Dr. Robert Kyle, a leading myeloma physician, researcher, and professor at the Mayo Clinic, spoke with The Myeloma Beacon about his approach to treating multiple myeloma patients; participation in clinical trials; many of the key issues for myeloma patients and physicians, including conventional and alternative treatment options; and the future of personalized medicine.

This article is the second part of a two-part series based on the Beacon’s conversations with Dr. Kyle. It will cover the role of clinical trials and key issues in the treatment of multiple myeloma as well as promising treatments for the future. For more information on Dr. Kyle and his approach to multiple myeloma treatment, please see part one of this series.

Clinical trials

Dr. Kyle advised that patients with multiple myeloma should go on clinical trials throughout their treatment, starting from when they are first treated. He stressed that participation in clinical trials is important because it can help answer questions about the efficacies of treatment regimens. “One of the major problems in this country is that only a small number of patients with multiple myeloma go on prospective studies,” he said. “In the United States, fewer than five percent of patients with a diagnosis of multiple myeloma go on a prospective clinical trial.”

The type of clinical trial people should choose depends on their condition. “If the patient had developing kidney failure and was in a lot of pain, you would want to treat the patient with a rapidly acting regimen,” he said. “And if the patient were not that symptomatic, then you could go to a less active regimen. That’s a judgment that the physician must make.”

Need For Stem Cell Transplants

According to Dr. Kyle, one of the key controversies among multiple myeloma doctors and researchers is “whether [stem cell] transplant is actually necessary or not in view of the novel agents thalidomide (Thalomid), Velcade (bortezomib), and Revlimid (lenalidomide).” He added, “Some physicians feel that the new agents, used either in combination or sequentially, will keep the patient in a chronic state and not require a transplant.”

However, “the three novel agents are not curative,” he said, and eventually, most people with myeloma will become resistant to the new drugs. “You need additional treatments, and one of the things that is helpful in myeloma is the transplant.”

Maintenance Therapy

“Another key controversy is whether a patient should be treated with maintenance therapy following the transplant,” said Dr. Kyle. “Our practice is not to treat the patient following the transplant. When the patient has relapsed, then we would treat the patient, or if the relapse has occurred several years after the transplant, we would seriously consider a second transplant.” He cited the need for studies comparing a maintenance regimen with no therapy.

Complementary Medicine

For those who are considering complementary therapies or alternative medicines, which are often billed as a less intense, safer choice, Dr. Kyle had some general words of caution. “In my opinion, patients should not take alternative medicines unless there is benefit or a trial in which you’re looking at benefit,” he said. He suggested that complementary therapies should be tested in clinical trials like conventional medicines.

Dr. Kyle warned against untested supplements. “Oftentimes, the person selling the supplement is the one who’s most likely to benefit. Some of these things could even be harmful.”

Emerging Therapies

Looking to the future, Dr. Kyle said that researchers are looking at potential new drugs as well as new combinations of drugs already in use. One of the new drugs he mentioned was pomalidomide (Actimid, CC-4047). “We are looking at [pomalidomide] in early studies, and in my mind, it looks very promising,” he said. There is no guarantee it will work for everyone with multiple myeloma. “It’s like all chemotherapy. Some patients will respond to Drug A and not to Drug B, and also patients will have different degrees of quality of response,” he said. “But we think that it is an active drug and will be a useful addition to the armamentarium for the treatment of myeloma.”

Dr. Kyle and his colleagues presented research on pomalidomide at this year’s Annual Meeting of the American Society of Hematology (see related Beacon news).

Other new drugs Dr. Kyle mentioned include tanespimycin, Zolinza (vorinostat), and carfilzomib. For these, as for all drugs, he is waiting to see clinical trial results. “It’s like anything else. You don’t really know what they will have to offer until you see the results of the studies,” he said. “There are many drugs over the years that have looked and sounded very, very good and have not made the grade.”

He said science’s next step is to tailor therapies to individual people based on their genetics or other features of their disease. People with different genes may respond differently to certain drugs or combinations of drugs. Scientists hope that by finding these gene-drug response relationships, they can better treat patients.

Dr. Kyle said he is also optimistic about finding a cure for multiple myeloma, “but the big question is, ‘When?’” He said the key to finding the cure is finding the cause of multiple myeloma. “That would be a very significant step forward.”

For more about Dr. Kyle's approach to multiple myeloma treatment, please see part one of this series.