May 7, 2011
The final day of this international meeting began with a comprehensive review of the latest International Myeloma Working Group consensus on criteria for diagnosis and treatment and retreatment of patients with multiple myeloma. In addition to discussing the importance of utilizing correct diagnostics, there were key discussions concerning the management of anemia, bone disease, vein thrombosis and the use of vaccination and infection prophylaxis.
Several abstracts of note were presented during the final plenary session, including:
- An Italian clinical trial that one compared the use of aspirin to low molecular weight heparin (enoxaparin) to prevent deep vein thrombosis in myeloma patients receiving Revlimid-based treatments, and found that both were similar in effectiveness.
- A Phase 3 trial from researchers in Sweden looked at the use of Velcade for consolidation after high dose melphalan and found that it appeared to prolong disease remission post stem cell transplant.
- Updated data from the MMRC-facilitated Phase 1 and 2 pomalidomide trial were presented by Dr. Paul Richardson; the data continue to show the promise of pomalidomide in working in some patients who are refractory to both Velcade and Revlimid.
- Updated data from the MMRC-facilitated Phase 2 carfilzomib trial, looking at heavily pre-treated patients, were presented by Dr. David Siegel. These encouraging results, showing efficacy in patients who had failed Velcade, could form the basis for an accelerated approval from the FDA in 2012.
- The final talk given by Dr. E. Libby on the declining rates of mortality in both the young and elderly. For the young, we saw an earlier decrease in mortality (starting in 1995) with the introduction of high dose chemotherapy followed by bone marrow transplant. However, this was not a treatment prescribed for those over the age of 65 because of the higher risk this posed for the population. The real shift for young and old started with the introduction of Thalomid. Once other new compounds like Velcade and Revlimid came to market, the decrease in mortality has been essentially equalized with lives being substantially prolonged regardless of one’s age.
On this last day, it was wonderful to see our very own Sara Tyghter address the Congress on behalf of the MMRF and MMRC. She graciously thanked the meeting organizers, physicians, nurses and most importantly the patients who make research possible by participating in clinical trials of high importance. Following this, there was a presentation by Dr. Kaz Shimizu who was setting the stage for the IMW Meeting in 2013 which will be held in Kyoto, Japan. In two years, so much can happen and so the excitement is already building for this meeting two years from now!
May 6, 2011
Day 3 of IMW began with an overview of treatments for newly diagnosed patients aged 65 and older. Several trials were presented, each with a slightly different approach to providing patients in this population with the best treatment while limiting toxicities. Overall, with the integration of newer agents like Velcade and Revlimid, we are now starting to see responses resembling those seen in younger patients who can tolerate tougher treatments - high dose chemo and transplants.
Additionally, several updates were provided regarding drug classes currently used to treat MM, specifically proteasome inhibitors and IMiDs. Data on carfilzomib, a second generation proteasome inhibitor which has been studied in four MMRC- facilitated clinical trials, continued to show very low incidence of PN (peripheral neuropathy) and responses in patients that have relapsed or are refractory to Velcade and/or Revlimid. Additionally, use of subcutaneous Velcade has been shown to reduce PN by approximately 50% while new oral formulations of proteosome inhibitors are currently in clinical trials which should provide a much easier route of administration when compared to intravenous delivery, including Millennium’s MLN9708. Pomalidomide, a more potent IMID, was also highlighted for its ability to overcome resistance to Velcade and Revlimid, as shown in trials facilitated by the MMRC and the Mayo Clinic.
Newer classes of drugs such as histone deacetylace inhibitors (HDAC) were highlighted for their ability to amplify Velcade’s activity and in some cases, overcome Velcade resistance. The MMRC participated in a key Phase 2 trial combining Zolinza, another HDAC inhibitor, and Velcade, as well as early trials of panobinostat, both of which are in Phase 3 clinical trials.
