Scientists are tapping the entire adult population of Iceland for a clinical test for treatments for multiple myeloma, a blood cancer. An expert explains the disease and how a whole country is pitching in to fight it.
- Dr. Brian Durie, Chairman, International Myeloma Foundation
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Nancy Benson: Virtually any kind of cell in the body may start growing out of control. Cancer is the result. It can even happen to the plasma cells in our bloodstream and bone marrow that are supposed to keep us well. When that happens, multiple myeloma is the result.
Dr. Brian Durie: These are the cells which are part of the immune system. These are the cells which produce antibodies typically against infection, and so it’s really a cancer of the immune system, of the immune cells in the bone marrow.
Benson: That’s Dr. Brian Durie, chairman of the International Myeloma Foundation.
Durie: It’s a bone marrow cancer, which is similar to leukemia, but the difference with myeloma is that the malignant cells build up in the bone marrow and damage the surrounding bone. And so the complications emerge from bone damage such as a fracture of your back or arm or leg and so this is painful and quite problematic for someone who is afflicted with myeloma.
Benson: The American Cancer Society estimates that about 30,000 people in the United States will be diagnosed with multiple myeloma this year, and that a little more than 12,000 will die of the disease. Durie says the “multiple” part of the name tips off one way it’s not the same as most other cancers. And it makes living with the disease difficult.
Durie: It’s a little bit different than for example breast cancer, where you might have a lesion and then maybe later on you might get some other lesions. But right from that outset myeloma is characterized by having more than one multiple lesions in different parts of the bones and so this is particularly problematic. You can have a problem in your back or arm or leg or elsewhere. Because of the central involvement of the immune system a patient can present with an impaired immune system and have susceptibility to infection, which means that they might have had a couple of episodes of pneumonia or maybe a kidney infection, bladder infection something like that so that can be a problem. As the cells build up in the bone marrow there can be decreased blood production and so anemia with tiredness and fatigue related to anemia can be an issue at the point of diagnosis. And since the back is the area typically infected, low back pain is one of the commoner presenting features.
Benson: However, back pain is extremely common and can occur for all kinds of reasons. Myeloma is usually far down the list, if it’s on the list at all, so it may go undiagnosed for some time.
Durie: This is definitely one of the issues. So that’s why we now have a focus on trying to diagnose earlier and with this educational process to diagnose earlier and then if you intervene earlier you would have a better chance of getting rid of all the cells and avoiding the emergence of resistant cells, which is the problem and what results in these relapses where the remission only lasts because the resistant cells are starting to kick in.
Benson: Durie says that’s a major problem in treatment of multiple myeloma—patients may get a very good response initially, but within a year or two, the disease often relapses as resistant cells take over. Close monitoring of patients is extremely important, and treatments may need to be changed. Fortunately, new therapies are arriving.
Durie: We have been most fortunate in that in recent years in the past decade several novel therapies have been introduced that allow us to have a high chance of success in treating this disease. Now what we’re going to get into I think maybe is how we want to be able to start curing the myeloma, but where we’re at right now is if a patient is diagnosed we have a 95 percent chance that we can advise therapy that will bring the disease under control, control the disease, achieve a remission for several years. It used to be that expectation was maybe for two, three, four years. Here in 2017 that expectation is more like four, five, six, seven years. So we’ve doubled that expectation with the introduction of what we call these novel therapies.
Benson: Interestingly, some of the new treatments for this immune disease turn the rest of the immune system against the cancer.
Durie: One of the most recent and most effective novel therapies is an agent called deratumumab. The commercial name is Darzalex and this is a monoclonal antibody. The monoclonal antibody is directed against a surface molecule called CD38, which is predominant on the myeloma cells. So this is a targeted immune therapy.
Benson: Clinical trials to test new therapies and new detection techniques are taking an unusual path… recruiting an entire country to do it—Iceland, population 330,000.
Durie: The size of the country is very favorable, which means that the susceptibility to myeloma is in patients who are over the age of 40. So in Iceland there are 120,000 people over the age of 40. So this is a large number, but it’s a manageable number where we can screen using a blood test and see if they have early myeloma. So that gets to this point, if you can diagnose it early then you can start to cure the disease.
Benson: The health system in Iceland lends itself to this kind of project as well.
Durie: Individuals in Iceland are part of a healthcare system where they get an annual checkup and they do mostly get a blood sample drawn, which means that we can use that blood for our screening process. So this is very helpful. In addition we do have the medical health records on all of these individuals so that we can check their medical background and we can also try to figure out why in the world do they get myeloma. Because we know where they live, we know their occupation, we know their prior health history, and we know their family health history. There has also been genetic testing of the people in Iceland, so they have their DNA sequence checked so we have the predisposition DNA background on all of these individuals.
Benson: All of that information—genetic, occupational, and family history data—will be ready when blood samples start to turn up people at risk of developing myeloma. Those are people who have a monoclonal protein called mgus (“m-gus”) in the blood.
Durie: What we know is that this will ultimately turn into myeloma but not in every case. So what we will learn in Iceland is which patients go from this early mgus stage into the myeloma. So then this will allow us to intervene with the curative therapy at the correct stage, so that we don’t want to treat patients who have a benign mgus. The key thing that we’re researching is which of those mgus patients are progressing to something called smoldering myeloma, which is the next stage, and then turning into the active myeloma. So from Iceland we can carefully characterize these patients and say, ah ha, this is the patient who needs to be treated early and is going to be curable.
Benson: As many as one percent of people with mgus will progress to myeloma each year. Durie hopes the Icelandic trial will help doctors cut that proportion dramatically.
You can find out more on the International Myeloma Foundation’s webpage at myeloma.org, or through a link on our website, radiohealthjournal.net.
Our production director is Sean Waldron.
I’m Nancy Benson.