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An Extraordinary Healer essay honoring TINA PURSGLOVE, RN, OCN [THE OHIO STATE UNIVERSITY WEXNER MEDICAL CENTER JAMES CANCER HOSPITAL, COLUMBUS, OHIO]

A Positive Guiding Light for Oncology Patients

Early detection of multiple myeloma, marked by fatigue, bone pain, and anemia, coupled with modern, patient-centered treatments like targeted therapies and supportive care, significantly improves outcomes and quality of life, an expert said.

CURE spoke with Dr. Joseph Mikhael, a professor in the Applied Cancer Research and Drug Discovery Division at the Translational Genomics Research Institute, an affiliate of City of Hope Cancer Center, and Chief Medical Officer of the International Myeloma Foundation. In the interview, he spoke about the importance of recognizing the symptoms of myeloma, making informed treatment decisions and the role of supportive care in managing the disease.

CURE: What are some early warning signs of multiple myeloma that patients should be aware of, and when should they seek medical evaluation?

: Typically, the signs and symptoms that patients have are that they experience fatigue, and not just the regular fatigue you and I might face on a regular basis, but when it really is beyond what is normal, an ongoing weakness that is not typical.

No. 2 is bone pain, or pain in the distribution of our bones. This is often in our backs, where we have obviously a lot of bones, because myeloma attacks the bone. And so often our patients — over half of our patients — present with bone pain.

And the third most common reason is what we call anemia, or a low hemoglobin. If that blood test has been done, a lot of times, family doctors and primary care will measure hemoglobin level in terms of what we call a CBC, or complete blood count. And about three quarters of the time, our patients have a low hemoglobin.

Now, of course, there's lots of causes for fatigue, there's lots of causes for bone pain, there are lots of causes for anemia. And myeloma is not the one that comes to the top of mind with these very common things. But when those are going on, and there really isn't a clear explanation, we want people to start to think about the potential of multiple myeloma. This is particularly important in patients who are at higher risk. Myeloma is more common as we get older, in particular, as patients get into their 60s and 70s, those of us of African descent are at twice the risk, and individuals of Latino American background also are diagnosed at a younger age.

What are the current standard treatments for myeloma? And how can patients work with their care teams to make informed treatment decisions?

Myeloma has gone through a revolution over the last several years. When I started in myeloma, over 20 years ago, we maybe had one or two drugs to treat it. Now we have 20 drugs to treat myeloma in a very different approach. I would start by the concept of saying, … “I don't treat myeloma. I treat people.” And so, it's important that patients realize and their care partners that they are the center of the attention; not the doctor or the provider, but the patient is at the center. And with all of these options that we have, the concept of shared decision making is so important, that patients feel a part of that decision making process.

What should patients know about these treatment options, whether that be immunotherapy or targeted therapy, and how might these new approaches impact their prognosis?

These are exciting times in cancer therapy, in general and in particular in multiple myeloma, where historically, we had to use the sorts of treatments that were really tough on the patient, not just tough on their myeloma. But now we have come to an era where we can be much more targeted. That is to say, we can try and hit the myeloma cell, but not the rest of the patient, as it were. And these are through novel treatments, things like monoclonal antibodies and antibody drug conjugates, different approaches where we can actually hone in on the specific myeloma cell, target it for destruction and not the cells around it. And this is clearly improving not only the quantity of patients’ lives, but the quality of patients’ lives.

Furthermore, the next huge wave is what we often call immunotherapy, which is basically the concept of employing a patient's own immune system — because it's there, it's trained to fight. It's the patient's own immune system, so they're not going to reject it, as it were, but engaging their own immune system to take down their own multiple myeloma. We do this now in myeloma, two primary ways. First is called CAR-T cell therapy, or chimeric antigen receptor T-cell therapy. I know it's a lot of words, but the key word there is receptor.