Monoclonal antibody therapy was also discussed. In particular, elotuzumab, which is entering a Phase 3 clinical trial in combination with Revlimid and dexamethasone, was also studied within the MMRC. This compound also helped amplify the effectiveness of Revlimid in the relapsed/refractory patient population. Other exciting monocolonal antibodies in earlier development include those targeting IL-6 and anti-CD38.
Perhaps the most highly anticipated session focused on the use of Revlimid maintenance. Encouragingly, for the first time, data from the US CALGB study showed an overall survival benefit. Grade 3 toxicities were reported for the Revlimid maintenance arm and were manageable. There continued to be an increase in the incidence of secondary malignancies in the Revlimid arm; however, given the survival benefit, the researchers presenting during this session agreed that, particularly for patients who did not achieve at least a very good partial response following high-dose chemotherapy and stem cell transplant, based on currently available data, the benefits do appear to outweigh the risks. It will be critical, however, to continue to follow these patients as well as those participating in other trials that combined Revlimid with melphalan to better understand the benefits and risks over time.
May 5, 2011
Day 2 kicked off a full day of sessions beginning with a discussion around the treatment of newly diagnosed patients who are not eligible for high-dose chemotherapy and stem cell transplant (SCT) with leading clinicians from around the world – US, France, Germany, Italy, Netherland, Spain and the UK sharing their individual perspectives. While treatment patterns differ by country, particularly because some treatments like Revlimid are not widely available outside the US for first-line treatment, encouragingly, when treatments like Revlimid and Velcade are used – regardless of the combination, we are virtually seeing everyone achieve a response though the depth and duration of response does vary between individuals.
So, the ongoing question remains whether, now that we have such highly effective combinations that include proteasome inhibitors and immunomodulatory agents (IMiDs) as backbone therapies, the high dose chemotherapy and SCT should remain as a standard treatment for younger patients (see tomorrow’s highlights for more discussion on this topic). And, as recently as the ASH meeting in December 2010, the impressive results in terms of delayed disease progression from the use of prolonged maintenance therapy post-SCT has given rise to more questions about whether we need to consider incorporating this into standard of care for patients. Possible answers may come out of a newly opened trial being led in the United States by one of MMRC’s member institutions – Dana-Farber Cancer Institute and in France, by the IFM. The IFM/DFCI randomized trial will enroll 1,000 patients in the US and France and will examine the role of high dose chemotherapy followed by SCT in the era of novel agents (is high dose chemo + transplant + novel agents needed, or not, to achieve a good level of response when compared to using novel agents alone?) and is maintenance therapy something we must seriously consider for use in future (is it effective or not at prolonging a patient’s initial response, regardless of the initial treatment and, for how long should it be administered?).
High risk myeloma was also covered in depth at this meeting with the MMRF’s Nature paper with sequencing results from the MMRF-funded Genomics Initiative once again garnering recognition for its contribution to our increased understanding of myeloma tumor cell biology. High risk presentations highlighted how complicated the MM biology really is – and not just at time of diagnosis as there can be multiple myeloma “clones” within one individual, and, as an individual’s disease progresses, new clones can emerge. New genomic discoveries have provided early direction in terms of druggable targets not previously explored in MM. Briefly, we can focus on drugs to address abnormalities of the BRAF cellular pathway and over-expression of a protein called MMSET which is clearly present in patients that have t(4;14) multiple myeloma. Although the myeloma tumor cell by nature is a ‘survivalist’, the only real way we can keep it at bay is by deepening our understanding of how it operates and have ready at hand all of the tools needed to overcome its peculiarities every step of the way.
May 4, 2011
Greetings from the XIIIth International Myeloma Workshop in Paris! The meeting kicked off on Tuesday with presentations on the biology and genetics of myeloma as well as bone diease, followed by the opening ceremony and presentation of the prestigious Waldenstrom’s Award. Overall, there continue to be advancements with regards to the understanding of cell biology in multiple myeloma; however, understanding classifications of various subtypes is still evolving. In the end, each one of us is unique and therefore will require tailored therapies. In this regard, the importance of focusing on mechanisms of various cytokines and mTOR pathways were highlighted. The MMRC is currently examining a novel mTOR (TORC-1 and TORC-2 inhibitor) with the INK 128 trial currently in Phase 1 and enrolling.
