When reviewing the study info on Velcade administered subcutaneously, it notes that race was not considered since most of the participants were Caucasian. This issue troubles me particularly since my partner (who is south Asian) doesn't not seem to be responding adequately after over 5 cycles.
I would like feedback on the efficacy of Velcade and other regimens on non-Caucasians.
I did see one study posted on the Beacon that noted responses to novel therapies seems to be more favorable for Caucasians etc.
Given that multiple myeloma is twice as likely if you are African American, how is this issue affecting patients.
Why would the company not include African Americans in their study?
How do we know what can be efficacious for African Americans and other people of color?
Comments and feedback would be appreciated.
Forums
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Pari - Name: Pari
- Who do you know with myeloma?: Research on academic websites
- When were you/they diagnosed?: May 2014
- Age at diagnosis: 60
Re: Multiple myeloma treatment and race
Is there any reason based on science to consider that race might be a factor in the effectiveness of Velcade? I am not a doctor but I cannot see any reason why Velcade would work any differently in people based on race due to biological or genetic differences. These differences are very small to begin with. I suppose it is possible, but drug differences based on race are pretty rare as far as I know.
In the study you referred to you did not say all the participants were Caucasian and other races were excluded, just that most of the participants were Caucasian. There likely were African Americans and other races in the study, especially if the number of participants were large. Some of the smaller trials though have double or even single digit numbers of participants. I do not have the study so I do not know the numbers.
The majority of the population with myeloma is Caucasian because they are the majority of the population. Yes, African Americans are about twice as likely to get myeloma, but African Americans are still a smaller percentage of the population than Caucasians. I went to an MMRF myeloma symposium in San Francisco a few years ago that had about 300 people with myeloma in attendance. There were a good number of African Americans there, as expected, but they were not the majority.
Having said all that, though, I could see how there may be a disproportionate representation of races from the general population in clinical trials that’s root causes lies in the disproportionate access to health care in this country based on economic status and not race. Then again, it is pretty common for people who are having trouble affording care to seek a clinical trial where much of the care and drugs are paid for by the trial. So maybe economically disadvantaged people are over represented in clinical trials.
In any case Velcade has been so widely used at this point in time in all races that if it were significantly less effective in one race or the other, I think it would be known by now.
In the study you referred to you did not say all the participants were Caucasian and other races were excluded, just that most of the participants were Caucasian. There likely were African Americans and other races in the study, especially if the number of participants were large. Some of the smaller trials though have double or even single digit numbers of participants. I do not have the study so I do not know the numbers.
The majority of the population with myeloma is Caucasian because they are the majority of the population. Yes, African Americans are about twice as likely to get myeloma, but African Americans are still a smaller percentage of the population than Caucasians. I went to an MMRF myeloma symposium in San Francisco a few years ago that had about 300 people with myeloma in attendance. There were a good number of African Americans there, as expected, but they were not the majority.
Having said all that, though, I could see how there may be a disproportionate representation of races from the general population in clinical trials that’s root causes lies in the disproportionate access to health care in this country based on economic status and not race. Then again, it is pretty common for people who are having trouble affording care to seek a clinical trial where much of the care and drugs are paid for by the trial. So maybe economically disadvantaged people are over represented in clinical trials.
In any case Velcade has been so widely used at this point in time in all races that if it were significantly less effective in one race or the other, I think it would be known by now.
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Eric Hofacket - Name: Eric H
- When were you/they diagnosed?: 01 April 2011
- Age at diagnosis: 44
Re: Multiple myeloma treatment and race
Readers of this discussion may find this Beacon news article to be relevant to it:
"African-American Myeloma Patients May Have Fewer chromosome 14 Translocations Than European-American Patients," The Myeloma Beacon, March 13, 2013.
The introduction to the article is worth including here:
"African-American Myeloma Patients May Have Fewer chromosome 14 Translocations Than European-American Patients," The Myeloma Beacon, March 13, 2013.
The introduction to the article is worth including here:
Findings from a recent analysis conducted in the United States indicate that African-American multiple myeloma patients may have a lower frequency of certain chromosomal abnormalities compared to European-American patients.
In particular, the investigators from the Mayo Clinic found that African-Americans with myeloma may have a lower rate of chromosome 14 translocations.
chromosome 14 translocations are typically associated with myeloma that is more aggressive and harder-to-treat.
