Blood Cancer Awareness Month

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:05Hospital and AstraZeneca.
00:07 --> 00:09Welcome to Yale Cancer Answers with
00:09 --> 00:12your host doctor Anees Chagpar.
00:12 --> 00:14Yale Cancer Answers features the
00:14 --> 00:16latest information on cancer care by
00:16 --> 00:18welcoming oncologists and specialists
00:18 --> 00:20who are on the forefront of the
00:20 --> 00:22battle to fight cancer. This week
00:22 --> 00:24it's a conversation about multiple
00:24 --> 00:25myeloma and other hematologic
00:25 --> 00:28conditions with Doctor Terri Parker.
00:28 --> 00:30Dr Parker is an assistant professor
00:30 --> 00:31of medicine in hematology at
00:31 --> 00:33the Yale School of Medicine,
00:33 --> 00:36where Doctor Chagpar is a
00:36 --> 00:38professor of surgical oncology.
00:38 --> 00:39Terri, maybe we can start off by you
00:39 --> 00:41telling us a little bit about
00:41 --> 00:42yourself and about what you do.
00:43 --> 00:45My specialty focuses on plasma cell
00:45 --> 00:48neoplasms or plasma cell disorders.
00:48 --> 00:50The most common of which is multiple
00:50 --> 00:52myeloma, which is considered to
00:52 --> 00:53be a haematological malignancy.
00:54 --> 00:56So let's back up a little bit.
00:56 --> 00:58What exactly is a plasma cell?
00:59 --> 01:01A plasma cell is a
01:01 --> 01:02type of white blood cell that
01:02 --> 01:04is found in the bone marrow.
01:04 --> 01:06It's derived from a B lymphocyte,
01:06 --> 01:08which is another type of white
01:08 --> 01:10blood cell again found in the bone marrow.
01:11 --> 01:13Tell us about multiple
01:13 --> 01:16myeloma and what exactly it is.
01:16 --> 01:17I mean when we think about
01:17 --> 01:19cancers of white blood cells,
01:19 --> 01:22oftentimes we're thinking about leukemias
01:22 --> 01:24lymphomas, is multiple myeloma
01:24 --> 01:26a type of that,
01:26 --> 01:28is it different? Tell us more.
01:28 --> 01:30As stated, a multiple
01:30 --> 01:33myeloma is considered to be a
01:33 --> 01:34hematological malignancy and so
01:34 --> 01:36that term encompasses leukemias,
01:36 --> 01:39lymphomas, and plasma cell neoplasms,
01:39 --> 01:42of which multiple myeloma is one.
01:42 --> 01:44So in multiple myeloma the
01:44 --> 01:46abnormal cell is a plasma cell
01:46 --> 01:48and these plasma cells proliferate or
01:48 --> 01:52increase in number in the bone marrow.
01:52 --> 01:54It's really not known what causes
01:54 --> 01:56the plasma cells to proliferate in
01:56 --> 01:58the majority of individuals,
01:58 --> 02:00and it's this proliferation that
02:00 --> 02:02is defined as multiple myeloma.
02:07 --> 02:10In general, blood cancers
02:10 --> 02:13are pretty rare, right?
02:13 --> 02:15If you look at multiple myeloma,
02:15 --> 02:16it's currently the 14th most
02:16 --> 02:19common cancer in the United States
02:19 --> 02:21and it represents roughly 1.8%
02:21 --> 02:23of all new cancers diagnosed
02:23 --> 02:24so not as common as some of
02:24 --> 02:25our solid tumors that we see.
02:26 --> 02:28And where does it rank relative
02:28 --> 02:30to leukemia and lymphoma?
02:30 --> 02:33There's some leukemias
02:33 --> 02:36that are more common and some that are rare,
02:36 --> 02:38so probably somewhere in
02:38 --> 02:41the middle, not to be too specific.
02:41 --> 02:44And who gets
02:44 --> 02:47these blood cell cancers?
02:47 --> 02:48These hematologic malignancies.
02:48 --> 02:51Are there certain risk factors that put
02:51 --> 02:53people at risk for developing them?
02:53 --> 02:56As I stated previously
02:56 --> 02:58for multiple myeloma,
02:58 --> 03:00for most people we don't really know
03:00 --> 03:01why they developed the disease.
03:01 --> 03:04However, there are some factors that may
03:04 --> 03:06increase the risk of developing myeloma.
03:06 --> 03:09One is age, so the majority of people
03:09 --> 03:12are over the age of 50 at diagnosis.
03:12 --> 03:15With the current median age of diagnosis
03:15 --> 03:17here in the United States being 69,
03:17 --> 03:20another risk factor is a precursor condition
03:20 --> 03:24known as Monoclonal gammopathy of undetermined significance
03:24 --> 03:26also known as MGUS.
