In this MD Newsline exclusive interview with oncologist Dr. Onyemaechi Okolo, we discuss her treatment strategy for multiple myeloma. We also discuss the newest treatment for multiple myeloma and how to diversify cancer clinical trials.
What is your treatment strategy for multiple myeloma, and how is it tailored to each patient? How do these treatments work? How do you decide when to switch treatments?
Dr. Onyemaechi Okolo:
“So before you start treatment, you must determine if the patient is eligible for a stem cell transplant. Drug treatment usually involves a three-drug regimen consisting of an immunomodulatory drug, a proteasome inhibitor, or a monoclonal antibody, and a steroid. A three-drug regimen is usually going to be used, whether or not the patient ends up getting a stem cell transplant. What changes is the duration of the cycles.
So, if a patient is going to receive a transplant, they’ll usually receive three to four cycles of this three-drug regimen, followed by stem cell collection. Once the stem cells are collected, they may receive the transplant at that point, or they continue with the three-drug regimen until the first relapse, and then they would receive the stem cell transplant.
The decision about treatment choice is going to be personalized based on the patient’s performance status, comorbidities, age, and their preference. So, although the backbone is a three-drug regimen, for an older patient, it can be modified to a two-drug regimen or even a one-drug regimen.
And then, when it comes to relapse, we’re looking at specific numbers on the patient’s blood work, such as their M-protein and their kappa-lambda ratio. If the patient’s numbers are initially going down or their M-protein is nonexistent, and then all of a sudden starts coming up, that’s a relapse, and we would need to switch therapy.
We typically don’t expose patients to drugs that they’ve already had before, and thankfully there are a lot of different drugs that allow us to do all these different combinations.
So the treatment becomes really tailored to each particular patient. And subsequent treatment planning is going to be based on what they’ve already been exposed to and what they can tolerate.”
Is there any research that excites you or that you think is important for physicians to know related to the diagnosis and treatment of multiple myeloma?
Dr. Onyemaechi Okolo:
“So right now, the newest treatment option for myeloma is CAR T cells. That’s chimeric antigen receptor T cells. The drug that’s been approved most recently for myeloma is idecabtagene vicleucel or ide-cel. So, this CAR T cell therapy was granted accelerated approval by the FDA, and it’s indicated after four or more lines of systemic therapy, including a proteasome inhibitor, an immunomodulatory agent, and an anti-CD38 monoclonal antibody.
When we do a three-drug regimen, in most cases, people are already being exposed to two. After their first relapse, they may get exposed to the third one. So, by the third relapse, they would already be eligible for CAR T cell therapy. So you don’t have to wait and wait to be eligible for this new treatment.
Like all treatments, you have to be aware of potential side effects. With CAR T cell therapy, the biggest concern is cytokine release syndrome, which presents with fever, hypotension, mental status changes, etc. You can also have neurologic events. Other side effects include those we typically see in cancer treatments, such as infection and prolonged cytopenias.
So idecabtagene vicleucel is really the biggest treatment on the scene right now for myeloma.”
How do you think we can increase recruitment and enrollment of diverse groups in cancer clinical trials?
Dr. Onyemaechi Okolo:
“So this is a big topic across all cancers. Many cancer groups are making it a priority to recruit more diverse patients to clinical trials. Major cancer societies like the American Society of Clinical Oncology, the American Society of Hematology, and the International Myeloma Foundation have made it a priority.
There are programs that are geared towards increasing minority investigators where young oncologists engage with them and decide if they want to become clinical trialists. It makes a difference if you see somebody who looks like you treating you. You know?
They’re also trying to create more courses to help physicians understand cultural differences and teach patients that most trials do not cost them directly. Cost or the fear of cost is also a big hindrance to people.
It’s important for oncologists to take the time to cultivate good relationships with their patients and feel comfortable offering clinical trials to all of their patients.
There is sometimes an unintentional bias when a physician will see somebody who they want to care for, but they worry if they offer them a new drug, it might impact their ability to pay their bills. So they’ll hold back on giving them options that they would have given somebody else, not because they’re being mean, but because they think they are helping.
So it also means educating oncologists to present all the options. Don’t be paternalistic. Let the patient decide for themselves. And that comes from mutual comfort between the physician and the patient.
It’s a lack of trust in the medical system that’s one of the biggest hindrances for why Black patients are suspicious about clinical trials. We’ve all heard about HeLa cells. We’ve all heard about Tuskegee. So, for a lot of Black patients, when you hear clinical trial, you hear ‘experiment.’
So, it’s a lot of education, building trust, and having people who look like them and have cultural competency. These are all of the factors that are going to lead to increasing recruitment and enrollment of a more diverse patient population in clinical trials.”
Responses have been condensed and lightly edited.