Seventy years ago, the only way to treat cancer was to either “cut it out or burn it away with radiation”. Meanwhile, any that couldn’t be surgically removed or irradiated, like blood cancers, were essentially untreatable. Yet, fast forward to today and we’re seeing some blood cancer patients reach ten years of remission thanks to a whole array of new, breakthrough therapies, coupled with a deeper understanding of the mechanisms of disease.
September marks Blood Cancer Awareness Month, a prime opportunity to highlight some of the lesser-known cancers, including multiple myeloma. Despite being the second most common type of blood cancer in Europe, multiple myeloma is not well known outside of the medical community. In Ireland, approximately 2,200 people are living with multiple myeloma and around 350 people are diagnosed with it annually.
Multiple myeloma occurs when healthy plasma cells become abnormal, multiply and produce abnormal proteins that cause complications. Plasma cells are white blood cells that form part of the immune system and originate in bone marrow. Myeloma cells “crowd out” healthy cells, like weeds crowding out healthy plants in a garden. As a result, the bones, kidneys and the body’s ability to make healthy red and white blood cells and platelets are affected.
While researchers have yet to pinpoint exactly what causes the plasma cells to become abnormal, it is known that genetic alterations play a central role. Multiple myeloma commonly occurs in people over sixty, those with a family history of the condition and those exposed to certain chemicals or radiation. It is slightly more common in men than women.
In the past two decades, survival rates have soared. Irish data shows that the five-year net survival for someone diagnosed with multiple myeloma has increased from 27 percent to 64 percent in the period from 1994-2018.
Recognising the symptoms
A complex condition, multiple myeloma varies from person to person, often with symptoms that can be difficult to initially detect. A collection of symptoms referred to as ‘CRAB’ may emerge as the condition develops:
· Calcium in the blood - Hypercalcaemia or too much calcium in the blood, due to bone cells being destroyed can manifest as muscle weakness, constipation, exhaustion, dehydration and poor appetite.
· Renal damage - As myeloma cells release proteins, the kidneys can stop filtering waste properly leading to fluid retention and nausea.
· Anaemia - A lack of red blood cells can cause fatigue and shortness of breath.
· Bone damage - Myeloma cells can destroy bone tissue creating soft spots resulting in pain, swelling, fractures, osteoporosis and numbness.
To reach diagnosis, clinicians use data from blood and urine tests; scans including x-ray, MRI, CT or PET; as well as bone marrow biopsies to determine patients’ stage of disease progression and risk category.
The evolution of treatment
In the past, treatment options for blood cancers, including multiple myeloma, were limited to chemotherapy and steroids. While chemotherapy is an effective and well-established systemic treatment, the side effects can be difficult for some patients to tolerate.
Advances in medicine have revolutionised the standard of care for multiple myeloma as stem cell therapy and targeted immunotherapies have come on-stream. For younger and medically fit patients, a bone marrow transplant in conjunction with chemotherapy may be offered.
Immunotherapy uses the power of a patient’s own immune system to attack cancer. The development of immunotherapies offers the potential to change the treatment paradigm for all types of multiple myeloma patients regardless of their age or whether they are newly diagnosed or experiencing a relapse.
With a growing armamentarium of treatments, we are no longer approaching blood cancer ‘one medicine at a time’, but combination treatments open the door to more effective treatment plans for patients, including those experiencing resistance to any one medication or those who have failed to respond to multiple previous options.
Recently, significant research and development has paved the way for new targeted immunotherapies which have helped transform the treatment journey for people with multiple myeloma. Foremost among these are T-cell redirecting bispecific antibodies which expand the power of antibody medicines by grabbing two surface antigens at once to activate the patient’s own T-cells to kill their tumour cells.
In January this year, the first ever clinical study in Ireland of CAR-T cell therapy for treating multiple myeloma opened at St James’s Hospital Dublin, supported by Janssen. The trial, CARTITUDE-5, is a multicentre global study which seeks to evaluate the efficacy and safety of CAR-T as a frontline therapy in people newly diagnosed with multiple myeloma.
Janssen has been at the forefront of these advances of precision medicine (or personalised medicine) in the management of multiple myeloma. Our portfolio in multiple myeloma includes compounds with different modes of action and multiple combination options to best address the unmet needs that we and the multiple myeloma community have identified together through research. As our current medicines portfolio continues to expand, we will have the ability to treat all patients across all stages of the disease.
The need for a holistic approach
While these treatments mark a great step forward, people living with multiple myeloma require holistic care, tailored to their individual needs. The burden of both the disease and its treatment often goes under-addressed. In real terms, the impact on everyday life can range from mild to profound, affecting patients’ physical function; emotional, psychological, and social well-being; ability to work; and relationships. Acknowledging distress early on and consolidating a support network centrally is important for patients going through treatment. In conjunction with the supervising clinician’s advice, certain lifestyle modifications such as prioritising sleep, a balanced diet and reducing stress can be implemented to support the immune system during treatment.
Multiple Myeloma Ireland (MMI) is the only charitable organisation in Ireland focused on multiple myeloma, providing invaluable support to patients, carers and healthcare professionals through education, advocacy and research. Janssen is proud to collaborate with MMI, supporting their activities which can assist the patient community.
To conclude, it excites me to think that we might reach a point in my professional lifetime where we can not only make it easier for multiple myeloma patients to manage their disease, but actually provide them with a functional cure. That, ultimately, is the future of multiple myeloma care we all want. Together, we can create it.
If you are concerned about any symptoms mentioned in this article, you should contact your doctor for medical advice. If you or someone you know is affected with multiple myeloma, or you require further information, visit https://www.multiplemyelomaireland.org/
References available upon request