03:29 --> 03:31Tell us more about that.
03:32 --> 03:35MGUS is considered to be a precursor condition
03:35 --> 03:38and the individuals are asymptomatic and
03:38 --> 03:41it's usually discovered when blood
03:41 --> 03:44work is done for another complaint,
03:44 --> 03:46sometimes it can be that a primary care
03:46 --> 03:49physician notices that there's an increase
03:49 --> 03:51in protein in a simple serum chemistry.
03:51 --> 03:53So that's a blood test that's
03:53 --> 03:54done for another reason.
03:54 --> 03:57Sometimes this laboratory work is
03:57 --> 03:59done for evaluation of other problems
03:59 --> 04:02such as osteoporosis or neuropathies
04:03 --> 04:05and then they get referred to a
04:05 --> 04:07hematologist and have further evaluation
04:07 --> 04:10that then reveals this precursor state.
04:11 --> 04:15Those are pretty
04:15 --> 04:17general risk factors in terms of age
04:17 --> 04:20and MGUS for multiple myeloma.
04:20 --> 04:22Are there risk factors for lymphoma
04:22 --> 04:24and leukemia as well?
04:29 --> 04:31In general, age again plays a
04:31 --> 04:34factor as we do tend to see certain
04:34 --> 04:35leukemias in older individuals.
04:35 --> 04:38It again depends on the type of leukemia,
04:38 --> 04:39as there are different types.
04:39 --> 04:42Acute and chronic lymphoid versus
04:42 --> 04:45myeloid. And other potential risks
04:45 --> 04:48can include environmental exposures,
04:48 --> 04:50so there have been studies looking
04:50 --> 04:52at the link between radiation in
04:52 --> 04:54addition to certain chemical exposures
04:54 --> 04:56such as pesticides or Agent Orange.
04:58 --> 05:01And so those increase your risk of
05:01 --> 05:04leukemias and lymphomas, but not
05:04 --> 05:05of multiple myeloma. Is that right?
05:06 --> 05:07Multiple Myeloma as well,
05:07 --> 05:09there have been studies
05:09 --> 05:11specifically looking at Agent Orange
05:11 --> 05:13and pesticides as well as radiation
05:14 --> 05:16so you know pesticides is something that I
05:16 --> 05:18think a lot of people kind of worry about.
05:19 --> 05:21And you know, as we're heading into the fall,
05:21 --> 05:23people are still using
05:23 --> 05:25pesticides as they're trying to
05:25 --> 05:27tend their lawn and do their gardening,
05:27 --> 05:29get everything ready
05:29 --> 05:30for the winter.
05:30 --> 05:33Should people really be concerned about
05:33 --> 05:35pesticides or are there particular
05:35 --> 05:38pesticides that they should watch out
05:38 --> 05:40for and others that might be safer?
05:40 --> 05:42That's a good question and I don't
05:42 --> 05:44have a specific answer for you
05:44 --> 05:46and a lot of these are
05:46 --> 05:49looked at and some of the common
05:49 --> 05:51pesticides that people may use
05:51 --> 05:53may have warnings on them most of
05:53 --> 05:55the time people are usually safe
05:55 --> 05:57because they're using the regular
05:57 --> 05:59household pesticides or chemicals
05:59 --> 06:01if you will and ventilated
06:01 --> 06:03outdoor space and really
06:03 --> 06:04have minimal exposure.
06:05 --> 06:07I think that that's
06:07 --> 06:09kind of good information to get across.
06:09 --> 06:10Just because
06:10 --> 06:11people can sometimes worry about
06:11 --> 06:13these things, but
06:13 --> 06:15it may be that it's really not as
06:15 --> 06:17toxic as some people may think,
06:17 --> 06:20unless you're in contact
06:20 --> 06:23with them in large quantities.
06:23 --> 06:25So now that we've talked
06:25 --> 06:27about the risk factors,
06:27 --> 06:30how do people present with
06:30 --> 06:32these hematologic malignancies?
06:32 --> 06:36For a solid tumor,
06:36 --> 06:39tumors we often can find a lump,
06:39 --> 06:42or we'll have some bleeding
06:42 --> 06:44or will have some pain.
06:44 --> 06:46Blood cells don't generally
06:46 --> 06:48cause those things, do they?
06:51 --> 06:53If we walk
06:53 --> 06:55through each thing individually,
06:55 --> 06:57for patients who have leukemia
06:57 --> 06:59a lot of times they will present
06:59 --> 07:01with abnormal blood counts.
07:01 --> 07:03By that I mean an abnormal
07:03 --> 07:04white blood cell count,
07:04 --> 07:07hemoglobin or red cells or platelets,
07:07 --> 07:09which are the cell that helps prevent
07:09 --> 07:11you from bleeding or blood clots.
