For the fourth year in a row, a group of physicians from leading medical institutions in China came to Los Angeles to learn about myeloma during the International Myeloma Foundation’s unique Myeloma Master Class. During the course of the seven days, they expanded their knowledge of what is possible in treating myeloma patients in China, and we learned about the challenges facing these incredibly dedicated and enthusiastic young physicians.
This year, the physicians came from centers in Beijing, Tianjin, Guangzhou, Fuzhou, Hangzhou, and Shanghai. They were taught by a group of highly experienced myeloma specialists: Joseph Mikhael, MD (Mayo Clinic); Tom Martin, MD (Helen Diller Family Comprehensive Cancer Center), Amrita Krishnan, MD (City of Hope), and Robert Vescio, (Cedars-Sinai Samuel Oschin Cancer Center). The Master Class components included teaching elements, such as lectures, case discussions, and summary presentations in English by Chinese physicians. The doctors also received some experiential learning, including a visit to the City of Hope National Medical Center, participation in the IMF’s Los Angeles Patient and Family Seminar, and participation in individual patient consultations.
Which myeloma treatments are available in China?
There were many important and memorable aspects of this year’s course. Firstly, all the physicians were very interested in how the information we presented in Los Angeles could apply in their hospital situations back home. Key discussions centered on “resource-stratified guidelines” – What tests can be performed? Which treatments are available in China?
The International Myeloma Foundation (IMF) and the International Myeloma Working Group (IMWG) have focused on resource-stratified guidelines for Asia in order to provide the best guidance when some baseline or monitoring tests are too expensive and/or many novel agents are not available and/or are also too expensive.
For example, in China, fluorescence in situ hybridization (FISH) testing and advanced imaging such as MRI or PET/CT may not be routinely possible. Both Velcade® and Revlimid® are available, but many patients cannot afford the costs of four cycles of Velcade in order to obtain five cycles for free or three cycles of Revlimid® to obtain 9 cycles free – which are the standard protocols for drug access outside the US. Carfilzomib and pomalidomide are not currently available in China. Fortunately transplant, both autologous and allogenic, is available within the healthcare system, although patients need to buy the melphalan, typically in Hong Kong. Thalidomide for maintenance post-transplant or for part of induction is available through a local Chinese company.
Seeing 80 patients each day
The added burden for Chinese physicians is their heavy workload, which can require them to see 80 patients each day, giving limited time with each patient, as well as little time at the end of a long day. It is apparent that providing the best care on an individual basis can be quite challenging. At the larger referral centers in Beijing and Shanghai, for example, 60 to 70 percent of patients are able to afford Velcade®. At some smaller centers, this drops to as low as 30 percent. This means that a backup treatment, such as the much cheaper and readily available combination of Cytoxan/Thalidomide/Dexamethasone (CTD) may be used.
This situation creates unique questions, such as: How effective is CTD followed by ASCT versus Cytoxan, Velcade (bortezomib), Dexamethasone (CyBorD) followed by ASCT? The relative benefits of CTD versus CyBorD in this setting are unknown. However, CTD is likely adequate for standard-risk patients. However, in higher-risk patients, the use of Velcade definitely improves outcomes as the Chinese physicians are well aware. Discussions along these lines during the Master Class were difficult but ultimately fruitful in identifying the best options under the circumstances.
As the Chinese physicians listened to and participated in individual consultations with myeloma patients, the reality of the many differences between American and Chinese medical care became apparent. We have much more time to spend with patients—as much as 20 to 30 minutes each in this course setting, versus 1 or 2 minutes in the clinic in China. In the US, doctors have more time to learn the patient’s true concerns and wishes, time to consider needed tests and review treatment options. And those options are so much greater, with many new agents available commercially or within trials in the US.
There was a definite note of sadness in the Chinese doctors, but it was countered by their excitement about what can hopefully be available soon. As one physician wrote upon her return to Beijing, “The new knowledge made me excited…I came back with a different mind to understand disease and medicine.”
Accessing myeloma education on China’s YouTube
Another challenge for Chinese physicians is access to new information. We learned that some online myeloma educational media is not accessible via YouTube in China. The IMF communications team worked with the Chinese physicians to load episodes of “Ask Dr. Durie” and other IMF educational videos onto “YouKu,” the Chinese version of YouTube. The doctors were also given flash drives, loaded with IMF videos, manuscripts, and other materials. All of this was truly a learning experience of how to help provide current and ongoing information in a timely manner.
There were also opportunities to discuss potential clinical trials and research projects. The IMF Team (Susie Novis, Brian Durie, Lisa Paik, and Dan Navid) will visit Beijing in October 2015 and will be able to follow up and consolidate ongoing plans.
Dr. Brian G.M. Durie serves as Chairman of the International Myeloma Foundation and serves on its Scientific Advisory Board. Additionally, he is Chairman of the IMF's International Myeloma Working Group, a consortium of nearly 200 myeloma experts from around the world. Dr. Durie also leads the IMF’s Black Swan Research Initiative®.