The Mayo researchers note that, although their results suggest that African-Americans may have myeloma which, on average, is less aggressive than myeloma in European-Americans, there are many other genetic differences between the two patient groups that were not accounted for in the study.
However, the researchers still believe their findings may help explain differences in treatment outcomes that have been observed between the two patient groups.
Previous studies have shown that African-Americans are diagnosed with multiple myeloma two to three times more frequently than European-Americans.
However, African-American myeloma patients also have higher survival rates.
Previous studies also have shown that African-Americans with the myeloma precursor disease monoclonal gammopathy of undetermined significance (MGUS) have lower levels of monoclonal (M) protein, and an earlier age of onset, compared to European-Americans.
Re: Multiple myeloma treatment and race
I had always thought that chromosomal differences between races were pretty small compared to the overall genome, but apparently there are differences that affect myeloma treatment outcomes.
I have still not come across anything yet on why African Americans get myeloma at twice the rate of Caucasians. I had wondered if this was because of differences in environmental exposure between the two populations groups or genome differences, I am thinking more towards genome differences now but I really have no idea.
If researchers learn the answers to these questions, hopefully that will give them more insight to how the disease works and how to treat it.
I have still not come across anything yet on why African Americans get myeloma at twice the rate of Caucasians. I had wondered if this was because of differences in environmental exposure between the two populations groups or genome differences, I am thinking more towards genome differences now but I really have no idea.
If researchers learn the answers to these questions, hopefully that will give them more insight to how the disease works and how to treat it.
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Eric Hofacket - Name: Eric H
- When were you/they diagnosed?: 01 April 2011
- Age at diagnosis: 44
Re: Multiple myeloma treatment and race
There are 2 things that are important to note in any trial results. One is race and the other is gender. So many of the clinical trials that were done on drugs in past years were only tested on males. Females respond quite differently to heart drugs, and many others, than males do, but the dosages were based on response in males.
I would imagine that response to many drugs varies in different races, too. So, this is an important thing to include in trial results no matter how low the number of participants. If there are differences noted that are significant, even if low in number, then a trial should be designed that looks at the differences. Maybe all trials should try to have race as an inclusion criteron.
Just some thoughts. I think that Pari raised a really good issue to be considered when treating people of various races, gender and size. One size fits all doses doesn't work in any treatment.
Nancy in Phila
ps: ok I'm stepping off of my soap box.
I would imagine that response to many drugs varies in different races, too. So, this is an important thing to include in trial results no matter how low the number of participants. If there are differences noted that are significant, even if low in number, then a trial should be designed that looks at the differences. Maybe all trials should try to have race as an inclusion criteron.
Just some thoughts. I think that Pari raised a really good issue to be considered when treating people of various races, gender and size. One size fits all doses doesn't work in any treatment.
Nancy in Phila
ps: ok I'm stepping off of my soap box.
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NStewart - Name: Nancy Stewart
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 3/08
- Age at diagnosis: 60
Re: Multiple myeloma treatment and race
Thanks for the comments, everyone, on this important subject.
Just to make sure we have the information here in this thread, there are two journal articles related to multiple myeloma and race that are worth adding to the discussion.
The first paper below is a general overview of what is known about the role of race in MGUS and multiple myeloma. Because the paper is from 2012, and it is a literature review, the results are already somewhat out of date. But it's not a bad starting point for those who want to read up more on the subject.
The second articles is more recent -- from last month -- and it presents results of a study that finds that about one-third of African Americans have a genetically inherited risk factor for developing MGUS and multiple myeloma. (Warning: this looks like a rather technical paper!)
The references and abstracts are as follows:
There is marked racial disparity in the incidence of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma, with a two to threefold increased risk in blacks compared with whites. The increased risk has been seen both in Africans and African Americans. Similarly, an increased risk of monoclonal gammopathies in blacks compared with whites has been noted after adjusting for socioeconomic and other risk factors, suggesting a genetic predisposition.
The higher risk of multiple myeloma in blacks is likely a result of the higher prevalence of the premalignant MGUS stage; there are no data to suggest that blacks have a higher progression rate of MGUS to myeloma. Studies are emerging that suggest the baseline cytogenetic characteristics, and progression may differ by race.