07:11 --> 07:15Sometimes an individual will be diagnosed
07:15 --> 07:17when they have a blood count done
07:17 --> 07:19for another reason and it's picked
07:19 --> 07:21up because there's an abnormality.
07:21 --> 07:23Sometimes people present because these
07:23 --> 07:25abnormalities lead to other symptoms.
07:25 --> 07:27For example, if there's an
07:27 --> 07:28alteration in a white blood cell
07:28 --> 07:30count is specifically a lower
07:30 --> 07:32white blood cell count,
07:32 --> 07:35someone may develop more frequent or
07:35 --> 07:37recurrent infections if the red cells or
07:37 --> 07:38hemoglobin is low.
07:38 --> 07:40That's also known as anemia,
07:40 --> 07:42and patients can
07:42 --> 07:44become more tired or fatigued,
07:44 --> 07:45and if their platelet count
07:45 --> 07:47is reduced they can present
07:47 --> 07:49with bleeding or easy bruising,
07:49 --> 07:51so sometimes these people present
07:51 --> 07:54because they have other symptoms and
07:54 --> 07:56then it's revealed that these symptoms
07:56 --> 07:58are because of a low blood count.
07:58 --> 08:00For individuals who have lymphomas,
08:00 --> 08:02sometimes they will present with a
08:02 --> 08:05large lymph node and so in that case
08:05 --> 08:07they may have a lump or bump if you will
08:07 --> 08:11that causes them to present to medical
08:11 --> 08:13attention and then for multiple myeloma,
08:13 --> 08:16which is what I specifically focus in,
08:16 --> 08:18sometimes people will not have any
08:18 --> 08:20symptoms and again it's picked
08:20 --> 08:22up because blood work is done
08:22 --> 08:23for another reason,
08:23 --> 08:26like an elevated total protein on a serum
08:26 --> 08:28chemistry which is a type of blood test.
08:28 --> 08:30Other symptoms that individuals
08:30 --> 08:32could have could again be anemia.
08:32 --> 08:34If the plasma cells increase in the
08:34 --> 08:36bone marrow to the point where they
08:36 --> 08:38start crowding out the normal cells,
08:38 --> 08:40plasma cells also produce high amounts
08:40 --> 08:43of protein that can be seen in the
08:43 --> 08:44blood that are cleared through the
08:45 --> 08:46kidneys and could lead to renal
08:46 --> 08:48dysfunction or failure in severe
08:48 --> 08:51cases if it has not been recognized,
08:51 --> 08:54and plasma cells also accumulate in the bone,
08:54 --> 08:56that can lead to weakness of the
08:56 --> 08:58bone and hence pain or fractures.
08:59 --> 09:02And so it sounds like a lot of these are
09:02 --> 09:05really picked up on basic blood tests
09:05 --> 09:08that you have when you go to your doctor.
09:08 --> 09:10So how frequently should you be
09:10 --> 09:12having routine blood tests done?
09:12 --> 09:14Especially if these things don't generally
09:14 --> 09:17present with a lot of symptoms?
09:17 --> 09:20There isn't currently
09:20 --> 09:22screening that's recommended
09:22 --> 09:24for multiple myeloma or MGUS
09:24 --> 09:27which is the precursor condition.
09:27 --> 09:29So typically we tell patients
09:29 --> 09:31to follow the guidance from
09:31 --> 09:32their primary care physician,
09:32 --> 09:35meaning their blood work really depends
09:35 --> 09:37on other medical problems.
09:37 --> 09:39For example, if someone
09:39 --> 09:40has a heart condition,
09:40 --> 09:43diabetes or another medical issue,
09:43 --> 09:45they're probably going to have blood
09:45 --> 09:47work done more frequently because
09:47 --> 09:49of monitoring of that condition and
09:49 --> 09:51the medications that are needed.
09:54 --> 09:56When you talk about these
09:56 --> 09:59conditions being found in older patients,
10:00 --> 10:02who are also the ones more likely
10:02 --> 10:05to have other comorbidities that
10:05 --> 10:07will require routine blood tests,
10:07 --> 10:10I wonder how many people who are younger
10:10 --> 10:13might be walking around completely
10:13 --> 10:16asymptomatic but actually harboring
10:16 --> 10:19one of these hematologic malignancies
10:19 --> 10:21that have never been picked up simply
10:21 --> 10:23because they've never had a blood test.
10:23 --> 10:26Is that possible or do these things
10:26 --> 10:28actually then progress to the
10:28 --> 10:30point of being symptomatic?
10:30 --> 10:32Again when you talk about
10:32 --> 10:33hematologic malignancies
10:33 --> 10:36that's a very broad topic and so
10:36 --> 10:40everyone is very individualized.