There was some interesting news for patients in the evolving field of bone disease. There were detailed presentations on the synergies between HDAC, HDACi and Velcade/Revlimid combination therapy (Zolinza (vorinostat)/Velcade in particular). We’re learning that there are synergistic effects on the ability to ‘turn on’ the osteoblasts (bone building cell mechanism) which in turn has negative effect on the myeloma tumor cells. In normal biology, we’re constantly building and deconstructing bone. Like the skin, the old is sloughed off to make way for the new. In multiple myeloma, the osteoclasts go into overdrive and break down more bone than normal. In myeloma, it’s thought that by healing the bones, the environment in which tumor cells thrive becomes less hospitable and this may have the additive effect of “flushing the fox out of the hole”. Clearly this frontier, although not entirely new with the introduction of biphosphonates back in the 90s, warrants more advanced research.
The MMRF was acknowledged by several speakers for the funding we’ve provided to support their work. Walter Capone, our COO, gave a comprehensive overview of the MMRF and MMRC highlighting all of our funding to date and clear stewardship of the funds we raise. Michael Kuehl, PhD, an old friend of the MMRF and myeloma community, deservedly received the Waldenstrom’s award and specifically highlighted Kathy Giusti, citing her for the enormous contribution she’s made to MM genomics and in particular, the recent Nature paper that detailed the genome sequencing of samples from the MMRC tissue bank as part of the MMRF’s Genomics Initiative. Stay tuned – busy day ahead and I look forward to sharing the updates with you.
February 21, 2011
Today, a patient diagnosed with breast cancer is most likely to be treated in one of three ways, as determined by a molecular analysis of her tumor. For a patient with lung cancer, treatment decisions are often informed by the existence of a specific genetic mutation known to make certain treatments more successful. In these and other cancers, multiple clinical trials are currently underway testing new medicines among genetically defined subgroups of patients.
In multiple myeloma, this kind of “personalized” clinical decision-making is not so advanced. We have made enormous strides in bringing new therapies to patients in the past decade – and in improving patients’ prognosis as a result – but there is still much to be done to advance our basic biological understanding of the disease and to tailor an individualized course of treatment.
In the near-term, we need answers to why some patients respond better than others to today’s medicines, and how we should respond when they develop resistance. Longer-term, we need a greater understanding of the biological changes that occur throughout the course of a person’s disease, in order to steer our clinical development efforts toward known mechanisms in multiple myeloma.
At MMRF and MMRC we are laying important groundwork toward these goals across the entire drug development continuum: supporting basic research to identify important molecular pathways that may be targets for drug development; advancing clinical development strategies that exploit this understanding; and organizing a community response that unites as many patients and physicians as possible to improve treatment for all.
Last week we previewed our long-term vision for personalized medicine in a half-day meeting with 40 of the leading minds in the field. We heard about the state of the art in cancer care from several perspectives – academic research institutions, community cancer centers, drug developers, diagnostics companies, IT companies, and others. We gained enormously helpful feedback that will be critically important to all of us as we move ahead.
As a group we also found many points of intersection that underscore the value in looking across the many forms of cancer, rather than segmenting our efforts. We talked about common pathways through which multiple cancers develop, where finding a way to intervene may have huge implications for several disease types.
I left the Roundtable more energized than ever about the progress we have already made against personalized medicine and the bold vision we will advance in the months to come. To do so we need patients’ support of this effort – specifically donating their tissue to our Tissue Bank – like never before. As a patient myself, I am truly excited at the prospect of helping to bring patients better, more personalized treatments, and I ask all those who can to join me by banking their tissue at their next bone marrow biopsy.