Myeloma Experts Drs. Joseph Mikhael and Rafat Abonour Discuss the Future of Myeloma

By Joseph Mikhael MD, MEd, FRCPC, FACP, FASCO
IMF Chief Medical Officer

 

When I started my work in myeloma more than 20 years ago, it was truly a terrible disease, and most patients did not live more than one to two years. I went into this field to treat the sickest of the sick. Treatment options were limited and the outlook for most patients was grim. Today, despite the fact that myeloma remains a challenging disease, I wholeheartedly believe in the IMF vision of a future where every myeloma patient can live life to the fullest, unburdened by the disease.

In 2024, the IMF added the “Future of Myeloma” session to our Patient & Family Seminar (PFS) program. At the inaugural session, we asked myeloma expert Dr. Saad Usmani (Memorial Sloan Kettering Cancer Center — New York, NY) to look into his crystal ball and tell us what the future will hold for patients with this disease.

This session of our PFS program has evolved into a dialogue between two myeloma specialists. In March 2025, the first PFS of this year took place during Myeloma Action Month at what has become an annual event in Boca Raton. The seminar was at capacity; it was wonderful to see participants who had joined us time and again in previous years as well as to meet new attendees for whom this was their first experience at an IMF educational event.

For the “Future of Myeloma” session, I invited myeloma expert Dr. Rafat Abonour (Indiana University Simon Comprehensive Cancer Center — Indianapolis, IN) to join me in a dialogue about where the journey of myeloma is headed. I consider myself to be an optimistic realist, so I approach these sessions with both realism of the fight so many have with myeloma, but also with optimism of how far we have come and how far we will go!
When we diagnose myeloma, we want to offer patients a good quality and quantity of life. Over the past decade, remarkable changes in the field have increased patient survival from an average of a couple of years to an expected survival of more than 13 years. Patients have options of exciting new treatment approaches and more intense therapies upfront.

How does the concept of “intercepting cancer” apply to the future of myeloma?

The first question I posed to Dr. Abonour addressed the ability to catch myeloma as early as possible. Early diagnosis is key to preventing complications. It is essential for us to better understand why some patients progress from the precursor states of MGUS and SMM to active myeloma while others never develop the disease. We need a deeper understanding of the role of the immune system in this process. The IMF-supported iStopMM researchers in Iceland are trying to answer these and other scientific questions.

Science is the path to a cure. It’s not just about the drugs. There is an expanding array of effective drugs being used in myeloma, but we need to better understand the science of myeloma. We can’t develop a drug to attack a myeloma target if we don’t understand the target. The model of cancer I use to explain myeloma to patients is this:

• Phase 1 is elimination by our immune system of cells that are trying to become cancerous.
• Phase 2 is the equilibrium of the control that the immune system can exert over cancer cells.
• Phase 3 is the escape of cancerous cells from being controlled by the immune system, and those cells growing in number.

Dr. Abonour and I concluded that if only we could capture myeloma at its earliest stages, we could have the potential to cure it, if not even prevent it altogether!

Will we be screening for myeloma 10 years from now, like we screen for breast cancer and colon cancer today?

Screening is usually a test for a person who is asymptomatic. For example, at a certain age you get a colonoscopy or a mammogram. My father sadly died of colon cancer, so I started my colonoscopies earlier due to my family history. In myeloma, primary care physicians diagnose 70% of cases. The average patient sees their doctor three times before the diagnostic pathway is triggered, so the IMF is working to raise awareness at the physician education level.

Dr. Abonour said that screening is not yet the key. Rather, the key is in educating both patients and doctors. Doctors need to know where to look and patients need to be empowered to ask questions about their symptoms. If myeloma is suspected, a doctor can do a needle biopsy to see if plasma cells are present or not.

My position is we already know that the rate of myeloma goes up after age 65 and that people of African descent have twice the risk of myeloma. So, although we do not screen everyone for myeloma until we have concrete guidelines, there may be grounds for screening based on specific factors in certain patients.