10:40 --> 10:42And so if we look at multiple
10:42 --> 10:44myeloma for individuals with
10:44 --> 10:46the precursor condition MGUS,
10:46 --> 10:49they can be asymptomatic for years
10:49 --> 10:52and for many patients
10:52 --> 10:54it never progresses.
10:54 --> 10:56For individuals who have a low risk
10:56 --> 10:57MGUS we
10:59 --> 11:01tell them that the risk of
11:01 --> 11:03progression is roughly 1% per year.
11:03 --> 11:05So there's a large majority of
11:05 --> 11:07people who will never progress.
11:07 --> 11:09If someone has multiple myeloma
11:09 --> 11:10and it's left untreated,
11:10 --> 11:13it will progress to the point where
11:13 --> 11:15they may develop syptoms,
11:15 --> 11:17what was discussed being
11:17 --> 11:19anemia leading to fatigue, potential
11:19 --> 11:22kidney damage, or bone damage,
11:22 --> 11:24so those patients will progress and
11:24 --> 11:26become symptomatic at some point,
11:26 --> 11:28it's difficult to predict that
11:28 --> 11:29rate of progression.
11:29 --> 11:32And what about
11:32 --> 11:34for lymphomas and leukemias?
11:34 --> 11:37Are those also ones that
11:37 --> 11:39will progress to symptoms?
11:39 --> 11:41Or is it possible for them to
11:41 --> 11:43be pretty asymptomatic until
11:43 --> 11:46they actually end up having a
11:46 --> 11:48test that that diagnosis it?
11:48 --> 11:50Yeah, so for your acute leukemias,
11:50 --> 11:52and even the majority of
11:52 --> 11:53your chronic leukemias,
11:53 --> 11:56they will often progress again,
11:56 --> 11:59varying rates of progression to the point
11:59 --> 12:00where people will become symptomatic.
12:00 --> 12:02Similarly, if someone had an aggressive
12:02 --> 12:05lymphoma or a high grade lymphoma,
12:05 --> 12:07they would progress to the point of symptoms.
12:07 --> 12:09It is possible for individuals
12:09 --> 12:12who have a indolent or a slowly
12:12 --> 12:13progressing lymphoma that they
12:13 --> 12:15may have had it for several years
12:15 --> 12:17before the point of progression.
12:17 --> 12:20The other question that I had was
12:20 --> 12:23you talk about one of the
12:23 --> 12:25things that's often a trigger to
12:25 --> 12:28finding diagnosis of these
12:28 --> 12:31conditions as being anemia.
12:31 --> 12:33And for example, in multiple myeloma,
12:33 --> 12:35where the plasma cells kind
12:35 --> 12:36of crowd out other cells,
12:36 --> 12:40and so the red blood cell count goes down.
12:40 --> 12:41Two questions,
12:41 --> 12:44first question is oftentimes anemia,
12:44 --> 12:46especially in older people,
12:46 --> 12:50can be associated with other things, right?
12:50 --> 12:52GI bleeds,
12:52 --> 12:54losing blood from other sources,
12:54 --> 12:56iron deficiency anemia.
12:56 --> 12:59How do you really tell that this
12:59 --> 13:02is from something like multiple
13:02 --> 13:04myeloma versus other things?
13:05 --> 13:07Yeah, that's a really good question,
13:07 --> 13:08and as you mentioned,
13:08 --> 13:10people who are older and even
13:10 --> 13:12younger individuals can have
13:12 --> 13:14anemia for a variety of reasons.
13:14 --> 13:17So typically we will work up and
13:17 --> 13:19do a basic anemia evaluation,
13:19 --> 13:21which includes looking at
13:21 --> 13:23things like iron deficiency,
13:23 --> 13:24other nutritional deficiencies,
13:24 --> 13:27vitamin B12, and folic acid to
13:27 --> 13:30make sure we exclude kind of
13:30 --> 13:32the most common and treatable
13:32 --> 13:35reasons for anemia first and then
13:35 --> 13:37when we really don't have a source,
13:37 --> 13:39then we kind of go on to kind of that
13:39 --> 13:41next level of evaluation that does
13:41 --> 13:43include hematological disorders.
13:43 --> 13:45Well, we're gonna need to take a
13:45 --> 13:47short break for a medical minute,
13:47 --> 13:49but when we get back we'll learn
13:49 --> 13:52more about how to diagnose and treat
13:52 --> 13:54these hematologic conditions with
13:54 --> 13:56my guest doctor Terri Parker.
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15:01 --> 15:03Welcome back to Yale Cancer Answers.
15:03 --> 15:04This is doctor Anees Chagpar
15:04 --> 15:06and I'm joined tonight by
15:06 --> 15:08my guest doctor Terri Parker.
