Myeloma hope new treatment in the horizon Dr Amin Islam MB, MRCP UK , FRCPath UK Consultant haematologist and Haemato-Oncologist Southend University Hospital NHS Foundation trust Myeloma patients support group meeting 28th June 2016

myeloma Multiple myeloma (MM) is a mature B-cell neoplasm accounts for 13% of all hematologic malignancies an age-adjusted incidence rate of nearly 6 per 100 000 persons per year . primarily affects older individuals with a median age at the time of diagnosis of nearly 70 years.

define MM is defined by the presence of ≥10% of clonal plasma cells (PCs) in the bone marrow or a biopsy-proven extramedullary plasmacytoma) Evidence of end-organ damage attributed to the PC disorder (hypercalcemia, renal insufficiency, anaemia, and bone lesions If none above then it is smouldering/asymptomatic myeloma Watch and wait strategy still valid with trial provisions

Pet scan

hope Over the past decade, Median survival of myeloma patients has almost doubled From 4 to 8 years

improvements This remarkable improvement is mostly because of the use of high-dose therapy Followed by autologous stem cell transplantation (ASCT) Addition to the widespread incorporation of novel agents including immunomodulatary drugs (IMiDs; (thalidomide and lenalidomide) proteasome inhibitor (PI; bortezomib).

Newer drugs and more The arsenal of effective novel agents for patients with relapsed disease is constantly increasing Includes a next-generation IMiD (pomalidomide) –(not available in NHS anymore) Next-generation PIs (carfilzomib, ixazomib, oprozomib, and marizomib), Histone deacetylase inhibitor (panobinostat), Monoclonal antibodies (directed against CD38: daratumumab, isatuximab [SAR650984], and MOR202; or against SLAMF7: elotuzumab).

Current standard Fit and good PS VAD/VTD total 4-6 course Leading to ASCT Non responder-option of clinical trials and next line Relapsed setting:------ Revlimid and dexamethaone and try to ASCT Ponabinostat/valcade and dexamethasone( available as second line therapy)

unfit MPV MPT CTD a VD etc

Supportive care Bone care 2 years of Bisphosphonate therapy Spine care Infections Role of orthopaedic interventions Role of Radiotherapy

Clinical trials UK Role of clinical trials Newer drugs development

Myeloma 11 This trial has two treatment pathways; an intensive treatment pathway which includes high-dose therapy and stem cell transplantation for younger and/or fitter patients, and a non-intensive pathway for older and/or less fit patients. The trial is looking at the effects of lenalidomide, bortezomib and carfilzomib for newly diagnosed myeloma patients as induction, consolidation and maintenance treatments involving: Lenalidomide, cyclophosphamide and dexamethasone (CRD) as induction/initial treatment Lenalidomide, cyclophosphamide, carfilzomib and dexamethasone (CCRD) as induction/initial treatment Bortezomib, cyclophosphamide and dexamethasone (CVD) as consolidation treatment for patients who do not respond well to their induction/initial treatment Lenalidomide as maintenance treatment to control the myeloma further

Daratumumab, Revlimid and dexamethasone for newly diagnosed myeloma patients Treatments: Daratumumab Lenalidomide (Revlimid) Dexamethasone Myeloma stage: Newly Diagnosed Trial phase: III Summary: This trial is determining whether daratumumab in combination with lenalidomide (Revlimid) and dexamethasone is more effective than Revlimid and dexamethasome alone in newly diagnosed myeloma patients who are not eligible for high-dose therapy and stem cell transplantation.

Carfilzomib for newly diagnosed patients prior to stem cell transplant (CARDAMON trial) Summary: This trial is for younger and/or fitter newly diagnosed myeloma patients. It is determining whether patients should be given high-dose therapy and a stem cell transplant straight after their induction treatment, or if they have responded well, whether it is better to delay the high-dose therapy and stem cell transplantation until relapse. All patients in this trial receive carfilzomib maintenance treatment. This is also known as the CARDAMON trial.

Daratumomab in smouldering myeloma List goes on….. There are many more Daratumomab in smouldering myeloma List goes on….. Hope of cure not far from reality……..

Palliative care options Macmillan support and grants myeloma Lets talk Support groups Palliative care options Macmillan support and grants