Multiple Myeloma: An Overview

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Guest: Dr. Robert K. Stuart, Hematology/Oncology

Host: Dr. Linda Austin – Psychiatrist

Dr. Linda Austin: I am Dr. Linda Austin and I am talking today with Dr. Rob K. Stuart, who is Professor of Medicine at the Medical University of South Carolina. He is a Hematologist/Oncologist at Hollings Cancer Center here in Charleston. Dr. Stuart let’s talk today about multiple myeloma. What is that disease?

Dr. Robert K. Stuart: Well, this is a disease that’s hard to describe. It’s a cancer that arises in antibody-producing cells. So, I think most people know that when we get an infection the body responds by making antibodies and that involves selecting a particular cell that is genetically programmed to produce antibody when stimulated by a particular germ, let’s say. We have all had the experience of a sore throat where a gland under the angle of the jaw swells up. Well, the cells that are genetically programmed to respond to that infection are producing billions and billions of other cells that will make antibody to fight that infection. But once the infection is over and stimulus is no longer there, those cells are supposed to die. It is just like putting in a key in the ignition of a car and turning the engine on. Well, when you turn the engine off and remove the key, the engine supposed to stop, but this is a situation where because of a mutation, those cells continue to grow. They normally like to live in the bone marrow, so they tend to fill up the bone marrow and in one of the problems with multiple myeloma is you begin to get weak spots in the bones. The cells actually erode the bone from the inside out and fractures are common occurrence in that. These cells, since their normal counter parts produce antibody, these malignant cells continue to produce antibody and that protein can cause problems with the kidney, so you can get kidney disease. Protein can also accumulate to the point, where the blood actually gets sick and people have trouble thinking and doing normal tasks. The infiltrations of bone marrow frequently leads anemia. The breakdown of the bone frequently raises the calcium level which can cause confusion and lots of other problem. So, you can see this is a very strange disease that can present in many, many different ways.

Dr. Linda Austin: So the typical first symptoms then might be a fracture or what?

Dr. Robert K. Stuart: Well, first of all, the population at risk tends to be people over 50. In South Carolina, I have seen a few cases in the 20s, but mostly older people. From what I have described, you can see there is no typical presentation, an unexplained fracture for instance could be and particularly fracture of the spine. So, somebody steps off a curve and suddenly has a sharp pain in the back. In the emergency room, they take an x-ray and one of the vertebral bodies is collapsed. That’s a classic presentation, but it’s a disease that can affect many parts of the body and so it can have varied presentations. Fortunately, most people are aware that if you do a special test for the protein levels in the blood, you will see an excessive antibody proteins and that’s usually the first clue of what you are dealing with.

Dr. Linda Austin: How do you go about treating it?

Dr. Robert K. Stuart: Well, this is a condition that not too long ago, the average survival was about three years and treatment was really unsatisfactory. However, in the last 10 years, there has been dramatic improvement in treatment and explosion of new drugs and the outlook from myeloma is totally different from what it was when I was a young physician seeing these patients. The treatment usually starts with chemotherapy and actually some of the most effective chemotherapy regimens now are entirely pills. So, although there are drugs given intravenously that are quite effective, it is not unusual for people to be able to begin therapy with tablets that they take and some people get remarkable responses to that. Usually, the second step in treatment involves something called high-dose chemotherapy with stem cell transplantation. This is also sometimes called bone marrow transplant, but this is a technique where once patients? bone marrows have improved because they responded to the initial therapy. We have a way to collect what we call bone stems cells which are really you can think of seeds and store them, and then we can give the patient very concentrated chemotherapy aimed at the myeloma, but unfortunately also causing death of innocent bystanders, mainly in the bone marrow. If we didn’t have seeds to re-seed the bone marrow, it would take six weeks or more to recover and people would really be invalids (ph) during that time. But by re-seeding the bone marrow immediately after the high-dose chemotherapy, we can shorten the recovery to as little as 10 to 14 days and that becomes quite acceptable for people. So, after the stem cells transplant, we are now learning that maintenance therapy mainly with pills seems to extend remissions. Now, we have people with myeloma, who are surviving 7 and 10 and more years, not cured. We don’t use that term yet because we can usually detect the presence of a few cells in the body, but this is turned from a very deadly disease to something that’s manageable and can lead to a long and productive 05:13.

Dr. Linda Austin: What is the quality of their lives, five years out?

Dr. Robert K. Stuart: It depends a lot on what problems they had to begin with. We used to have a lot of people that because to spine fractures had chronic pain. Now, we have developed techniques that actually overcome that. We can actually re-expand those collapsed vertebral bodies and relieve pain, so the quality of life is actually quite good.

Dr. Linda Austin: Any interesting research going on here at Hollings in multiple myeloma?

Dr. Robert K. Stuart: Well, first of all, we have the oldest and largest bone marrow and stem cell transplant program in South Carolina established in 1987, and we have done over 700 stem cell transplants here. Currently, the most common condition for which we perform stem cell transplant is multiple myeloma. We do it for other diseases as well. So in terms of that option, people really don’t have to leave home to get that part of the treatment. There are also some very exciting new drugs. The drugs that have been approved for multiple myeloma just in last five years include thalidomide, Revlimid, Velcade, that’s three I can think of just off the top of my head brand new. A lot of our research now is looking at how to integrate and combine these various effective therapies in ways that give people the best response rates, the best quality of life and minimize the side effects.

Dr. Linda Austin: So, some of the clinical trials and now we are looking at things like drug dosage and schedule and combinations of medications that we already know are effective, which is don’t necessarily the optimal way to combine them in dosage.

Dr. Robert K. Stuart: This is exactly right, very well put.

Dr. Linda Austin: Dr. Robert Stuart, thank you so much for talking with us today.

Dr. Robert K. Stuart: Thank you.

Announcer: If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection at 1-843-792-1414.

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