15:08 --> 15:09We're talking about hematogic
15:09 --> 15:11malignancies,
15:11 --> 15:13and particularly Doctor Parker's
15:13 --> 15:16specialty of multiple myeloma.
15:16 --> 15:18Now, right before the break,
15:18 --> 15:22Terri, you were saying that a lot of people
15:22 --> 15:25are diagnosed with multiple myeloma when
15:25 --> 15:28anemia is found on a routine blood test.
15:28 --> 15:29And that
15:29 --> 15:31the first step is oftentimes to
15:31 --> 15:33rule out the things that are common,
15:34 --> 15:37rule out iron deficiency,
15:37 --> 15:40anemia and B12, and folic acid.
15:40 --> 15:42And all of those good things.
15:42 --> 15:43But ultimately,
15:43 --> 15:46if all of those things are ruled out,
15:46 --> 15:48how then does the diagnosis
15:48 --> 15:50proceed for people actually to be
15:50 --> 15:52found to have multiple myeloma?
15:53 --> 15:55And so the first step is actually
15:55 --> 15:57additional blood in urine studies,
15:57 --> 16:00so we will do a battery of tests,
16:00 --> 16:03specifically tests that are called a serum
16:03 --> 16:04protein electrophoresis,
16:04 --> 16:07which is a blood test that looks to
16:07 --> 16:09see if there's an increase in abnormal
16:09 --> 16:11or monoclonal protein in the blood.
16:11 --> 16:14We do a similar test in the urine.
16:14 --> 16:17We will test other specific things
16:17 --> 16:19called an immunofixation electrophoresis,
16:19 --> 16:20quantitative immunoglobulins,
16:20 --> 16:23and serum free light chains.
16:23 --> 16:25And we put together all of these blood
16:25 --> 16:28test and urine studies to determine if
16:28 --> 16:30there is a monoclonal protein present
16:30 --> 16:33which is a protein that's being secreted
16:33 --> 16:35by an abnormal plasma cell.
16:35 --> 16:38And so if you find that,
16:38 --> 16:41then that means that people have
16:41 --> 16:43multiple myeloma?
16:43 --> 16:45Not necessarily, as I mentioned earlier,
16:45 --> 16:47we can see a monoclonal
16:47 --> 16:49protein precursor conditions,
16:49 --> 16:52and so we take a look at the whole picture.
16:52 --> 16:54So we look at the amount
16:54 --> 16:55of monoclonal protein.
16:55 --> 16:58If the patient has any other
16:58 --> 17:01systemic symptoms, such as anemia,
17:01 --> 17:03renal kidney insufficiency,
17:03 --> 17:06or bone pain,
17:06 --> 17:08this is more consistent with what
17:08 --> 17:10we would call a monoclonal gammopathy
17:10 --> 17:12of undetermined significance,
17:12 --> 17:14that would be considered low risk
17:14 --> 17:16that we would just have to observe,
17:16 --> 17:19or if there were a significant amount
17:19 --> 17:21of protein or other symptoms that
17:21 --> 17:24would make us go one step further,
17:24 --> 17:26which would be a bone marrow biopsy,
17:26 --> 17:29which is the definitive way to
17:29 --> 17:30diagnose multiple myeloma.
17:31 --> 17:33And so when somebody has a bone
17:33 --> 17:36marrow biopsy what exactly does that
17:36 --> 17:39tell you?
17:39 --> 17:40The bone marrow
17:40 --> 17:44biopsy itself tells us what is the actual
17:44 --> 17:46percentage of abnormal plasma cells.
17:46 --> 17:49So we're looking for these abnormal
17:49 --> 17:50or monoclonal plasma cells.
17:50 --> 17:53So kind of one type of plasma cell,
17:53 --> 17:55and they need to be over
17:55 --> 17:5710% in the bone marrow.
17:57 --> 17:58So that's what we're looking for,
17:58 --> 18:01and that is diagnostic of multiple myeloma.
18:01 --> 18:03And then if you find that,
18:03 --> 18:05what's the next step?
18:05 --> 18:07Is there staging or do you
18:07 --> 18:08go straight to treatment?
18:08 --> 18:10How does that work?
18:10 --> 18:13Then we have to make another determination
18:13 --> 18:16so we have what we call smoldering
18:16 --> 18:18Multiple myeloma, which are symptomatic
18:22 --> 18:25so individuals who have smoldering multiple
18:25 --> 18:28myeloma meet that strict cutoff of 10%
18:28 --> 18:31involvement of bone marrow but
18:31 --> 18:33are really otherwise asymptomatic,
18:33 --> 18:36meaning they don't have anemia,
18:36 --> 18:38they have preserved kidney function,
18:38 --> 18:41their calcium levels are within normal range,
18:41 --> 18:44they don't have any bone pains or what we
18:44 --> 18:47call lytic lesions or holes in their bones,
18:47 --> 18:49and so these people we would really observe.
