Dr. Joseph Mikhael

Early detection, personalized treatment and strong support systems are key to improving outcomes for multiple myeloma patients, Dr. Joseph Mikhael explains.

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 this 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.

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. 

Dr. Joseph Mikhael

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