In contrast to the increased risk noted in blacks, studies suggest that the risk may be lower in certain racial and ethnic groups, notably persons from Japan and Mexico.
We review the literature on racial disparity in the prevalence, pathogenesis and progression of MGUS and multiple myeloma between blacks and whites. We also discuss future directions for research that could inform management of these conditions and positively influence patient outcomes.
As hyperphosphorylated paratarg-7 (pP-7) carrier state was shown to be the first molecularly defined autosomal dominantly inherited risk factor for monoclonal gammopathy of unknown significance (MGUS) and multiple myeloma (multiple myeloma) in a European population, the prevalence of pP-7 carrier state among African-Americans who have a significantly higher incidence of MGUS/multiple myeloma is of interest.
We therefore determined pP-7 carrier state and paraproteins with specificity for P-7 in African-American, European and Japanese patients with MGUS/multiple myeloma and healthy controls. By isoelectric focusing and ELISA, a paratarg-7-specific paraprotein and the associated pP-7 carrier state was observed in 30/81 (37.0%) African-American, 42/252 (16.7%) European and 7/176 (4.0%) Japanese MGUS/multiple myeloma patients (p < 0.001).
A pP-7 carrier state was found in 11/100 (11.0%) African-American, 8/550 (1.5%) European and 1/278 (0.4%) Japanese healthy controls (p < 0.001), resulting in an odds ratio for MGUS/multiple myeloma of 4.8 (p < 0.001) among African-American, 13.6 among European (p < 0.001) and 11.5 (p = 0.023) among Japanese carriers of pP-7.
We conclude that pP-7 carriers are most prevalent among African-Americans, but a pP-7 carrier state is the strongest molecularly defined single risk factor for MGUS/multiple myeloma known to date in all three ethnic groups. The high prevalence of pP-7 carriers among African-American patients emphasizes a predominant role of this genetic factor in the pathogenesis of these diseases.
The large number of pP7 African-American patients and controls should facilitate the identification of the SNP or mutation underlying the pP-7 carrier state.
Just to make sure we have the information here in this thread, there are two journal articles related to multiple myeloma and race that are worth adding to the discussion.
The first paper below is a general overview of what is known about the role of race in MGUS and multiple myeloma. Because the paper is from 2012, and it is a literature review, the results are already somewhat out of date. But it's not a bad starting point for those who want to read up more on the subject.
The second articles is more recent -- from last month -- and it presents results of a study that finds that about one-third of African Americans have a genetically inherited risk factor for developing MGUS and multiple myeloma. (Warning: this looks like a rather technical paper!)
The references and abstracts are as follows:
- AJ Greenberg, "Disparities in the prevalence, pathogenesis and progression of monoclonal gammopathy of undetermined significance and multiple myeloma between blacks and whites," Leukemia. 2012 Apr;26(4):609-14 (abstract at journal website, full text version at PMC)
There is marked racial disparity in the incidence of monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma, with a two to threefold increased risk in blacks compared with whites. The increased risk has been seen both in Africans and African Americans. Similarly, an increased risk of monoclonal gammopathies in blacks compared with whites has been noted after adjusting for socioeconomic and other risk factors, suggesting a genetic predisposition.
The higher risk of multiple myeloma in blacks is likely a result of the higher prevalence of the premalignant MGUS stage; there are no data to suggest that blacks have a higher progression rate of MGUS to myeloma. Studies are emerging that suggest the baseline cytogenetic characteristics, and progression may differ by race.
In contrast to the increased risk noted in blacks, studies suggest that the risk may be lower in certain racial and ethnic groups, notably persons from Japan and Mexico.
We review the literature on racial disparity in the prevalence, pathogenesis and progression of MGUS and multiple myeloma between blacks and whites. We also discuss future directions for research that could inform management of these conditions and positively influence patient outcomes.
- C Zwick et al, "Over one-third of African-American MGUS and multiple myeloma patients are carriers of hyperphosphorylated paratarg-7, an autosomal dominantly inherited risk factor for MGUS/multiple myeloma," Int J Cancer. 2014 Aug 15;135(4):934-8 (abstract at journal website)
As hyperphosphorylated paratarg-7 (pP-7) carrier state was shown to be the first molecularly defined autosomal dominantly inherited risk factor for monoclonal gammopathy of unknown significance (MGUS) and multiple myeloma (multiple myeloma) in a European population, the prevalence of pP-7 carrier state among African-Americans who have a significantly higher incidence of MGUS/multiple myeloma is of interest.
