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Dr. Ola Landgren Of Memorial Sloan Kettering Discusses MRD Testing As An End Point For Treatment And Research

8/26/2017

Dr. Ola Landgren of Memorial Sloan Kettering Cancer Center in New York was the myeloma expert guest on Cure Talks 8/31/17 program. CLICK HERE to listen to this Cure Talk, and his answers to questions provided by the Cure Panel and listeners.

MRD testing just may be one of the most important initiatives in the area of treatment and research for myeloma, and Dr. Landgren has been at the very forefront of its development. Can MRD be used as a new endpoint for treatment??

One thing that has hindered progress in myeloma treatment is the lack of a test for myeloma which had the potential to be used as an indicator of disease cure. We had M spike tests, light chain tests, and bone marrow tests, all of which we came to understand were not sensitive enough to ensure the myeloma was truly gone. Other diseases like leukemia had MRD(minimum residual disease) tests, which were sensitive enough to be used as a confirmation that your disease had been eliminated if you were MRD negative. The treatment had been successful in eliminating the leukemia and there was a high probability if it stayed that way for 5 years, you were in fact cured. No such test has been developed for myeloma, and being incurable treatments were thought in most cases to allow an undetected residual cancer to remain in your bones and bone marrow. We were never told we were in remission which would lead to cure, we were told we had a CR(complete response) and later with improved testing a sCR(scringent complete response). However, the many new drugs and drug combinations have improved the depth of response to treatments and a more sensitive test was now felt to be of far more valure. In Europe, they had been working on tests which would have much greater accuracy, with the hope of duplicating the success MRD testing had achieved with leukemia.

Both the MMRF and IMF have been working with the worlds myeloma specialists community to develop a test which will be able to perform to levels sensitive to find 1 in 1 million plasma cells in the detection of myeloma cells in the bone marrow. It is felt if we can do this and absent of bone lesions, where myeloma can hide outside the marrow, this may just be the measure we have been looking to achieve.

Dr. Ola Landgren providing us with his knowledge and incites into myeloma testing and MRD test development, differences in MRD accuracy, types of MRD tests, as well as the limitations of testing of the bone marrow and its heterogeneity. Please do listen to his entire broadcast because MRD will become a key part of the new future of myeloma treatment and cure.

Good luck and God Bless your Myeloma Journey/ [email protected]

For more information on multiple myeloma CLICK HERE and you can follow me on twitter at: https://twitter.com/grpetersen1

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Multiple Myeloma 2017 Update - Why Do People Beat the Average Myeloma Life Expectancy Prognosis? Or How To Improve Your Multiple Myeloma Survival Rate!

8/16/2017

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A newer 2020 version of this post can be viewed if you CLICK HERE! I updated this post more than two years ago, and it has been very helpful to many in the myeloma patient community One thing has become very clear to me, the pace of change and progress for myeloma has become exponential. This is a very good thing! We have had 4 drugs approved for myeloma since 2015 (two are new classes of drugs).

In this period, myeloma approvals have been 13 times greater than the average cancer. I can only say thank you to the researchers, drug companies, myeloma specialists, clinical trial patients, and advocates for such an outstanding achievement. Nothing less than an ALL STAR performance. In addition, the pipeline is packed with new drugs, CAR T, checkpoint inhibitors, MIL's and initiatives to treat as early as practical. As a patient advocate I find it nearly impossible to keep up with the avalanche of new data. I can not see how anyone but a skilled myeloma specialist can keep up to date with this rapid pace of change. But Dr. Lonial, a world class myeloma specialist from Emory University, says it best: CLICK HERE to view his advice.

In the last two years, the average life expectancy has gone from 4 years to 5.5. years, according to The SEER(Surveillance, Epidemiology, and End Results) data for multiple myeloma published in April of 2017 by the National Cancer Institute. This is outstanding progress in that life expectancy had been stagnant at 4 years for 5 consecutive years. Some patients beat the odds and live 10 to 20 years or more. When I was first diagnosed, the data for a person with dialysis-dependent kidney failure was just 3 months, and the average for myeloma patients overall was about 3 years. Now, I am beyond thankful to be an 11 & 1/2 year survivor. I believe there are three critical components to beating the odds: Part one is early diagnosis and treatment before end organ damage. Part two is disease dependent, or the hand that you were dealt. Part three is related to the level of care that is available to you. For more information on survival rates and life expectancy CLICK HERE.

