The Personalized Medicine Approach to Treating Myeloma

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Dr. Noopur Raje, Director of the Center for Multiple Myeloma at Massachusetts General Hospital, shares information on the latest approaches to personalized medicine to treat myeloma. Dr. Raje discusses recent research that included over 1500 patients. and how the results of the trial have impacted the standard of care in multiple myeloma. She goes on to explain how genome sequencing has influenced personalized medicine and the difference that this approach to treatment could make in terms of outcome for patients

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With us is one of our favorite experts in the field, Dr. Noopur Raje from Boston, from the MGH hospital and cancer center there, the myeloma center where you're the director.  So, okay.  Lot of abstracts.  Lot of presentations in myeloma.  For our audience of patients, what do you feel is significant? 

This year at ASH, we actually had a plenary session abstract presented yesterday. So those of you who were able to attend that abstract, it was great.  So this was rated as one of the highest abstracts in the whole entire meeting, which is a really big deal.  And what Thierry Facon from the international—the IFM, which is a French intergroup, presented was the first study also called MM20, and this MM20 was probably the largest randomized trial which has ever been conducted in the context of myeloma in the up?front setting. 

And what I really liked about the study was, you know, it was more of a real?world experience because we do all of these clinical trials at our major academic centers, and it's not necessarily applicable to most patients.  This was different.  It was about a little over 1,500 patients.  All the patients were not transplant?eligible patients, and that honestly is the majority of multiple myeloma.  If you think about myeloma, 70 percent of multiple myeloma is above the age of 70, which is a transplant?ineligible population. 

The other thing which was very nice, and Dr. Facon highlighted this at the plenary session, was typically when we talk about clinical trials we exclude a lot of people with co?morbidities.  What was really nice to see in this trial was about 10 percent of people in each of the three arms were people who had renal dysfunction.  Those of you who have myeloma, those of us who take care of people with myeloma know that renal dysfunction is a really big deal.  It happens in about, you know, renal insufficiency happens in as many as 30 percent of people, so this was the first large randomized trial including people with creatinine clearances of less than 30, and that was really significant. 

What this trial really showed was a comparison.  It was three arms where lenalidomide (Revlimid)/dexamethasone (Decadron) was given indefinitely until progression.  There was a second arm where lenalidomide/dexamethasone was given for a period of 18 months.  And there was a third arm, which used the old treatment, which was melphalan (Alkeran), prednisone (Deltasone) and thalidomide (Thalomid) given for again 18 months. 

And what was really striking here was folks who got lenalidomide/dexamethasone in the up?front setting and who continued it until progression have done well from a progression?free survival standpoint.  Their risk of progression was reduced very significantly, and they also lived longer so really changing the standard of care. 

You know, we in the United States do tend to use a lot of len/dex in the up?front setting.  Lenalidomide/dexamethasone is certainly not approved in Europe, but this first study is going to get this drug approved, I hope, by the EMEA.  And the other piece which we learned was the fact that once you start on lenalidomide, it's important to continue on it, right?  Do not stop it just because you've had a response.  The benefits of that progression?free survival as well as the overall survival really speaks to being able to stay on these medications for protracted periods of time. 

And a lot of this comes out of the data which was presented on whole genome sequencing of the myeloma genome and what was seen in that whole genome analysis was amongst other mutations which are common in myeloma, the one which kind of stood out was called the BRAF mutation.  Now, it's certainly not as commonly seen as it is in melanoma patients.  Melanoma patients are the skin cancer patients.  There's a lot of confusion between myeloma and melanoma, but skin cancer patients, the folks who have malignant melanoma, have this BRAF mutation in about 80 percent of people.  When we did the whole genome sequencing in myeloma, we saw it in about 4 percent, so 400 people. 

But the neat thing about this is there is a certain drug which can target people with that BRAF mutation, and at least there is experience now worldwide where a few patients have been treated with these BRAF inhibitors.  So at least at centers like ours, we are looking, we are being proactive, and I think that's the first step towards a curing, towards a personalized medicine approach.  We're already thinking about doing trials with combinations of BRAF inhibitors and, for example, MEK inhibitors. And even though it's uncommon if you pick those four people out of a hundred and give them what their cancer's really addicted to, I think you're going to make a big difference in terms of outcomes.  

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on April 30, 2014