We therefore determined pP-7 carrier state and paraproteins with specificity for P-7 in African-American, European and Japanese patients with MGUS/multiple myeloma and healthy controls. By isoelectric focusing and ELISA, a paratarg-7-specific paraprotein and the associated pP-7 carrier state was observed in 30/81 (37.0%) African-American, 42/252 (16.7%) European and 7/176 (4.0%) Japanese MGUS/multiple myeloma patients (p < 0.001).
A pP-7 carrier state was found in 11/100 (11.0%) African-American, 8/550 (1.5%) European and 1/278 (0.4%) Japanese healthy controls (p < 0.001), resulting in an odds ratio for MGUS/multiple myeloma of 4.8 (p < 0.001) among African-American, 13.6 among European (p < 0.001) and 11.5 (p = 0.023) among Japanese carriers of pP-7.
We conclude that pP-7 carriers are most prevalent among African-Americans, but a pP-7 carrier state is the strongest molecularly defined single risk factor for MGUS/multiple myeloma known to date in all three ethnic groups. The high prevalence of pP-7 carriers among African-American patients emphasizes a predominant role of this genetic factor in the pathogenesis of these diseases.
The large number of pP7 African-American patients and controls should facilitate the identification of the SNP or mutation underlying the pP-7 carrier state.
Re: Multiple myeloma treatment and race
Thank you all for your responses.
I dug a little further and found some numbers with regard to the company’s study on Velcade that made it the universal drug of choice for multiple myeloma.
Here’s information from Velcade's U.S. prescribing information on the extent to which race affects the concentration of Velcade in the blood, and length of time Velcade stays in the blood, after it is given to patients:
"Race: The effect of race on exposure to bortezomib could not be assessed as most of the patients were Caucasian.”
This statement made me wonder about the impact of race on efficacy.
I further found the following information on the earlier study that led to FDA approval:
" Age, Gender, and Race: The effects of age, gender, and race on the pharmacokinetics of
bortezomib have not been evaluated.
Patient Characteristics: Velcade, N=333. Dexamethasone, N=336
Median age in years (range) 62.0 (33, 84); [dex] 61.0 (27, 86)
Gender: male/female 56% / 44%; [dex] 60% / 40%
Race: Caucasian/black/other 90% / 6% / 4%; [dex] 88% / 7% / 5% "
Nancy, It's good to see that the gender distribution is pretty well balanced, and, yes, with regard to race, 6% were African American in the original Velcade pharmaceutical study.
I hear what you say, Eric, about "science and race," and that's certainly not the intent of my question, nor is a deeper sociological analysis which might be relevant in another forum. But the Velcade studies themselves declare that they have not not looked at the efficacy [or lack thereof] (there are perhaps more urgent issues of just the treatments being effective) based on race.
Statistically there are more African Americans with multiple myeloma in proportion to the population. Neither am I sure if ,as Eric notes, economically disadvantaged are largely represented in clinical trials, though I think that is not the question being raised here. We cannot generalize or immediately correlate race to economic disadvantage. Posts by fellow MB users suggest that some take advantage of clinical studies since they could provide the possibility of new research and cutting edge solutions, which indicates an educated knowledge base rather than economic disadvantage. Eric, I appreciate your response and it certainly underlines that this issue is not and should not be treated simplistically.
Thanks MB staff for adding those studies that do explore this issue. That’s exactly the question I have, i.e., whether there are difference in treatment outcomes [in the use of Velcade] based on race and the study on chromosomes that you included does suggest such a possibility.
This is such a great forum where people share their personal experiences alongside data. I really would like to hear from those willing to share whether Velcade is effective (and perhaps want to know more of when it has not been effective and whether they have moved to other regimens or found others more effective). That’s the personal element for me.
I'm still exploring and trying to better understand the chromosome deletions etc with regard to myeloma and haven't yet received the test results in our own case. But I do understand the general findings from the human genome studies.
Again, thanks to anyone who can share their "not so positive" experience with Velcade. I'm wondering out loud even anecdotally whether race might have anything to do with it with the sole intent of considering what other options are there and whether it would be helpful to examine these.