And so what we do is we take T cells out of a patient. T cells are just some of the cells that live in our body. They're kind of like soldier cells. They've been trained to fight. We take them out of the patient, and we essentially train them to fight against their myeloma. We put a receptor on the outside of them that is specific to that patient's myeloma, multiply them and give them back to the patient. So now these amped up soldier cells are just aching to find myeloma. They go find myeloma and they destroy it. I mean, this almost sounds like a futuristic movie, but it is actually what we're doing right now. And we have seen unprecedented response rates with CAR-T cell therapy, and it gives people a period of time off treatment.

What supportive care strategies can help improve daily life for patients living with myeloma.

No. 1, open, honest, clear communication with your healthcare team. Sharing the side effects that you're experiencing, what you're going through, both emotionally and physiologically, as it were, that becomes so important, because we want to 

 through this. We can pick up side effects early on and make adjustments, or provide other supportive care medications that may overcome that. And that approach is so important. We have actually learned in oncology, when you have a strong relationship with your healthcare team, it actually improves your survival.

No. 2, make sure you have your own support. That support can be from your family, from your friends and, indeed, from support groups. The 

 has over 150 support groups across the country. And we've also demonstrated that when patients have support around them, they actually have better outcomes because they're better informed and they're better empowered to face the future.

And No. 3, I always talk about empowerment through education. Not everybody wants to learn every last detail about every aspect of their disease, but knowledge is power.

Transcript was edited for clarity and conciseness.

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Dr. Joseph Mikhael discusses early signs, treatments and supportive care for multiple myeloma in an interview with CURE. 

Tumor

Expert Explains Early Signs, Treatment Advances and Care in Multiple Myeloma

Meta: Dr. Kandace P. McGuire discusses how targeted axillary staging differs from traditional methods of staging in patients undergoing breast cancer treatment.

Targeted Axillary Dissection Offers a Precise Option in Breast Cancer

Targeted axillary dissection is used for patients with known positive lymph nodes, allowing surgeons to accurately stage breast cancer, Dr. Kandace P. McGuire emphasized in an interview with CURE® at the 42nd Annual Miami Breast Cancer Conference. She went on to explain that this is done by marking affected nodes and performing a sentinel node biopsy while minimizing the removal of unnecessary lymph nodes, thereby reducing the risk of complications such as lymphedema and nerve damage.

McGuire is a professor of surgery in the Department of Surgical Oncology at the Virginia Commonwealth University (VCU) School of Medicine, VCU Health, and she discussed how targeted axillary staging differs from traditional methods of staging in patients undergoing breast cancer treatment, highlighting what benefits it offers in terms of treatment planning and outcomes.

The targeted axillary dissection is really meant for patients who have known positive lymph nodes. According to our national guidelines, the National Comprehensive Cancer Network Guidelines — which are [what] most surgeons and medical oncologists will use when taking an approach to cancer — you can do the targeted axillary dissection before any whole-body treatment, or you can do it after. However, the technique is the same.

Once you have a biopsy of your lymph node, if it unfortunately has some cancer in it, most radiologists put a little clip in there. That clip is fantastic, because if this ends up being nothing, it can sit there the rest of your life and never bother you. It's made of titanium, but titanium is not detectable in the operating room, and so for the targeted axillary dissection, the surgeons have to ask the radiologist or do it themselves. They need to place some sort of marker that they can find in the operating room. For some people, that's a wire, and for others, it's a non-radioactive seed, so that gets placed ahead of time, which is different from your standard lymph node surgery. Standard lymph node surgery [can include] a sentinel node biopsy, [for example].

The patient then goes to sleep, you inject some dye, it travels up to the lymph nodes and you just take out the ones that light up with the dyes, because they're the ones most likely to have something in it. In this technique, we know there's one with cancer in it, so we mark it so that we can find it, and then we inject the dyes and do the sentinel node biopsy on top of it. What that does is it allows us to do that lymph node biopsy instead of taking out all the lymph nodes in the axilla, which is what most people call the armpit. Underneath that area, most women will have 30 lymph nodes or so, and the huge benefit is to be accurate in staging without taking out a whole bunch of lymph nodes and causing things like lymphedema and nerve damage.

Transcript has been edited for clarity and conciseness.

Dr. Kandace P. McGuire discusses how targeted axillary staging differs from traditional methods of staging in patients undergoing breast cancer treatment.