Part 1 - Early Diagnosis and Treatment

If you are lucky enough to have a general practitioner who picks up high protein in the blood and finds the disease early while it is smoldering, or stage one, you have won the Myeloma Lottery. Life expectancy of stage one disease is 3 times greater than if you have been found in stage three. Treatment guidelines were published in November of 2014 with the express purpose of finding and treating the disease before it has progressed and causes end organ failure. A National Institute of health article states the intent of this clearly; "The concept of initiating therapy after end organ damage is analogous to initiating treatment after the development of metastatic cancer in solid tumors. Indeed, screening, early detection and intervention have played a large part in the major curative advances that have been achieved in solid tumors whereas metastatic cancer remains incurable in these same malignancies. It is, therefore, not surprising that MM remains incurable, in spite of all the advances in therapeutic interventions. Could it be because we are waiting too long – until metastatic myeloma occurs – to treat our patients? In such a condition, watchful waiting may actually be more harmful to the patient than early intervention."  To read the whole article CLICK HERE! If you are one of the lucky ones who are found in the early stages of active myeloma or smoldering myeloma, you will have the luxury of time to understand the treatment options, find a myeloma specialist (a must), and plan to confront your disease before permanent end organ damage. Dr. Rajkumar of Mayo Clinic did a wonderful job of explaining the new criteria for myeloma diagnosis, and you can read it if you CLICK HERE. Dr. Irene Ghobrial is doing some great work to follow MGUS and smoldering stages of the disease, to develop treatments to cure, or at least prevent end organ damage. CLICK HERE to view a myeloma crowd interview with Dr. Ghobrial on the subject. Just as a note, the country of Iceland is testing all of its adult population over 40 to screen for MGUS, Smoldering, and active myeloma. They call it iStopMM, a clinical trial supported by the IMF(International Myeloma Foundation). This is a future I pray we will all see where we could cost effectively find MM early and treat it before end organ damage. CLICK HERE or HERE to learn more about iStopMM.

Unfortunately, Myeloma UK has reported that 1 in 5 myeloma patients die within the first two months of diagnosis, and that it takes nearly a year from the first symptoms to diagnosis for 25% of newly diagnosed patients. Dr. Morgan of UAMS said it best when he outlined his thoughts on the subject of awareness and delayed diagnosis. He believes the fact that it takes 3 to 6 months and more often 6 months from first symptoms to diagnosis is a bit of a scandal.   To make real inroads in the myeloma we need to get it diagnosed early before we have organ involvement. We need to make family doctors and family practitioners more aware of the disease. They should do M spike and light chain tests on patients. This makes a lot of sense to Dr. Morgan. It is really tragic when patients develop renal failure when awareness of myeloma by a General Practitioner might have allowed the patient to get a consult or treatment from a myeloma specialist. A myeloma specialist is critical to a patient's long term care and survival. It is a disease that does not come on overnight but is years in the making. Patient organizations can make a difference.   Like with Smoldering, there might be a non toxic and safe treatment for MGUS which would be a chemo prevention program. He believe the future of Myeloma will be to get earlier diagnosis, safe treatments, chemo prevention strategy, regular screening for para protein, and early intervention. This is the future we are striving to achieve.

I have kidney damage, a good friend of mine has debilitating bone pain, others collapsed vertebrae, one suffers from a myeloma caused stroke, and many have died from delayed diagnosis. All of which might have been prevented with a simple test of light chains and M spike costing under $150 without insurance, and no cost if covered by insurance and referred by a General Practitioner. It is what could be!

Part 2 - Disease Dependent

Some people are just plain lucky and are given a form of myeloma that is not that aggressive. In other words they have myeloma, but it happens to be smoldering myeloma.   This form of the disease can be present in the patient but not show any outward symptoms. It can remain in this mode for 5, 10, or even 20 years.