Our experience has been 5 cycles with Velcade-dex and we are now in the second CyBorD cycle with minimal progress. My own situation of course would fall under the "other" 4% in the Velcade pharmaceutical studies. I’m not sure who were actually included in this 4% - probably nonwhite Hispanics, Asians (such a broad category) maybe Native Americans, etc., and I think some of these studies were international even if most of the participants were Caucasians.
I feel like Alice in Wonderland … things are getting curiouser …
I dug a little further and found some numbers with regard to the company’s study on Velcade that made it the universal drug of choice for multiple myeloma.
Here’s information from Velcade's U.S. prescribing information on the extent to which race affects the concentration of Velcade in the blood, and length of time Velcade stays in the blood, after it is given to patients:
"Race: The effect of race on exposure to bortezomib could not be assessed as most of the patients were Caucasian.”
This statement made me wonder about the impact of race on efficacy.
I further found the following information on the earlier study that led to FDA approval:
" Age, Gender, and Race: The effects of age, gender, and race on the pharmacokinetics of
bortezomib have not been evaluated.
Patient Characteristics: Velcade, N=333. Dexamethasone, N=336
Median age in years (range) 62.0 (33, 84); [dex] 61.0 (27, 86)
Gender: male/female 56% / 44%; [dex] 60% / 40%
Race: Caucasian/black/other 90% / 6% / 4%; [dex] 88% / 7% / 5% "
Nancy, It's good to see that the gender distribution is pretty well balanced, and, yes, with regard to race, 6% were African American in the original Velcade pharmaceutical study.
I hear what you say, Eric, about "science and race," and that's certainly not the intent of my question, nor is a deeper sociological analysis which might be relevant in another forum. But the Velcade studies themselves declare that they have not not looked at the efficacy [or lack thereof] (there are perhaps more urgent issues of just the treatments being effective) based on race.
Statistically there are more African Americans with multiple myeloma in proportion to the population. Neither am I sure if ,as Eric notes, economically disadvantaged are largely represented in clinical trials, though I think that is not the question being raised here. We cannot generalize or immediately correlate race to economic disadvantage. Posts by fellow MB users suggest that some take advantage of clinical studies since they could provide the possibility of new research and cutting edge solutions, which indicates an educated knowledge base rather than economic disadvantage. Eric, I appreciate your response and it certainly underlines that this issue is not and should not be treated simplistically.
Thanks MB staff for adding those studies that do explore this issue. That’s exactly the question I have, i.e., whether there are difference in treatment outcomes [in the use of Velcade] based on race and the study on chromosomes that you included does suggest such a possibility.
This is such a great forum where people share their personal experiences alongside data. I really would like to hear from those willing to share whether Velcade is effective (and perhaps want to know more of when it has not been effective and whether they have moved to other regimens or found others more effective). That’s the personal element for me.
I'm still exploring and trying to better understand the chromosome deletions etc with regard to myeloma and haven't yet received the test results in our own case. But I do understand the general findings from the human genome studies.
Again, thanks to anyone who can share their "not so positive" experience with Velcade. I'm wondering out loud even anecdotally whether race might have anything to do with it with the sole intent of considering what other options are there and whether it would be helpful to examine these.
Our experience has been 5 cycles with Velcade-dex and we are now in the second CyBorD cycle with minimal progress. My own situation of course would fall under the "other" 4% in the Velcade pharmaceutical studies. I’m not sure who were actually included in this 4% - probably nonwhite Hispanics, Asians (such a broad category) maybe Native Americans, etc., and I think some of these studies were international even if most of the participants were Caucasians.
I feel like Alice in Wonderland … things are getting curiouser …
-
Pari - Name: Pari
- Who do you know with myeloma?: Research on academic websites
- When were you/they diagnosed?: May 2014
- Age at diagnosis: 60
Re: Multiple myeloma treatment and race
Hi Pari,
Sorry to hear that your partner has not responded well so far to either Velcade-dex or CyBorD.
I don't know why you have assumed, however, that race is what is playing a key role in your partner's response to treatment. With the Velcade-dex regimen, about 20 to 25 percent of newly diagnosed patients do not respond to the regimen. With the CyBorD regimen, about 10 percent of newly diagnosed patients do not respond to the regimen, and the percentage of non-responders probably would be much higher if a study were done looking at people who go on to CyBorD after failing to respond to Velcade-dex.
