March 18, 2021
Despite the challenges COVID-19 presents around the world, myeloma researchers are carrying on. Two helpful myeloma publications appeared recently in the journal Blood.
The role of dexamethasone
Dr. Meletios Dimopoulos (University of Athens) and colleagues published the results of a phase II study in which dexamethasone was added to treatment with the monoclonal antibody against CD38 isatuximab, which is approved for use in the U.S. and Europe. In this randomized study 109 patients received isatuximab alone and 55 patients had weekly dexamethasone added (at a dose of 40mg or 20mg for patients over age 75). The results were quite convincing. In these relapsed/refractory patients, adding dexamethasone to isatuximab increased the response rate from 23.9% to 43.6% and the progression-free survival from 4.9 months to 10.2 months. There were no detrimental effects on safety with the combination.
In an accompanying commentary in Blood, Dr. María-Victoria Mateos (University Hospital of Salamanca, Spain) and Dr. Verónica González-Calle (University Hospital of Salamanca, Spain) concluded that the added value of dexamethasone is clearly shown. However, they note, there was no quality-of-life assessment to evaluate the well-known intolerance to dexamethasone in some patients. It is truly surprising that the value of dexamethasone first documented in the 1980s and 1990s continues to emerge 40 years later as a clinically relevant addition in combinations of new immunotherapies.
The importance of the 17p- chromosome deletion
Dr. Jill Corre (University Hospital, Toulouse, France) and colleagues confirm the poor prognostic impact of the presence of the 17p- chromosome deletion in patients. This is important since recent studies have emphasized the especially poor outlook in patients with what is called a “double hit”—when one of the two 17p chromosomes is lost or deleted and the other chromosome has a 17p that is mutated, making it non-functional. This new study confirmed the poor situation for such patients, with a survival of 36 months. It also showed that the occurrence of the 17p- deletion alone really reduced anticipated survival from 152.2 months to 52.8 months. This finding is very important in assessing outcomes in ongoing clinical trials and re-focuses attention on the need for better therapies for such patients. (I answer a patient question about the 17p- chromosome deletion in this video.)
Understanding the nuances of COVID-19
The source: The source of COVID-19 remains controversial. However, a new report suggests that the COVID-19 virus may have emerged from wildlife farms that are part of a 20-year Chinese government project to feed the poor living in rural areas.
These farms breed exotic animals, including porcupines, civets, pangolins, raccoon dogs and bamboo rats. Several of these animals have been suspected as the source of COVID-19. As usual, more research is required, but this awareness is key in efforts to prevent future pandemics.
The evolution of new variant strains: There is considerable public concern currently about the occurrence and spread of new (and potentially more dangerous) COVID-19 strains. A recent article highlights infections in those with weakened immune systems. When the immune system is weak there is a greater chance for virus levels to build up and allow new variants develop.
This argues strongly for the early vaccination of vulnerable populations in whom these scenarios may play a leading role. Fortunately, in most states, vaccination IS being made available to those with myeloma and I strongly encourage all to proceed to get vaccinated as soon as feasible. Obviously, please discuss planning with your doctor to make sure there are no particular concerns in your case.
Which vaccine to receive: The priority is to get whichever vaccine is available. The Pfizer and Moderna vaccines are clearly excellent. The Johnson & Johnson vaccine has slightly lower overall efficacy but has 100% efficacy in preventing hospitalization and serious disease. The notion that the J&J vaccine is a live vaccine that should be avoided is simply not true. The J&J vaccine uses only a small piece of the coronavirus, not the live virus itself. The convenience of the one dose is quite important, especially in rural communities.
The AstraZeneca vaccine has been under evaluation in Europe, with some vaccinations being stopped due concerns over reports of blood clots. There were 57 instances of individuals with blood clots out of several million vaccinated—a level not higher than in the general population. And on Thursday, the European Medicines Agency ruled that the AstraZeneca vaccine is safe and effective.
Continued safety precautions: Despite the accelerated rollout of vaccinations, it is still very important for myeloma patients to continue safety precautions in public, especially by wearing a mask. A new study suggests why masks may be so effective in reducing virus spread. It turns out that a combination of humidity, the impact of mucous and the way in which the immune system is triggered may all be important.
Separately it has emerged that the new COVID-19 variants are more likely to infect young adults and children. Thus, although children have been considered to be at a much lower risk, this may not be true with the new variants.
Bottom line on COVID-19: Continued mask-wearing is really important to reduce spread. Limiting travel, especially on airlines, is also recommended until community levels of infection are much reduced. We now have several cautionary tales: Italy has had to re-impose lockdowns because of spikes of infection from the new variants and serious second waves have occurred in Malta and Hungary.
Some Good News
As of now, one in 3 Americans has received at least one COVID-19 vaccine shot. This will really start to slow the spread of the virus.
As of today (Thursday, March 18), the U.S. will have reached the promised target of 100 million vaccinations in the first 100 days of Biden’s presidency and one month early!
We have heard in the past about the value of monoclonal antibody treatment for those with COVID-19 infections and there is continued evidence of benefit.
For anyone unfortunate enough to develop ongoing serious lung infections, a device called ECMO (extra corporeal membrane oxygenation) is now being used. It’s basically a backup heart-lung machine designed to take over when the body is not getting enough oxygen. The ECMO machine has saved the lives of a number of very sick patients and it is helpful to know this extreme measure is possible for seriously ill patients. We sincerely hope that the number of patients requiring this type of drastic approach will soon be very few indeed.
And finally, there is a true sense of optimism right now as more restaurants, movie theaters and businesses reopen (even operating at 25% capacity is a positive move), including the Disneyland parks in California.
Stay safe. Get vaccinated. Wear a mask. And be optimistic that together we are moving in a good direction and we WILL get through this together. As artist David Hockney said so well last year with a beautiful painting of bright yellow daffodils in full bloom, “Do remember they can’t cancel the spring.”
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®.