Deciding on Treatment
Nooka says the overarching goal after making a multiple myeloma diagnosis is “to improve the longevity of myeloma patients with a good quality of life.” The first step in deciding upon treatment is to determine whether a patient is eligible or not for stem cell (bone marrow) transplant. Recent research at Emory has found that even the eldest patients can benefit from stem cell transplant. “So age should not be a criteria for offering or not offering stem cell treatment,” says Nooka. Generally, patients are not eligible for a transplant only if it is unsafe — for example, if they are in a frail condition or have lost organ functions.
Patients are classified as either “high risk” or “standard risk.” Most cases are standard risk. This classification is performed by using genetic profiling of the individual’s myeloma cells to determine whether certain chromosomal parts are missing or translocated, an abnormality in which a chromosome breaks and a portion of it re-attaches to a different chromosome.
“The goal for both transplant-eligible and ineligible patients,” says Nooka, “is to use the best treatment, put the best foot forward, gain the best depth of response.” This means choosing the treatment that will kill the greatest number of abnormal plasma cells.
For a transplant-eligible patient, Nooka says a combination of three or four drugs is used for a period of four months to move them toward transplant. The stem cells are collected before the patient receives high doses of a chemotherapy called melphalan, which kills both the myeloma cells and normal cells. By transplanting stem cells, a patient’s normal cells are increased or rebuilt. This allows the high-dose chemotherapy to give the greatest benefit and kill more myeloma cells.
For transplant-ineligible patients, dose adjustments and reductions must be made as appropriate. “One size does not fit all,” says Nooka.
There are other considerations, too, when deciding on treatment—including what are the toxicities of a particular drug that the patient has faced with previous treatments, what treatments the patient previously received, and what comorbidities the patient has. “Last but not least,” says Nooka, “even the patient’s convenience should be taken into consideration so that you make the right choice for that specific patient.”
Maintenance and Management
After the first induction therapy, the chemotherapy and then the transplant, patients usually receive maintenance therapy that depends on the kind of disease the patient has. “If the patient has a high-risk disease,” Nooka explains, “we do not want to lose control of the disease.”
“We offer high-risk patients a combination maintenance treatment to control the disease for a much longer time,” says Nooka. Those who are classified as having standard risk receive a single drug agent, preferably a pill, for maintenance. He says the simple oral regimen is convenient and well tolerated.
“Once a patient gets a good remission,” says Nooka, “you don’t need to continue all these treatments forever.” He says they can “peel off” treatments based on the patient’s tolerability of particular drugs. When someone goes onto a maintenance regimen, he explains, “it is not uncommon to see these patients in remission for around seven to eight years on average.” Even for those with high-risk disease, combination treatments can keep patients in remission for four to five years.
What Happens When the Disease Comes Back?
Nooka says this is a common question patients ask him. “Unfortunately,” he says, “the disease comes with multiple relapses. So, first you have a disease. You’re treated. It remains in remission for a certain amount of time, then the disease comes back. That is the nature of multiple myeloma.” Short of a complete cure, the goal is to prolong each of these remission periods, which add up to improved survival duration.
Nooka emphasizes the dramatic change these longer remissions represent. “Think about where we have come,” he says. “Even 20 years ago, patients were living for an average of three years. With this approach, the first remission itself is lasting seven to eight years.”
Even frail patients who aren’t able to receive treatments like a stem cell transplant are benefiting from modern immunotherapy approaches. Sixty percent of them survive for approximately six years, a significant improvement over the two to three years that all multiple myeloma patients faced two decades ago.
“While this is great progress,” says Nooka, “no one wants to hear about any time limit on their lifespan. That’s exactly why we’re working to bring all these new drugs into the pipeline.”
