much greater leaning towards oral regimens for as long as possible, or towards all-oral regimens when possible. I'm sure that there are financial challenges there as well. As we are a tertiary referral center, the patients who get to us certainly have challenges, but sometimes the hurdle of even getting to a center is too much for patients in other places. We don't even see those patients.
What are some of the promising advances in multiple myeloma treatment that you expect to see in the near future?
Dr. Huff: Some of the most promising advances are therapies that target novel pathways and novel antigens. Probably the farthest along in development are those efforts to target B-cell maturation antigen, or BCMA. Those are monoclonal antibody-drug conjugates, where an antibody binds to the drug and then when it gets inside the cell, it releases through metabolism a toxin that helps kill the cells. It's sort of a targeted payload, if you will.
People are also targeting BCMA with chimeric antigen receptor (CAR) T-cells and engineered immune cells. Both of these strategies have shown promise; they are also being incorporated in combination with existing therapies because unfortunately, even these strategies are not curative. So efforts are ongoing: are there ways to augment the effectiveness of these strategies or enhance existing combination therapies?
In addition, there is a newer immunomodulatory drug, iberdomide, in development, which will hopefully continue to move forward. Another one that I hope is close to coming to fruition is venetoclax, which targets BCL2 and has shown quite significant activity in translocation T (11;14) patients with myeloma. That is far along in phase 3 development.
What advice would you give to community oncologists and hematologists caring for patients with multiple myeloma?
Dr. Huff: My advice would be ideally to partner with myeloma experts to help facilitate optimal care of patients in their centers using a collaborative approach. For lots of patients who come to see us, when the care doesn't need to be delivered in a tertiary care center, transplant clinical trial, or similar situation, they get their care closer to home. Many, many physicians reach out to me routinely via email or telephone, and we talk about patients from a new perspective.
One of the things that physicians should keep in mind is that as the diagnostic criteria have changed recently for smoldering myeloma versus active myeloma, we see that patients are diagnosed as having smoldering myeloma but without having more sophisticated bone imaging in the form of a magnetic resonance imaging (MRI) scan to truly exclude bone lesions that are present in earlier disease. I think that skeletal surveys will likely go away, and MRIs, low-dose computed tomography (CT) scans, and positron emission tomography (PET) scans will certainly replace that.
Another thing that I would encourage community oncologists and hematologists to do when possible is to participate in clinical trials so that they can bring new agents to their patients. In addition, physicians should keep in mind that there's really a wealth of resources out there that their staff can reach out to in order to help patients and help physicians keep up with all of their patients.
About Dr. Huff
Carol Ann Huff, MD, Medical Director for the Johns Hopkins Kimmel Cancer Center and Associate Professor of Oncology and Medicine at the Johns Hopkins University School of Medicine, is an expert in the treatment of multiple myeloma and amyloidosis. She has been the principal investigator of numerous clinical trials. Dr. Huff and her collaborators have identified a flow cytometric-based blood analysis that can be used to quantify the number of myeloma cancer stem cells and track their response to treatment. Dr. Huff has received multiple awards for clinical and teaching excellence, including the Kimmel Cancer Center's Director's Teaching Award in Oncology in both 2006 and 2012, and has authored numerous research publications and book chapters on multiple myeloma and bone marrow transplantation.
For More Information
Dr. Huff is the Chair of i3 Health's CME-approved visiting faculty meeting series, Evolving Treatment Paradigms in Multiple Myeloma and Implications for Shared Decision Making. Contact i3 Health to request a meeting if you are interested in hosting this free presentation at your institution.Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily represent those of i3 Health.