18:49 --> 18:52But they have a higher risk of
18:52 --> 18:53progression to symptomatic multiple
18:53 --> 18:56myeloma that would need treatment.
18:56 --> 18:57Wait a minute, wait a minute.
18:57 --> 19:00So how do these people with
19:00 --> 19:01smoldering multiple myeloma
19:01 --> 19:04present if they don't have anemia?
19:04 --> 19:05They don't have any
19:05 --> 19:07abnormal kidney function.
19:07 --> 19:09How do you see them?
19:09 --> 19:13Yeah, so a lot of times these individuals
19:13 --> 19:15are referred because they had a blood
19:15 --> 19:18test done and that was what we call
19:18 --> 19:20a comprehensive metabolic panel that
19:20 --> 19:22included a total protein and they
19:22 --> 19:25were noted to have a total protein
19:25 --> 19:27that was elevated and so their primary
19:27 --> 19:29care physician picked up that the
19:29 --> 19:32total protein was high and then sent
19:32 --> 19:34them for further evaluation for an
19:34 --> 19:36issue such as a monoclonal protein.
19:36 --> 19:38So that's one way we often will see
19:38 --> 19:43these individuals, another is that monoclonal
19:43 --> 19:45gammopathy's and multiple myeloma can
19:45 --> 19:48be associated with other medical problems,
19:48 --> 19:51for example as serum protein electrophoresis,
19:51 --> 19:54which is the blood tests that we do
19:54 --> 19:57as part of the evaluation for myeloma
19:57 --> 19:59is often done an evaluation for
19:59 --> 20:01secondary causes for osteoporosis,
20:01 --> 20:04so sometimes patients will have it done as
20:04 --> 20:08a work up if they are have osteoporosis at
20:08 --> 20:11a younger age.
20:11 --> 20:13We also can see neuropathy,
20:13 --> 20:15so that's kind of numbness and tingling
20:15 --> 20:17in the extremities in patients who
20:17 --> 20:19have come up with these as well and
20:19 --> 20:21so sometimes a neurologist as part
20:21 --> 20:23of a work up for other reasons for a
20:23 --> 20:25patient to have a peripheral neuropathy
20:25 --> 20:27will send these studies,
20:27 --> 20:29so that's how a lot of these
20:29 --> 20:30patients present to us
20:30 --> 20:34if they don't have any other organ damage.
20:34 --> 20:37So these people with smoldering
20:37 --> 20:39multiple myeloma
20:39 --> 20:41still could have symptoms, right?
20:41 --> 20:43They could still have this
20:43 --> 20:44peripheral neuropathy,
20:44 --> 20:46or they could still have osteoporosis,
20:46 --> 20:48but they just can't have the other
20:48 --> 20:51things that you mentioned, right?
20:51 --> 20:53The anemia, the kidney function,
20:53 --> 20:55the lytic lesions of the bone?
20:55 --> 20:56Do I have that right?
20:56 --> 20:57Yeah, that's
20:57 --> 20:58right. So they can't really have
20:58 --> 21:00what we call this end organ damage.
21:00 --> 21:03You know our classification between
21:03 --> 21:05smoldering myeloma and myeloma
21:05 --> 21:07has changed over the years,
21:07 --> 21:10and we now also have a set of criteria
21:10 --> 21:13that I call my myeloma defining
21:13 --> 21:15events which don't have to be organ
21:15 --> 21:17damage but just a kind of a significant
21:17 --> 21:20amount of disease burden, and we will
21:20 --> 21:22treat those individuals as myeloma,
21:22 --> 21:24even if they don't have any of the other
21:24 --> 21:26classic symptoms you just mentioned.
21:26 --> 21:28So really, we're looking for a significant
21:28 --> 21:30involvement of the bone marrow,
21:30 --> 21:32and we classify that as over 60%
21:32 --> 21:35involvement or a very significant
21:35 --> 21:38serum free light chain burden.
21:38 --> 21:40And for those individuals we will treat them
21:40 --> 21:41as multiple myeloma,
21:41 --> 21:43even if they don't have those classic
21:43 --> 21:45end organ damage that we mentioned.
21:46 --> 21:49What does treatment entail?
21:49 --> 21:51Yeah, so treatment for a
21:51 --> 21:54newly diagnosed patient is
21:54 --> 21:57a combination of drugs.
21:57 --> 21:57Typically what you would
21:57 --> 21:58consider chemotherapy.