Conference

Dr. Sarah M. Tolaney discusses breast practices associated with CDK4/6 inhibitors for the treatment of breast cancer.

Understanding the Best Practices Associated With CDK4/6 Therapy in Breast Cancer

At the 42nd Annual Miami Breast Cancer Conference, Dr. Sara M. Tolaney sat down for an interview with CURE to discuss the efficacy and breast practices associated with CDK4/6 inhibitors, highlighting what the role of CDK4/6 inhibitors is in adjuvant therapy for patients with hormone receptor (HR)–positive, HER2-negative breast cancer.

CDK4/6 inhibitors, which were originally proven effective in metastatic HR-positive breast cancer, are now FDA-approved for early-stage cases, reducing recurrence risk. Notably, the choice between these inhibitors depends on factors such as hormone therapy compatibility, offering new hope for improving cure rates in early-stage breast cancer, Tolaney emphasized.

Tolaney works as a breast medical oncologist at Dana-Farber Cancer Institute, where she is the chief of the Division of Breast Oncology, and serves as an associate professor of medicine at Harvard Medical School, located in Boston.

CDK4/6 inhibitors are oral pills that stop the cell cycle, so it takes a cancer cell and puts it to sleep. We found that these drugs are highly effective in women who have metastatic hormone receptor (HR)–positive breast cancer, where, in fact, it was doubling the duration by which their cancer was controlled and allowing them to live longer. [This provides], clearly, huge benefits. It seemed natural to think, “Well, if it's helping patients who have metastatic breast cancer, could it help us cure more patients who have early-stage breast cancers?”

Now we have two different CDK4/6 inhibitors that are FDA approved for patients who have early-stage HR-positive breast cancers. The question then arises: Which one do you choose? We have Verzenio [abemaciclib] and Kisqali [ribociclib]. I don't think there's a clear wrong or right answer here, but in fact, I think it's a little bit more nuanced. Generally speaking, what we're seeing is that these drugs reduce risks of recurrence by about 30%. That's a relative reduction that translates somewhere to a 5% to 8% absolute benefit across these two drugs, clearly, reducing risk a lot.

The Verzenio is given for two years, and it's given with the hormone therapy that patients are receiving, whereas the Kisqali is dosed for three years — so a little bit longer — and also given with the hormone therapy. Although with Kisqali, you cannot take it with tamoxifen, it has to be given with an aromatase inhibitor. Again, incredible to have these two options available because I do think it is allowing us to potentially be curing more patients with early-stage breast cancer.

Dr. Sara M. Tolaney discusses breast practices associated with CDK4/6 inhibitors for the treatment of breast cancer.

A clinical trial manager emphasizes the importance of a phased approach to educating patients about complex protocols and potential side effects.

Empowering Patients With Cancer Through Clear Clinical Trial Communication

Open communication is prioritized in the clinical trial process for patients with cancer, beginning with a general discussion of participation before study-specific details are presented to ensure potential participants are fully informed and empowered, a clinical trial manager said.

This step-by-step approach may prevent patients from feeling overwhelmed by the details behind a clinical trial, Mikaela Dougherty, clinical trial manager at Mount Sinai Ruttenberg Treatment Center in New York, said in an interview with CURE®.

We sat down with Dougherty to learn more about the strategies her team uses to educate patients about complex clinical trial protocols and potential side effects.

So when we first identify a potential clinical trial patient, myself or a clinical research coordinator will go in the room with the physician, the principal investigator, and talk with the patient in more of abstract terms of kind of what it's like to be on the clinical trial, not necessarily the specific of that trial right away. Because when we talk about clinical trials, patients can get very overwhelmed, especially if it's their first one. So we like to take it a step by step.

You know, our first conversation is initially, you know, what we do, what clinical trials are, and then we'll go into how this study specifically might help them. And the physician will go over, you know, the potential side effect profile, our plans of how we could — we'll mitigate those side effects. And then someone like myself would go into more detail about what they could expect while being on study.