The age of the patient is very important, in that you are 2 times more likely to survive if you were diagnosed at 49 years of age or less. The average age of the typical myeloma patient is 70. You can read more on this subject if you CLICK HERE.

Some people may have an active disease but do not have any of the negative prognostic indicators. These indicators include, but are not limited to, deletion of chromosome 17p and  translocation of 4;14 or 14;16 or 14;20. Your myeloma specialist will run the FISH test or other genetic tests like GEP(gene expression profiling) to determine if you have any of these negative prognostic indicators. If you are considered high risk(15% of patients) , the life expectancy is less than half of the current average, or just 2 years. You can read more about high risk multiple myeloma if you CLICK HERE.

The sensitivity of the disease to treatment is also important. My myeloma seemed to be very sensitive to the combination of Cytoxan, Thalamid and Dexamethasone, a treatment that put me into remission very quickly. Some people might have the same experience with Revlimid, Velcade, or Dex, or any combination of these drugs. If the disease comes back, as it often does, the re-application of the same regimen may continue to work for years. I know one patient who has taken Thalomid for years as his only treatment and remains in remission.

And of course if the average is 5.5 years, half of the people will invariably beat the average.

Part 3 - Quality of Care

There are some elements that you may or may not have much control over, the first of which is the availability of insurance. If you do not have insurance or have no access to care, the average life expectancy is less than one year. However, Medicare has a Compassionate Allowance Program where you can be approved in less than two weeks if you go to your local office and can show that you will not live without care. To see the program CLICK HERE. The Affordable Care Act may provide an option for the 15% who are not insured, and Medicare, Medicaid, and drug company assistance programs are also available. In addition, there are other programs which can provide assistance listed on the bottom of the home page, to view CLICK HERE.

Multiple Myeloma is a rare blood cancer, so many hematologist/oncologists may not see one patient in a year. As a result not all oncologists or hematologists are the same. However, some are very skilled and experienced with Multiple Myeloma and have treated many myeloma patients. The data shows these myeloma specialists provide an average life expectancy of 10+ years or more, compared to the average which is at 5.5 years.

For a listing of these exceptional specialists CLICK HERE or for a more extensive list without survival history just CLICK HERE. I chose to get my SCT(stem cell transplants) at University of Arkansas for Medical Sciences, UAMS, which has a myeloma program called MIRT, Myeloma Institute of Research and Therapy. At the time they had over 10,000 transplants under their belt, and as a result they were expert at the process, and knew what could go wrong and had a plan in place to get you through any potential complications. I have found from my work on this site that centers like Mayo, Dr. Hari(Medical College of Wisconsin), UAMS, or Dr. Berenson's (IMBCR) have very different approaches to treatment, but because they are expert in what they do, they have similar results. You would choose a brain surgeon over any other surgeon if you had a brain tumor, why would you not do the same for myeloma? Find out how to find a myeloma specialist by CLICKING HERE or CLICKING HERE .

Myeloma specialists have access to drugs that other oncologists do not. Because they are the thought leaders, they are involved in clinical trials, and can obtain some drugs through other programs that lesser known oncologists do not have access to. Worse yet, oncologists who are not myeloma specialists may not even know that some of these drugs even exist. For example, some of the well connected specialists have access to drugs or treatments like CAR T, MILs, Venetoclax or Selinexor which are not approved treatments. But these experts can get approval for initial therapy through clinical trials or other programs. Or some specialists can use drugs that are only approved for relapse or secondary therapy options (Daratumumab, Ixazomib, Krypolis and Pomalyst), and obtain approval to use them for newly diagnosed patients. They also have access to the best clinical trials like KRDD(Krypolis, Revlimid, Darzalex, & dexamethasone) for first line therapy which provides a response in 100 percent of patients. When you run out of options with the currently approved drugs, they can provide access to those that have done great in clinical trial, but are not currently available to the general public. Because you need a significant infrastructure to conduct clinical trials at your facility and they cost the facility $15,000 per patient, few local oncologists have access to clinical trials. Sometimes it is who you know!