Dr. Abonour and I concluded that until we have a concrete plan for general screening to facilitate early and accurate diagnosis, it is critical right now to raise awareness of the signs and symptoms of myeloma in the lay and medical communities.

Will frontline therapies 10 years from now still include transplants? Or bispecific antibodies or CAR T-cell therapies?

The myeloma drugs we are using currently are working well in relapsed or refractory multiple myeloma (RRMM), even in patients with high-risk disease. Clinical trials must first test treatment approaches in RRMM patients and only later in newly diagnosed patients, but if a drug is able stimulate the immune cells to destroy myeloma cells in RRMM patients, it’s likely that it’s also going to work well in the newly diagnosed patients.
In the words of Dr. Abonour, “Patients need access to effective drugs in the frontline setting. Why wait until the patient relapses? Truly, we’re close to being able to cure patients!” 

We agreed tha the future of myeloma treatment is in immunotherapies rather than in transplant. Using drugs like bispecific antibodies early and in the right sequence is highly promising. We look forward to data being reported soon from clinical trials using bispecific therapies or using CAR T-cell therapies in the frontline setting.

Over the last two years, we’ve been able to markedly reduce the amount and the severity of cytokine release syndrome (CRS) and the neurological toxicities seen with CAR T-cell therapy, but this approach is still more involved than using a bispecific antibody. First, we must harvest the T cells, wait for them to be modified and multiplied in a lab, then give them back to the patient. Dr. Abonour is a little reluctant about using CAR-T in frontline therapy until we have longer follow-up and know why some patients develop side effects.  However, newer CAR T-cell therapies being studied are demonstrating amazing efficacy and improved safety.

Dr. Abonour and I concluded that the future of myeloma has a lot to do with CAR T-cell therapies and bispecific antibodies and their use even earlier in the disease course, as opposed to transplant.

WHAT will a cure look like in multiple myeloma? No, I’m not asking HOW we will cure myeloma.

Will a cure of myeloma look like two years of intense therapy, followed by my favorite therapy… NO therapy!? Will a cure look like taking a daily pill for the rest of your life (with no side effects)? Will a cure look like controlling myeloma with medication, like we now control high blood pressure? Or will a cure be a balance between those things?

The IMF’s mission is to support patients throughout their myeloma journey while we seek prevention and a cure. As an optimistic realist, I’m always careful when I use the word cure. The optimistic part of me says, “We’ve come so far, patients are living longer and betterand, as it were, dying of something else like old age.” But I also know the struggle that we have in controlling this disease.

Dr. Abonour thinks that the right answer is balance. “Going to a clinic every week to get a shot or an infusion, to be on pills the rest of your life that may cause fatigue or anemia, is that really a cure? I think a cure is keeping the disease at bay while you live your life to its fullest. And I think we have the tools today to make this happen. We have effective drugs that we can use wisely. Using zoledronic acid once every three months is effective in preventing bone destruction in our patients, and we can use some of the newer anti-myeloma drugs in a similar way. Patients can get a tune-up to try to keep the disease from interfering with their life.

“If we maintain patients in remission for 5 years, whereby sensitive imaging and testing we don’t find myeloma, then we can start taking them off treatment so these patients can live longer without any drugs. This is what gives me hope that we can aim to cure myeloma. We’ve come a long way in the field of myeloma, and we’re getting closer every single day to truly controlling it in such a way that people can consider themselves to be cured.” Beautifully phrased, Dr. Abonour!

Join us!

Some patients at the Boca Raton PFS have lived with myeloma for more than 20 years, and many are living a good life. One of the goals of IMF meetings is to hear about both the struggles and the successes that patients are experiencing.

IMF seminars also include sessions on controversies in myeloma, therapy for newly diagnosed and relapsed/refractory disease, supportive care and management, the connection between diet and cancer, what causes myeloma, shared decision-making, clinical trials, navigating the financial journey, and more. Each PFS meeting has so much to offer that I highly encourage all members of the myeloma community to attend one of our upcoming 2025 seminars:

 

• Los Angeles Patient & Family Seminar on August 15-16, 2025
• Chicago Patient & Family Seminar from October 3-4, 2025