Thought Leader Perspective: Dr. Kenneth Anderson On Treating Multiple Myeloma

Dr. Kenneth Anderson is a multiple myeloma thought leader, physician and researcher at Dana-Farber Cancer Institute, where he is Director of the Jerome Lipper Multiple Myeloma Center. He also is the Kraft Family Professor of Medicine at Harvard Medical School in Boston.
Dr. Anderson's research has played a key role in the development of several new multiple myeloma drugs and, more broadly, the significant improvement in treatment outcomes for myeloma patients that has occurred over the past 10 to 15 years.
In an interview with The Myeloma Beacon, Dr. Anderson spoke about his approach to treating multiple myeloma patients as well as the future of myeloma treatment and how this may lead to a cure for myeloma. This article, part one of a series of two, will cover Dr. Anderson’s approach to treating myeloma. Part two will cover Dr. Anderson’s thoughts on the future of myeloma treatment.
Combination Versus Sequence Therapy
When asked whether patients should begin treatment with a combination of therapies upfront or sequence novel agents to save options for a later relapse, Dr. Anderson stated, “There’s no question that we really should use combination therapies right from the start.”
“Now that we have defined active drugs, the best way to use them for sure is early in a cocktail,” explained Dr. Anderson.
He compared myeloma to tuberculosis and human immunodeficiency virus, in which patients can develop drug resistance if treated with sequential single drugs. Like with those diseases, Dr. Anderson said that myeloma patients should use combinations of drugs right from the start so that the disease will not become resistant to available treatments.
Dr. Anderson indicated that the best combination as of today is Revlimid (lenalidomide), Velcade (bortezomib), plus dexamethasone (Decadron), which achieves a 100 percent response rate (52 percent complete response, 22 percent very good partial response, and 26 percent partial response). “There are ongoing studies that are trying to improve upon that by adding a fourth drug, either a standard chemotherapy or other novel therapy,” Dr. Anderson added.
Stem Cell Transplantation
As more and more studies demonstrate a high frequency and long duration of response to novel myeloma agents such as Revlimid, thalidomide (Thalomid), and Velcade, the myeloma community is debating whether stem cell transplantation continues to be necessary for myeloma patients or whether treatment with novel agents is as effective.
Dr. Anderson stated that the current standard of care for multiple myeloma patients continues to include stem cell transplantation for those who are physically eligible for the process.
In particular, Dr. Anderson recommended participation in a clinical trial whenever possible. He also said that patients should receive initial treatment with Revlimid-dexamethasone or Velcade-dexamethasone, or Revlimid-Velcade-dexamethasone. Patients should then have their stem cells collected and proceed directly to treatment with high-dose melphalan (Alkeran) and transplantation using the patient’s own stem cells (autologous stem cell transplantation).
He specifically recommended, “All patients should receive novel agents as their initial treatment. In those patients who are transplant candidates, they should then go ahead and receive the transplant, followed by novel agents to consolidate and maintain the response to transplant.”
However, Dr. Anderson was extremely cautious about the use of allogeneic stem cell transplants, in which the stem cells come from a matched donor, due to the high risk of complications associated with this type of transplant.
Studies have shown that allogeneic stem cell transplantation is associated with long-term remission in myeloma patients. It is also the only potential cure at this time for multiple myeloma. Unique to a donor transplant, the donor stem cells may recognize the recipient’s myeloma cells as foreign and launch an immune attack on the myeloma cells. This is known as the graft-versus-myeloma effect.
Despite the long-term remission associated with donor transplants, Dr. Anderson stated, “We rarely use allogeneic transplantation in myeloma anymore.”
Just as the donor cells may recognize the recipient’s myeloma cells as foreign, the donor cells may also recognize the rest of the patient’s cells as foreign and launch an immune attack against them. This immune response, which is known as graft-versus-host disease, can cause severe skin, liver, and gut problems. It also contributes to the 10 percent to 20 percent mortality rate associated with donor transplants.
“Especially in the era of novel therapies, allogeneic transplantation is being used less commonly,” explained Dr. Anderson. “When used, it should be done nowadays only in the context of a clinical trial in order to exploit the graft-versus-myeloma effect while minimizing the toxicity.”
Dr. Anderson indicated that patients with multiply relapsed myeloma or those with very high-risk disease might be considered for donor transplantation.
Maintenance Therapy
Following stem cell transplantation, or initial therapy for those who are not transplant candidates, Dr. Anderson recommended maintenance therapy with Revlimid.
This recommendation is based on three clinical trials that have shown progression-free survival is significantly longer in patients who receive Revlimid maintenance.
Dr. Anderson said that early results have also indicated promising results for Velcade-thalidomide maintenance therapy in newly diagnosed elderly myeloma patients as well as Velcade maintenance after stem cell transplantation.