Myeloma patients seldom die from myeloma, they die from the complications from myeloma. The number one complication is pneumonia, and others include infections, kidney failure, anemia, etc. This, therefore, brings me to the realization that supportive care for the treatment of the many complications of this disease may just be as important as the cancer treatment itself. Or a great Defense(supportive care) is as important as the Offense(cancer therapy). MD Anderson and Mayo Clinic emphasize supportive care in their programs, UAMS actually has a Director of Supportive Care in their myeloma program, and Dr. Elias Anaissie, the Director of the Myeloma Program at the University of Cincinnati Cancer Center, has an extensive background in supportive care. Dr. Anaissie has published a well written example of an exceptional supportive care model. You can read this publication if you CLICK HERE. To read my blog post on supportive care CLICK HERE.

I also think the quality of care that you receive can be affected by the knowledge of the patient, and this can be obtained by doing your research on finding the best approaches to care by looking at the work of the best myeloma specialists on-line, and by going to great sites as listed in the Resource Section of www.myelomasurvival.com. To find out how to get educated about multiple myeloma CLICK HERE. In addition, joining a support group of the International Myeloma Foundation or the LLS (Leukemia, Lymphoma, and Myeloma Society) will provide more great information to improve your life expectancy. I have found that the average life expectancy of most of these support groups far out-performs the average. Knowledge is power! Additional information on the benefits of support group membership can be found if you CLICK HERE.

With 30,000 new cases of multiple myeloma in the USA, we can estimate the total number of patients in just the USA at 165,000. If we can move the average life expectancy from 5.5 years to 11 years by having myeloma specialists guide your care, we could save 165,000 times 5.5, or 907,500 years of LIFE. Many times more if we include the entire world. You all can help by getting this message out to the myeloma patient community though Facebook and Twitter. Everyone knows someone who has myeloma or may have a friend or family member that can be helped by this information. With your help we can "SAVE LIFE"!

Good luck and God Bless your Myeloma Journey/ [email protected]

For more information on multiple myeloma CLICK HERE and you can follow me on twitter at: https://twitter.com/grpetersen1

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Can We Dream? Can Myeloma Reduced Kidney Function Be Recovered?

8/8/2017

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Dr. Ketan (Edward Scissorhands) Badani

First an update on my kidney tumor removal. Dr. Katan (Edward Scissorhands) Badani of Mt. Sinai is one of 5 or so doctors in the US who has completed 3000 kidney resection surgeries using the Da Vinci Robotic Surgery. If practice makes perfect, Dr. Badani should be able to do a kidney resection in his sleep. That is why I went from Wisconsin to New York for this procedure. I have chosen, if possible, to never leave a complex disease or procedure in the hands of anyone other than an expert in his field. So the result, the tumor was removed with good margins, and initial indications are I have not lost much, if any, kidney function. My daughter Andrea said the doctor indicated the tumor in her words, not his, was "really gnarly". I will find out after 1 week whether the tumor was malignant, but even if with good margins, Dr. Badani says any cancer is gone. If you have kidney insufficiency(mine caused by myeloma) this type of tumor is far more likely to develop than if you have normal kidney function. Secondary myeloma cancer, cancer aggravated by myeloma kidney insufficiency, or just chance, who knows?

One of my major concerns was my kidney function is marginal at best, and surgery could make it even worse, to the point that I would need to resume dialysis. My original diagnosis was multiple myeloma with "end stage renal disease, with a life expectancy of just three months. I spent two years on dialysis, until my kidney function miraculously recovered to the point where I could discontinue it. Typically kidney resection will result in a 20% reduction in function in the affected kidney and 10% reduction overall. This is caused both by the removal of some good kidney tissue so the surgeon can get clean margins and what is known as ischemia time where blood flow is cut off to prevent bleed out during the tumor removal and repair. Doctors try to keep this time down to 10 to 20 minutes, but in 10% to 15% of cases the time is too long and the kidney tissue dies, forcing the removal of the entire organ. Dr. Badani has developed a procedure to cut down on ischemia time, named FAST, which he teaches to other doctors around the world. Using this process he kept my ischemia time at just under 9 minutes.