So it's not some statistical fluke that your partner hasn't responded to Velcade-dex or CyBorD so far. Unfortunately, it still happens. I do hope, however, that there is eventually a response, and that it's a deep one.
Here are references for the response rates I quoted above:
Harousseau et al., "Bortezomib Plus Dexamethasone Is Superior to Vincristine Plus Doxorubicin Plus Dexamethasone As Induction Treatment Prior to Autologous Stem-Cell Transplantation in Newly Diagnosed Multiple Myeloma: Results of the IFM 2005-01 Phase III Trial," Journal of Clinical Oncology, October 20, 2010 vol. 28 no. 30 4621-4629
Reeder et al, "Once- versus twice-weekly bortezomib induction therapy with CyBorD in newly diagnosed multiple myeloma," Blood, 22 April 2010, 115:16.
Sorry to hear that your partner has not responded well so far to either Velcade-dex or CyBorD.
I don't know why you have assumed, however, that race is what is playing a key role in your partner's response to treatment. With the Velcade-dex regimen, about 20 to 25 percent of newly diagnosed patients do not respond to the regimen. With the CyBorD regimen, about 10 percent of newly diagnosed patients do not respond to the regimen, and the percentage of non-responders probably would be much higher if a study were done looking at people who go on to CyBorD after failing to respond to Velcade-dex.
So it's not some statistical fluke that your partner hasn't responded to Velcade-dex or CyBorD so far. Unfortunately, it still happens. I do hope, however, that there is eventually a response, and that it's a deep one.
Here are references for the response rates I quoted above:
Harousseau et al., "Bortezomib Plus Dexamethasone Is Superior to Vincristine Plus Doxorubicin Plus Dexamethasone As Induction Treatment Prior to Autologous Stem-Cell Transplantation in Newly Diagnosed Multiple Myeloma: Results of the IFM 2005-01 Phase III Trial," Journal of Clinical Oncology, October 20, 2010 vol. 28 no. 30 4621-4629
Reeder et al, "Once- versus twice-weekly bortezomib induction therapy with CyBorD in newly diagnosed multiple myeloma," Blood, 22 April 2010, 115:16.
Re: Multiple myeloma treatment and race
Pari wrote: " ... study on Velcade that made it the universal drug of choice for multiple myeloma ...."
Did I miss something? Since when is Velcade the "universal drug of choice for multiple myeloma"?
Did I miss something? Since when is Velcade the "universal drug of choice for multiple myeloma"?
Re: Multiple myeloma treatment and race
Hi Pari, This may seem really 'off the wall', but is your husband adhering to guidelines about what not to eat or drink while taking Velcade? When I took it, which was a few years ago, we were warned not to drink green tea, take vitamin C supplements, or other anti-oxidant type supplements. Even though I think that some of that research is no longer in vogue, we patients at that time were careful to take the advice. And I assume that he is taking dexamethasone along with the Velcade? 'Dex' seems to enhance the effectiveness of the myeloma fighting drugs.
Also, I have read that Velcade is actually recommended as a good choice of drug for 'high risk' patients, as shown by chromosomal deletions. I think that being 'high risk' as measured in that way crosses gender or ethnic lines.
I hope he does get a good response to some sort of treatment. Maybe your doctors will switch him to another type of drug if the Velcade isn't working. Velcade is a 'proteasome inhibitor' type drug, as is Kyprolis (carfilzomib), and 'Revlimid' is an immunomodulatory drug, as are thalidomide and pomalidomide (Pomalyst). They all have useful applications, and if one drug combination doesn't work, perhaps another will.
Also, I have read that Velcade is actually recommended as a good choice of drug for 'high risk' patients, as shown by chromosomal deletions. I think that being 'high risk' as measured in that way crosses gender or ethnic lines.
I hope he does get a good response to some sort of treatment. Maybe your doctors will switch him to another type of drug if the Velcade isn't working. Velcade is a 'proteasome inhibitor' type drug, as is Kyprolis (carfilzomib), and 'Revlimid' is an immunomodulatory drug, as are thalidomide and pomalidomide (Pomalyst). They all have useful applications, and if one drug combination doesn't work, perhaps another will.
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Nancy Shamanna - Name: Nancy Shamanna
- Who do you know with myeloma?: Self and others too
- When were you/they diagnosed?: July 2009
12 posts
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