Rare Cancers: What Is Multiple Myeloma?
Not all cancers are created equally. Even though they might be similar in nature - i.e. uncontrolled division of abnormal cells in a part of the body - they’re not all treated the same way. Myeloma is a cancer of the plasma cells that sees about 200,000 US cases a year, according to Dr. Rafael Fonseca of Mayo Clinic.
“Multiple myeloma belongs to the group of diseases we think about when we think about blood cancers. Specifically, myeloma is a form of adult bone marrow cancer that comes about when plasma cells convert into malignant cells.
Under normal circumstances, plasma cells help protect our bodies. They produce the antibodies that give us immunity. Occasionally, those cells become malignant, and that’s what we call myeloma,” Dr. Fonseca says.
Dr. Fonseca is a hematologist, professor of medicine and chair of the department of internal medicine at Mayo, and he has more than 25 years of experience. He explains myeloma as a disease with three sub-types. MGUS, smoldering multiple myeloma and active multiple myeloma.
MGUS - Monoclonal Gammopathy of Undetermined Significance
It may be helpful to think of MGUS as tier 1. Generally speaking, patients with MGUS won’t have any outward symptoms, and it’s actually not too rare. More than 2% of adults over 50 have it.
“That condition is when there’s very discrete growth of the plasma cells, usually that they’re going to be less than 10% of the cells in a person’s bone marrow,” Dr. Fonseca says.
Smoldering Multiple Myeloma
There’s a condition that can be considered tier 2. Smoldering multiple myeloma happens when the number of myeloma cells present is more than 10% but not enough for you to be symptomatic.
He says, “It will remain as such for as long as there is no evidence of complication.
Once we see that someone has complications, that’s when we say they have multiple myeloma, active myeloma or simply, ‘myeloma.’”
Active myeloma, multiple myeloma or myeloma is when a patient has enough myeloma cells that they start having symptoms. Dr. Fonseca says these can be bone problems, fractures, a history of back pain, unexplained anemia or kidney problems like renal failure. This is when a patient will most definitely need treatment. Sometimes, advanced cases of smoldering multiple myeloma will require treatment as well.
There are several different newer types of treatments for multiple myeloma, and there are always new clinical trials being conducted.
A common treatment for multiple myeloma might be the chemotherapy regimen: RVd - Revlimid, Velcade and dexamethasone. This is still the standard of care (along with autologous stem cell transplant) in new cases of multiple myeloma, according to Mayo Clinic.
Dr. James Berenson is also a myeloma specialist who runs his own private practice and has more than 35 years of experience. He no longer believes in stem cells transplants and bone marrow transplants. He does not recommend them for his patients anymore.
“You’ve got to kill the myeloma, not the patient. Transplants involve a lot of non-specific chemo that does a lot of collateral damage. It doesn’t make people happy or give them a good quality of life.
Most doctors do still recommend them, but I certainly do not. I think we have better treatments that are better tolerated and offer a better quality of life. I don’t want people to have to go through holy hell with no upside,” Dr. Berenson says.
There are newer types of treatments coming out. The newest treatment that has gained FDA approval for myeloma is a drug called Selinexor.
“Selinexor is supposed to be a blocker of a pump that moves certain proteins from a cell nucleus. The premise upon which this was developed is if you can increase the concentration of certain proteins that act as tumor suppressors, perhaps that would allow cells to signal and divide more until they die,” Dr. Fonseca explains.
There are currently more than 40 clinical trials involving CAR-T cell therapy for multiple myeloma. CAR-T is already approved and commercially available for other forms of cancer like certain leukemias and lymphomas, but it’s only available in trials for myeloma. Dr. Fonseca breaks down CAR-T cell therapy in layperson’s terms:
“CAR-T therapy is when you take out one of those T cells that we have in our body. They can collect them from your blood and then they send them elsewhere. They send them to a factory to be genetically engineered.
They become assassins who target myeloma cells, and then they’re shipped back to the patient and given back to the patient in their vein. Essentially, you’re taking T cells, training them to kill myeloma cells and giving them back.”
If you’re interested in more of the newer options, there are also proteasome inhibitors. You can research them more and ask your doctor if they might be an option for you.
“Pathway inhibitors stop pathways that grow myeloma or makes the soil in which the myeloma grows less hospitable. It makes it like a barren desert instead of fertile ground for the myeloma,” Dr. Berenson says.
Prognostics from Real Experts
Dr. Fonseca urges patients to think about how far cancer research has come and how far it will go:
“When I first started in myeloma, we would tell patients they were looking at 2 or 3 years at best and we had almost no drugs. Now, the prognosis is measured in several or many years and sometimes even decades.
I remind patients of one thing all the time: if I see you today in 2019 and the life expectancy is 10 years, how will we treat myeloma in 2029? That is what we call the valley of options because with all the research being done, they will have options at that point that don’t exist today.”
Dr. Berenson agrees. He tells patients not to get caught up in the numbers the internet might through in your face. Ask a real doctor about your treatment plan.