21:58 --> 22:02So we often refer to it as frontline
22:02 --> 22:04or induction chemotherapy,
22:04 --> 22:07as we're trying to induce a response.
22:07 --> 22:09The treatment typically consists
22:09 --> 22:11of a combination of three
22:11 --> 22:13or four drugs and the determination
22:13 --> 22:16of how many drugs and which drugs
22:16 --> 22:18are often based on a few different
22:18 --> 22:21patient specific factors in addition
22:21 --> 22:23to disease specific factors.
22:23 --> 22:25And so when we talk
22:25 --> 22:26about patient specific factors,
22:26 --> 22:29we really look at a patient and ask
22:30 --> 22:32the question, how well do we think
22:32 --> 22:34this individual could tolerate the treatment?
22:34 --> 22:38What is their fitness?
22:38 --> 22:40We don't necessarily look at
22:40 --> 22:42age but kind of the overall person.
22:42 --> 22:44What are their other medical problems,
22:44 --> 22:45their comorbidities?
22:45 --> 22:49What medications are they taking?
22:49 --> 22:51Do they have heart dysfunction
22:51 --> 22:52at baseline?
22:52 --> 22:54Do they already have a neuropathy
22:54 --> 22:55that's pretty severe?
22:55 --> 22:58And then we look at the myeloma itself,
22:58 --> 23:00meaning for every bone marrow
23:00 --> 23:02biopsy that we do,
23:02 --> 23:04we also send a study called cytogenetics
23:04 --> 23:07and that is the study of
23:07 --> 23:09chromosomes within that plasma cell.
23:09 --> 23:10So we're really looking to see
23:10 --> 23:12if there is any rearrangements.
23:12 --> 23:14Additions, deletions,
23:14 --> 23:17breaks and by utilizing these
23:17 --> 23:19cytogenetic testing,
23:19 --> 23:21we determine if someone is considered
23:21 --> 23:24high risk or standard risk and that
23:24 --> 23:26influences which treatment we give.
23:27 --> 23:29And so what is the difference
23:29 --> 23:31between a high risk and a standard
23:31 --> 23:33risk patient in terms of treatment?
23:33 --> 23:35I mean is it more drugs?
23:35 --> 23:37Is it more duration?
23:37 --> 23:39Is it more toxic?
23:39 --> 23:41Yeah, so it's not necessarily
23:41 --> 23:42more drugs. Fortunately,
23:42 --> 23:45in multiple myeloma most of our drugs
23:45 --> 23:48are very targeted to the plasma cell,
23:48 --> 23:50but it may just be a
23:50 --> 23:52different type of drug.
23:52 --> 23:55So it may consist of four
23:55 --> 23:58drugs versus a 3 drug regimen.
23:58 --> 24:00You know there's still a lot
24:00 --> 24:02of research being done to see
24:02 --> 24:03what is truly the best regimen
24:03 --> 24:04for high risk individuals,
24:04 --> 24:07and there's a lot of different
24:07 --> 24:08opinions out there,
24:08 --> 24:09but it's usually going to be
24:09 --> 24:10a four or three drug regimen
24:10 --> 24:11with potentially one difference
24:11 --> 24:13in one of the medications.
24:15 --> 24:18And as we think about
24:18 --> 24:21multiple myeloma and how you treat it,
24:21 --> 24:24it seems to me that
24:24 --> 24:27part of this has to do with how advanced
24:27 --> 24:30the myeloma is in terms of how much of
24:30 --> 24:32the bone marrow is actually involved,
24:33 --> 24:35whether there's end organ damage,
24:35 --> 24:38health, how fit the patient is, and so on.
24:38 --> 24:41All of which makes me wonder about
24:41 --> 24:45how important it is to get to a doctor
24:45 --> 24:47as soon as you have those symptoms,
24:47 --> 24:50how important it is to come to
24:50 --> 24:53get diagnosed early versus late?
24:53 --> 24:54I mean certainly that's something
24:54 --> 24:56we talk about in a lot of cancers,
24:56 --> 24:59but it sounds like in multiple myeloma
24:59 --> 25:01there's really no real screening tests.
25:01 --> 25:04No recommendations for annual blood work,
25:04 --> 25:04for example.
25:04 --> 25:07So does that really play a role?
25:07 --> 25:09Or does it not matter as much?
25:10 --> 25:12Yeah, so in multiple myeloma
25:12 --> 25:15as in a lot of the hematological
25:15 --> 25:15malignancies
25:15 --> 25:20we don't stage it as we do our
25:22 --> 25:24solid tumors and
25:24 --> 25:27we don't talk about metastasis and
25:27 --> 25:30so really the amount of bone marrow
25:30 --> 25:33involvement doesn't play a role in what
25:33 --> 25:36we decide to do for upfront treatments.
