This week, the IMF is launching a new initiative to provide current recommendations for myeloma management for the busy physicians, pharmacists, and nurses who are on the frontlines of providing patient care. The impetus for the initiative is the recognition that community health care providers need, and value, up-to-date expert recommendations delivered in convenient formats over a variety of platforms—video, online, in print, and in person.
The first program in this effort focuses on the use of the proteasome inhibitors bortezomib (Velcade®), carfilzomib (Kyprolis®), and ixazomib (Ninlaro®). This is a key area of educational need and is the subject of a series of six videos that use the “Ask Dr. Durie” format, but are designed to be viewed by doctors. In the videos (available soon to doctors through Medscape as part of a curriculum for continuing medical education credits, and to patients and caregivers on the IMF website), I interview Drs. Joseph Mikhael (IMF), Shaji Kumar (Mayo Clinic), Tom Martin (University of California, San Francisco), and Saad Usmani (Carolinas Medical Center) about different aspects of proteasome-inhibitor use.
As part of this effort to connect to community physicians, Paul Hewitt of the IMF’s Infoline team has reached out to support groups across the US and received names and contact information for doctors who provide day-to-day treatment for myeloma patients. The IMF will send these doctors copies of key disease-management guidelines, with brief “top line” introductory comments, designed to be a helpful resource for making diagnostic and treatment decisions.
Preparing for community “Grand Rounds”
This past weekend, a group of myeloma experts gathered in Los Angeles to prepare slides and other educational materials for the second project in the IMF education initiative, conducting virtual and in-person “Grand Rounds” seminars for community hematology-oncologists across the US. Interestingly, this exercise revealed a disparity between the regimens these myeloma experts use to treat patients at their own centers and the more formal regimens recommended in treatment guidelines issued for community physicians to follow.
For example, the myeloma experts agree that carfilzomib (Kyprolis) has superior efficacy versus bortezomib (Velcade). But the FDA-approved carfilzomib dosing schedule—given for two days per week (to maximize efficacy)—is considered very inconvenient by both patients and the myeloma expert doctors who treat them. So, the experts, who have the experience that accrues to those working in large centers, may be inclined to modify the “approved” two-day approach and dose their patients once weekly, while their community doctor counterparts, who see far fewer myeloma patients, are stuck with following the more rigid recommendations. The result is that the community doctor and the patient might opt for a more convenient, yet less effective drug than Kyprolis.
This practice highlights the need for multiple phase II trials to validate the efficacy of practical, user-friendly regimens frequently used in the clinic. This was a mandate coming out of the 2017 International Myeloma Working Group (IMWG) Summit in Madrid. But so far, only a few trials of user-friendly regimens are in progress.
The difficulty in developing practical guidelines
In truth, making the best recommendations for physicians who are on the frontlines of providing care is quite difficult. Preferred treatment regimens must not just work well, they must also be manageable in terms of out-of-pocket expense, logistically feasible for clinic visits, and, of course, have acceptable or manageable side effects. The mSMART guidelines for frontline and relapse therapy attempt to reconcile these aspects as best as possible.
It does not help doctors’ decision-making process that there is so much controversy surrounding drug costs and healthcare spending overall. A recent White House panel recommends determining “value” for increasingly expensive cancer treatments. Determining the “value” is the problem. This is especially true for the many new CAR T-cell approaches that are now emerging. Just this week, yet another trial—this time with Sorrento Therapeutics—was announced, led by Dr. Edward Stadtmauer at the University of Pennsylvania. Last week, a trial from Cartesian Therapeutics, called Descartes-08, was announced. There are many exploratory trials with potentially huge price tags for whichever regimen(s) turn out to have the most favorable outcomes. The true value of CAR T-cell therapies remain yet unknown.
For now, it is crucial to guide both treating physicians and patients to use available, effective therapies, and reserve CAR T-trials for the most appropriate, later-relapse settings.
Educating community pharmacists and nurses
The third phase of the new IMF initiative is to extend education beyond doctors to pharmacists and nurses at the community level. This will greatly enhance the quality of care. And if this pilot project goes well over the coming months, our intent is to cover all aspects of myeloma.
So, please wish us luck as we embark on this new educational initiative, which I am convinced will make a big difference in community-level care.
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®.