Myeloma Is Many Diseases, and Treatment Must Reflect That

For Nikhil C. Munshi, MD, the biggest change in multiple myeloma is not a single drug but a shift in what patients can expect. Munshi, director of basic and correlative science, Jerome Lipper Multiple Myeloma Center; professor of medicine, Harvard Medical School/Dana-Farber Cancer Institute; and member, IMF Scientific Advisory Board, began his career when treatments and responses were few and survival was short.

Today, he said, the picture is very different. “We believe that today we are curing around 25% to 30% of the patients,” Munshi said in an interview with The American Journal of Managed Care^®. In his view, moving myeloma from incurable to curable is the most important end point the field has reached. Still, challenges remain.

“What keeps me up at night is that patients still relapse,” he said. Although therapies can eliminate millions of myeloma cells, he explained, it is the few cells that survive that drive the disease, so the field must find ways to help every patient reach cure. Access is his second concern, because the best treatment cannot help a patient who cannot receive it, he said—making improved access a challenge to be solved.

Scientifically, Munshi pointed to the recognition that myeloma is not 1 disease. Genomic and laboratory studies have shown that 2 myelomas that look alike can behave very differently and lead to disparate outcomes. That realization is pushing researchers toward understanding each patient’s disease before treating it. Yet, DNA alone does not tell the complete story, he said. RNA, metabolism, and interactions with the microenvironment all influence the cellular state, and myeloma’s ability to change state helps cells resist treatment. The task ahead, Munshi said, it to look beyond a single cell to the entire ecosystem.

He summed it up this way: “DNA tells us what myeloma can become. The cell state tells us what it is today and what it may do to survive tomorrow. That intersection, he added, is what researchers must understand to make a greater impact in this disease.