25:36 --> 25:38So our staging is really based
25:38 --> 25:40on blood work and we
25:40 --> 25:42will often treat someone who is
25:42 --> 25:44say a stage one versus stage three,
25:44 --> 25:47very similarly because we have very
25:47 --> 25:49effective drugs in the first line setting.
25:49 --> 25:51But obviously we would want
25:51 --> 25:53to seek medical attention
25:53 --> 25:54if you had any symptoms,
25:54 --> 25:57because say you present with kidney
25:57 --> 25:59dysfunction, renal failure that
25:59 --> 26:02does limit some of the treatments
26:02 --> 26:04that we could give up front.
26:04 --> 26:07And obviously if you start to have bone pain,
26:07 --> 26:09you want to seek medical attention
26:09 --> 26:11because you wouldn't want to end
26:11 --> 26:12up with a pathological fracture.
26:12 --> 26:14So we do encourage people if
26:14 --> 26:16they have any symptoms to really
26:16 --> 26:17seek medical attention.
26:19 --> 26:21And the sooner you are diagnosed,
26:21 --> 26:23the potentially more treatment options
26:23 --> 26:25you have and the better shape you
26:25 --> 26:27will be in to tolerate treatment.
26:28 --> 26:30The other thing that you mentioned,
26:30 --> 26:31which I think is something that
26:31 --> 26:33it's important that we pick up on,
26:33 --> 26:34is that you said that the
26:34 --> 26:36treatments now are very effective.
26:36 --> 26:38So tell us a little bit about
26:38 --> 26:40prognosis of patients who are
26:40 --> 26:42treated with multiple myeloma.
26:43 --> 26:46Fortunately we have keep
26:46 --> 26:49moving our overall survival and
26:49 --> 26:51the percent surviving at five
26:51 --> 26:54years each year thanks to the
26:54 --> 26:56development of newer treatments.
26:56 --> 26:58And so it used to be,
26:58 --> 27:00several years ago, say in 2005,
27:00 --> 27:02if we were giving this talk,
27:02 --> 27:04we would talk about an overall
27:04 --> 27:06survival of two to five years
27:11 --> 27:13and so more recently we say
27:13 --> 27:15five to 10 years and we're now
27:15 --> 27:16talking about potentially
27:16 --> 27:19moving that to 10 to 15 years.
27:19 --> 27:21If you look at the most recent
27:21 --> 27:23data in the United States regarding
27:23 --> 27:25the percentage of patients that
27:25 --> 27:27are alive at five years,
27:27 --> 27:29it's about just over 55%.
27:29 --> 27:30So, very encouraging.
27:31 --> 27:33That's really great, and I guess
27:33 --> 27:35that leads me to my next question,
27:35 --> 27:37which is what are the exciting
27:37 --> 27:39advances that are going on in
27:39 --> 27:41terms of multiple myeloma research.
27:41 --> 27:44How are you and others trying to move
27:44 --> 27:47the ball even further down the field?
27:47 --> 27:49That's a great question.
27:49 --> 27:51There is so much exciting research
27:51 --> 27:53being done here at Yale and within
27:53 --> 27:55the field of multiple myeloma.
27:55 --> 27:57And really at all stages.
27:58 --> 28:01Right now we often will refer to multiple myeloma
28:01 --> 28:04as a cancer that is treatable
28:04 --> 28:06but not curable.
28:06 --> 28:08So we're currently looking at
28:08 --> 28:10ways to improve that frontline
28:10 --> 28:11therapy maintenance therapy,
28:11 --> 28:14in individuals who have relapsed refractory.
28:15 --> 28:17The most exciting things are
28:17 --> 28:19probably the development of CAR T
28:19 --> 28:20which recently gained FDA approval
28:20 --> 28:23and in addition to looking at the
28:23 --> 28:25biospecific antibodies which are
28:25 --> 28:26currently in clinical trial.
28:27 --> 28:29Doctor Terri Parker is an assistant
28:29 --> 28:31professor of medicine and hematology
28:31 --> 28:34at the Yale School of Medicine. If
28:34 --> 28:35you have questions, the address is
28:35 --> 28:38cancer answers at yale dot edu
28:38 --> 28:40and past editions of the program are
28:40 --> 28:42available in audio and written form at
28:43 --> 28:44yalecancercenter.org.
28:44 --> 28:46We hope you'll join us next week to
28:46 --> 28:47learn more about the fight against
28:47 --> 28:49cancer here on Connecticut Public
28:49 --> 28:51radio funding for Yale Cancer
28:51 --> 28:53Answers is provided by Smilow Cancer
28:53 --> 28:55Hospital and AstraZeneca.

Information

Blood Cancer Awareness Month with guest Dr. Terri Parker September 5, 2021 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095