And I think it's really important that someone like myself does their due diligence to really ensure that the patient fully understands the commitment of what it's like to be on the study, because it's — it can be overwhelming and it's time intensive. So especially for patients that are still working full time, we want to make sure that they have the resources available to them, you know, either setting them up with social work or patient advocacy groups, where they can help them find the resources that they need to ensure that it's not taking over their life.

You know, I think that's something that our team is really proud of, is that we want the clinical trial to extend your life, enhance your life, but not feel like it's taking over your life, where you can't enjoy the things that you want to enjoy, like going on vacation. So we make our patients aware that, you know, if, if you have stuff planned, we want to make sure we can still accommodate all of those things. So, you know, we're very open and honest with our patients and in hopes that we get that back.

So I think doing all of those, kind of guiding them through what it's like to be on a study, and then also talking to them very honestly about the side effects, and also our mitigation plan and that we want to know everything. I think sometimes patients, they don't want to share with you, the side effects, because of fear of being taken off the trial. But we make it very clear to them that, you know, a lot of the side effects, there's mitigation tools and, you know, ways that we can prevent them, or if they do experience them, make them more tolerable.

So, you know, we all work together and within our research team to ensure that the patient feels comfortable and that their questions are always answered. And also, we tell them that this is an ongoing journey and an ongoing discussion about participation.

Effective communication is crucial in the clinical trial process for cancer patients, starting with a general discussion before delving into study-specific details. This approach helps prevent patients from feeling overwhelmed. Mikaela Dougherty, a clinical trial manager, emphasizes the importance of ensuring patients fully understand the commitment involved, including potential side effects and mitigation strategies. The goal is to enhance patients' lives without the trial taking over. Open dialogue and resource support are prioritized to maintain patients' quality of life while participating in trials.

Richard French describes how he knew that his public service announcement (PSA) about myeloproliferative neoplasms (MPNs) was working — and what more work still needs to be done.

After French’s daughter was diagnosed with thrombocythemia, he grew frustrated at the lack of awareness about MPNs. So, he put his television background to good use and worked on a PSA that would air in markets across the nation. And while the PSA led to more money raised for the disease, French mentioned that he still hopes to grow the donor base of people contributing to the cause.

After realizing how little awareness there was about MPNs, one advocate looked to his TV background to help.

A PSA for Myeloproliferative Neoplasms

The treatment landscape for myeloproliferative neoplasms (MPNs) is ever-changing. “It’s hard to keep up, but it’s exciting,” said Dr. Steven Applebaum, a hematologist oncologist at UCLA Health in Pasadena, California.

In an interview with CURE®, Applebaum explained that discoveries in other diseases could pave the way for a better understanding of MPNs, a rare group of blood cancers including polycythemia vera, essential thrombocythemia and myelofibrosis.

“Knowledge is somewhat exponential,” he said. “You make one discovery, which seems big, and then that kind of leads to not one more, but five more.”

Of note, Applebaum said that researchers and clinicians continue to learn more about genetic mutations and targeted therapies that will help personalize MPN therapies and make them more effective — helping patients with the disease to live longer and with a better quality of life.

Ongoing Research May Lead to ‘Exciting’ Advancements for Myelofibrosis Years Down the Line

Looking at a lot of other diseases, I mean, knowledge is somewhat exponential. You make one discovery, which seems big, and then that kind of leads to not one more, but five more. The guys doing research in the lab, I expect us to learn a lot more different mutations, you know, targeted therapy. So I think we're all really excited just looking at a lot of other diseases as a model, that there's going to be increasing numbers of treatments that again, are going to help people live longer, but also improve their quality of life.

So the thing about being an oncologist is that (when) you've finished your training, you realize you don't know anything; everything's in evolution. So, the things I knew back then are really so cursory relative what we know now, so it's part of what motivates us to keep going as you know that the changes in the discoveries and new treatments are going to be coming almost daily. I mean, it's hard to keep up but it’s exciting.

One scientific development can lead to many more for patients with myeloproliferative neoplasms, a type of rare blood cancer, according to an expert. 

Mollie Maggied, M.H.A., B.S.N., RN, CPN, ATC Assistant Nurse Manager, Blood

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