Bisphosphonates
Myeloma often causes bone complications, including holes in the bone or fractures. Bisphosphonates are used to slow or prevent this bone disease, thereby improving the quality of life of myeloma patients.
Research from this past year showed that Zometa (zoledronic acid) may also prolong survival of myeloma patients.
Dr. Anderson said that “Bisphosphonates are a very important supportive therapy for myeloma. It has been postulated for years that they may also have some anti-myeloma affect.” Despite the prolonged survival, Dr. Anderson said, “The primary use for bisphosphonates has been and always will be to abrogate bone disease.”
Implications For Myeloma Patients
Based on Dr. Anderson’s experience treating multiple myeloma patients, he said, “The median survival, especially in younger patients, is seven to eight years. Maintenance is adding at least another several years to that. So a newly diagnosed patient today has a likely median survival of over ten years.”
For more information, please see part two of this series, in which Dr. Anderson discusses the future of myeloma treatment.
Related Articles:
- Revlimid, Velcade, and Dexamethasone, Followed By Stem Cell Transplantation, Yields Deep Responses And Considerable Overall Survival In Newly Diagnosed Multiple Myeloma
- Stem Cell Transplantation May Be Underutilized In Multiple Myeloma Patients In Their 80s
- Number And Type Of Stem Cell Transplants Carried Out Each Year For Multiple Myeloma Vary Markedly Across U.S. Cancer Centers
- Sustained Complete Response To Initial Treatment Associated With Substantial Survival Benefit In Multiple Myeloma
- U.S. FDA Okays First Clinical Trial Of An Allogeneic CAR T-Cell Therapy For Multiple Myeloma
Dr. Anderson
I have had MM for 6 years, the last 5 of which my lab values have been in the normal range. There are several bone lesions and I took zometa for 2 years, stopping after 2 years because of the opinion of the Mayo Clinic which said that 2 years is enough because of the long half life of zometa. The bone lesions stopped spreading after the zometa therapy. Also, the anti-myeloma effect of zometa has not been clearly been proven (I could be wrong here). My maintenance therapy is Medrol 4 mg, Revlimid and Biaxin. This cocktail seems to work but I would like to hear your opinion on this low dose steroid combined with Revlimid 10 mg and Biaxin 500 mg BID.
Your article is very encouraging, thank you for taking the time to share with all of us.
Ben Lankheet MD
Dear Beacon-Team, your site is getting really cool. With such great interviews it becomes the institution for myeloma in the web.
I personally would like to hear more about the basic research in myeloma. What do experts as Dr. Anderson say about the biology of our disease? How far are scientists in understanding myeloma? I heard, that we know nothing about the progression from smm to mm. And what about the genomic screening? Is the IT/Broad-Paper, that will be published in nature soon, really a milestone, that will bring us nearer to fight the disease more effectively? And what do we need to make myeloma a chronic disease? What is the next milesonte on this path? Is there a kind of roadmap? Thank you very much! Peter
I'm excited The Myeloma Beacon Staff is starting to do more interviews with experts like Dr. Anderson! Bravo! Pat
Hi Pat,
Just wondering how you are doing since your last update informing us of your relapse. Have you decided on a plan of attack? Hope you are doing well and finding the answers to help you decide on your next step. I really enjoy reading the Beacon and want to thank you for your contributions!
Carol
For those of us who were of the "older" thalidomide/dex regimen prior to and after dual SCTs/melphalan (along with zometa following it), are the results as positive as the newer regimen? Was thalidomide replaced with revlimid due to the thalidomide side effects, the remission results, or both? Can anything be interpreted by those of us over five years out from treatment who has "stayed" in complete remission; another words, is long-term survival (ie., 10 years or longer) a more probable outcome than for those with shorter remissions/less than complete response after first treatment regimen?
Thank you everyone for your positive feedback about the interview with Dr. Anderson.
Peter, hopefully you will find that the second half of the interview answers a number of your questions. It will be published next week.
Lynda,
Revlimid is generally used more often than thalidomide in the United States both due to higher efficacy and fewer side effects. Here's an article on the topic: http://www.myelomabeacon.com/news/2010/01/07/revlimid-may-be-more-effective-than-thalidomide-in-newly-diagnosed-multiple-myeloma/
The good news is that Revlimid is often effective in those who were previously treated with thalidomide, which gives thalidomide-treated patients one more treatment option.
There is evidence to support that those who have been in remission for a very extended time are more likely to stay in remission. In a number of studies, the percent of patients who replase tend to plateau after several years and the remaining patients tend to stay in remission. A number of studies have also shown that response/remission is often linked to longer survival: http://www.myelomabeacon.com/news/2009/10/20/multiple-myeloma-study-determines-complete-response-to-treatment-is-generally-correlated-with-survival/
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