The second most exciting development during my visit was Dr. Badani asked me if I wanted to be part of a clinical trial. Dr. Badani is on a mission to find a way to regenerate kidney function in patients undergoing resection so they lose no function overall. How is this possible? In the clinical trial, Dr. Badani is using a material called AmnioFix, which has been to show to have regenerative characteristics in preliminary animal studies and in other areas of surgery and orthopedics. If it proves successful, this development could eventually lead to help for myeloma patients with kidney insufficiency--whether they need kidney resection or not. The need is critical since we usually can't be approved for kidney transplants or are pushed low down on the priority list. The clinical trial has 45 pages and I did a little cut and past to provide a peak into it (It isn't posted yet on clinicaltrial.gov:

Onset chronic kidney disease (CKD) is a significant risk associated with radical nephrectomy as a treatment for renal cell carcinoma.[1 2] PN is a safe alternative for the treatment of renal cell carcinoma (RCC) that mitigates this risk.[3] While PN reduces the risk of CKD, PN does result in a reduction in renal function. In a literature review of the etiology and prevention of renal function decline following PN, Mir and colleagues found that within the first few weeks to several months following PN, estimated glomerular filtration rates on average in the operated kidney are reduced by 20% and in patients with two kidneys, global kidney function is reduced by 10%.[4] After this period of renal function decline following PN (~first 3 months), renal function is maintained constantly.[5]
A primary determinant in the loss of renal function following PN is a loss of renal parenchymal volume associated with the procedure. Specifically, loss of renal parenchymal volume during PN results from excision of the tumor and surrounding tissue to avoid positive surgical margins in addition to renal tissue necrosis resulting from damage associated with reconstruction of the kidney. Results from seven series demonstrate that the median percentage of parenchymal volume lost from PN is 17% (Range: 10-21.4%).[6-13] These studies furthermore demonstrate that the loss of renal parenchymal volume is the strongest and most significant predictor of reduced renal function following PN. [6,9,10] In a study by Lane and colleagues, it was found that when controlled for surgical factors (e.g., ischemia time, blood loss), tumor factors (e.g., size, interpolar location) and patient factors (e.g., age, gender, preoperative GFR) every 10% of renal parenchyma spared increased GFR by 0.89 ml per minute per 1.73m2.[7] In a similar study controlled for age, BMI tumor location, tumor size, operative method (laparoscopic, open), protuberancy and warm ischemia time, Song et al. found that for every 1% reduction in renal parenchymal volume, postoperative GFR decreased by .95 ml per minute per 1.73m2.11 Thompson et al. also found that for every 5% increase in renal parenchyma volume preserved, risk of de novo stage IV CKD decreased by 17% when controlled for preoperative GFR and warm ischemia time.[12]
In summary, AmnioFix®’s anti-inflammatory, anti-scarring, regenerating and healing properties have been evidenced in its ability to facilitate recovery of the neurovascular bundle following radical prostatectomy. We hope to further expand on these findings by extending the use of AmnioFix® to the regeneration of renal parenchymal volume with the goal of recovering lost renal function resulting from PN. A randomized trial is necessary to understand whether AmnioFix® can be used to treat renal insufficiencies and a damaged renal parenchyma.

To think we could regenerate kidney function may be as outlandish as to consider myeloma to one day be curable. I am just thankful there are doctors like Dr. Badani who dare to challenge the impossible, and make it possible.

Good luck and may God Bless your cancer journey. For more information on multiple myeloma survival rates and treatments CLICK HERE and you can follow me on twitter at: https://twitter.com/grpetersen1

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Dr. Ola Landgren Of Memorial Sloan Kettering Discusses MRD Testing As An End Point For Treatment And Research

Multiple Myeloma 2017 Update - Why Do People Beat the Average Myeloma Life Expectancy Prognosis? Or How To Improve Your Multiple Myeloma Survival Rate!

Can We Dream? Can Myeloma Reduced Kidney Function Be Recovered?

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