January 28, 2021

As we look forward to what we hope will be a much better year ahead, it is heartwarming to see that important research continues and can guide the way to scientifically based decision-making. A whole range of recent publications informs best practices for myeloma care. Unfortunately, the approach to COVID-19 infections remains part of our management strategies for the foreseeable future. 

Standardized use of PET/ CT scanning

PET/CT scanning is currently the accepted technique to confirm the absence of myeloma disease outside of the bone marrow in patients achieving a complete response (CR) and/or minimal residual disease (MRD) negative at the 10 to minus 5 level or better. The problem has been that there have been no criteria to indicate cutoffs for a PET/CT to be negative versus positive. 

A new study published in the Journal of Clinical Oncology, with Dr. Elena Zamagni (University of Bologna, Italy) as lead author, uses special criteria called the “Deauville Criteria” to classify scan results as positive or negative—to confirm CR and MRD negativity in clinical trials with transplant-eligible patients (IFM/DFCI 2009 and EMN 02/HO95). The results are very successful and confirm that the uptake in focal lesions (FL) and bone marrow can be used to assess response and predict improved progression-free survival (PFS) and overall survival (OS) in a new standardized fashion. As a result, the current IMWG response criteria are enhanced by use of these Deauville Criteria, with full details available in the JCO manuscript. 

This is great news and really strengthens the ability to assess if patients are truly MRD negative and if they will have the correspondingly excellent outcome expected. 

Importance of circulating myeloma cells in the blood  

There is increasing interest in using blood tests to detect circulating myeloma cells when assessing a patient’s status. If there are myeloma cells in the blood, a patient is definitely not in full remission, and early progression or relapse is more likely. A recent publication from the IMF Black Swan Research Initiative team summarizes the various methods for testing, as well as the biologic role and clinical implications of circulating myeloma cells. 

Using the highly sensitive NGF (next-generation flow cytometry) method, regular testing of a patient’s blood is possible throughout the disease course, from MGUS (monoclonal gammopathy of undetermined significance) to SMM (smoldering multiple myeloma), active myeloma response and relapse states. As NGF testing becomes more broadly available, it will provide an excellent resource for accurate disease monitoring that will be complementary to the PET/CT scanning discussed above.

COVID-19 updates for myeloma patients

• FEATURES OF COVID-19 INFECTIONS: A recent paper summarizes the clinical features of COVID-19 in patients with myeloma. As we have learned from many studies now, the key points are: 
  • COVID-19 infections are very dangerous for patients with active (out of control) myeloma at the time of infection. Such patients are highly vulnerable and must receive maximum protection and early management. 
  • Vaccination is recommended, as is the strict use of masks, even two masks, as Dr. Anthony Fauci recommended this week, for a double layer of protection in higher risk situations, such as grocery shopping.
  • An immediate CT of the chest in any patient who tests positive for the virus is important check for any early lung involvement. 
  • Pulse-oximeter monitoring is also a good idea, to pick up any early drop in blood oxygen. 
  • If a patient is hospitalized, the early use of anti-COVID-19 monoclonal antibodies is excellent, if available, and extra dexamethasone can be considered.

• VALUE OF VACCINATIONS IN MYELOMA PATIENTS: The exact value of vaccinations in patients with myeloma has been questioned due to their underlying immune-compromised state and the possible impact of a patient’s ongoing therapies. A recent study evaluates vaccination in patients with CLL (chronic lymphocytic leukemia), a disease similar to myeloma. CLL patients have impaired immunity and undergo complex treatment protocols. The issues and questions are the same as for myeloma: how many patients have reduced antibody response to vaccinations? And what is the impact of different therapies?
  
  Limited data indicate that with a variety of vaccines, vaccination may frequently not achieve optimal results. Thus, although vaccination is recommended, other measures must continue to maintain protection from possible infection. Real world data must be gathered as quickly as possible to assess ongoing risks for myeloma patients. 

•  SOME GOOD NEWS ABOUT COVID-19 
  • The major surges of COVID-19 in the U.S. appear to be stabilizing, with restrictions being eased in several places including California.
  • Moderna reports that their vaccine most likely works against the new U.K. variant, which is more infectious. 
  • We hope that vaccine availability will continue to improve, especially with pending approvals for additional vaccines. 
  • Simple measures such as masks, social distancing and other precautions DO work to protect against COVID-19 infection. 
  • The anti-COVID-19 monoclonal antibodies are available and reduce the risk of serious disease. A really positive report this week describes the recovery of a gorilla at the San Diego Zoo, who was treated with the antibody cocktail.
  • Better “psychological first aid” is available to help us all be more resilient in the face of the pandemic.   

Science for the future 

Environmental science is moving forward with results that will lead to a better, greener future. Two recent examples:

• Solar technology can be used to create clean new fresh water from salt water. 
• Flight formations used by birds could hold the key to cutting airplane fuel emissions and reduce global warming. In an innovative approach, airlines are looking to learn from birds, who fly in a “V” formation to decrease wind resistance. Flights across the Atlantic and Pacific can use similar strategies.

It is great to see so many research teams committed to creating a better future for all of us, including science that will lead to both preventing cancer, such as myeloma, and better, simpler treatments. So, let us celebrate new ways forward and, in the words of Presidential Inauguration poet Amanda Gorman, be brave enough to both see and be the light! 

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