MMR Vaccine Safety & CAR‑T Eligibility, and More: Top 10 Myeloma Patient Q&A  

Dr. Joseph Mikhael: 

What are the first things you should and shouldn't do when you receive your diagnosis of multiple myeloma? Do myeloma patients need to be concerned about the rise in measles? Are there any myeloma treatments that would affect your eligibility for CAR T-cell therapy? Hi everybody. Dr. Joseph McHale here, Chief Medical Officer of the International Myeloma Foundation. On a regular basis, I host a live Q&A at facebook.com/myeloma to answer the questions of the myeloma community. Unfortunately, we can't get to all the questions during the live Q&A, I have the privilege of answering some of them with you today. Please feel free to reach out to us. Use the #AskTheIMF through any of our channels, be it Facebook, be it Instagram, be it X, to bring your questions to us and I'll do my very best to answer them. We've got a lot of great questions today, let's get to it. 

Here we go with question number one from Peggy. "When do you think it is appropriate to receive the MMR vaccine after undergoing an autologous stem cell transplant? Generally, should I be concerned about the rise in measles?" This is a hot topic, isn't it? And the short answer is we all should be concerned about what's happening with measles, but this is rather complicated for the myeloma patient. To specifically answer Peggy's question, the guidance that we have and the guidelines that we have would say that people should not receive the MMR measles, mumps, rubella vaccine until at least two years after an autologous stem cell transplant. The reason for this is the measles vaccine is what we call a live vaccine, meaning we give a tiny amount of measles to people to trigger their immune system, to build antibodies, to fight measles. And if you're in a situation right after a transplant where you don't have that ability to produce antibodies, it could be a problem. 

And in fact, patients can actually develop measles from the vaccine. Now, of course, that's extremely rare, but we want to be careful in a disease like myeloma that affects the immune system that we make sure the immune system can respond to a vaccine. As you're thinking about measles in general, I give this guidance to my myeloma patients. Number one, be aware of your surroundings. Are you in an area where there has been an outbreak? Number two, know your titers if there's going to be a consideration of getting the measles vaccine. Even though as a myeloma patient, your immune system can be weakened by the disease or by treatment, very often the titers that you have from previous vaccinations are still okay. And it may be helpful and may be valuable with you and your healthcare team to discuss the level of your titer. 

And then number three, in some unusual circumstances, but still important, we may look at other measures of your immune system, things like a CD4 count that tell us about your susceptibility to infection. Really what bathes all of this is the importance of discussing this with your healthcare team to decide, "Do I need the vaccine or not? What precautions should I take or not take considering the potential of measles in my community?" Great question, Peggy. We really appreciate you asking it. 

Here's another question from my friend Todd. By the way, shout out to you, Todd, for the wonderful video that you did with us. It's amazing how many people are watching your video and touched by your personal experience with multiple myeloma. And if you haven't seen it, by the way, go to our YouTube channel and you can watch Todd Kennedy. "Is myeloma curable? How do you define cure? Do you predict patients being cured?" 

This might be one of the most common questions we receive. One way, Todd is to ask you, how do you define cure? Or to ask any of our listeners, how do you define cure? We may have medical terminology to define it, but I always want to define it the way a lay person on the street would. If I walked up to someone on the street and said, "How do you think a disease is cured?" They typically say, "You get treated, you stop treatment. You don't have to think about it again." That's how I would love to describe cure in multiple myeloma, we give people a defined period of treatment and then their disease goes away, they don't have to think of it again. We've always had a very small fraction of patients over the years who with very limited treatment have gone into very long remissions, but thankfully that number, that fraction is growing. 

I'm not saying that we're curing the majority of myeloma patients, but we are definitely seeing such an improvement as people live longer and the proportion of patients that go for long periods of time off treatment or on minimal treatment is growing. As we work towards a cure, we're not going to wake up one morning and all of a sudden instantly have a cure. It is step by step making the disease more controllable, making the disease more chronic before we make the disease curable. Great question, Todd. Appreciate it very much. 

Here's another friend of mine, Steve, great question Steve, "Do you encourage clinical trials at each stage of treatment?" The quick answer is yes. Clinical trials are fundamental to moving the field forward, whether it's in precursor conditions like smoldering myeloma, frontline therapy, relapse therapy in the context of transplants, supportive care at every stage and at every level of myeloma, we encourage people to participate in clinical trials, speak to your healthcare team about it, not just because it helps the field, because it may help you in a way that standard therapies cannot. 

Another great question from Frank, "If a patient is refractory to REVLIMID, would they have a higher rate of relapse with the entire class of IMiDs or immunomodulatory drugs?" To be clear, when we say refractory, it means that someone's disease grows while on REVLIMID. Frank, the short answer is we have other drugs in that class right now, pomalidomide or Pomalyst that can overcome resistance to REVLIMID. Even if someone is refractory to REVLIMID so their disease is growing while they're on REVLIMID, we can use a pomalidomide-based combination and see response to it. Just because two drugs are in the same class, it doesn't mean that they exclude each other from subsequent treatments. I'm noticing a lot of great questions are coming from our support group leaders, and this reminds me to share with you the importance of support groups. In fact, we've demonstrated unequivocally when people are connected to a support group, it facilitates their shared decision-making with their healthcare team and improves their outcomes. 

The IMF supports over 150 support groups in the United States, and we'd encourage you to learn more at support.myeloma.org and find a support group near you or one that is done virtually so we can help you in the best way possible. 

Donna asks, "Just got my measles titer checked since my stem cell transplant was in May. Can all childhood diseases be titered so I can avoid getting revaccinated at my two-year anniversary?" That's a great question, Donna, and one that is not so simple to answer because we don't necessarily measure every titer, but there are certain ones that we can look for. It's so important after someone has had a stem cell transplant to, if you will, top up their vaccinations. We know that most of our patients don't lose all of their immunity to the vaccinations they've had, but we want to protect our patients as much as possible. We have a standard process after transplant to revaccinate them to make sure that they have their full complement of vaccines so that they can be protected as best as possible. 

Here's a question for Meredith, "For patients who are dialysis dependent because of multiple myeloma kidney damage, are kidney transplants more likely to result in the myeloma coming back faster or more aggressively?" This is a fascinating question because for many years we never even thought that a myeloma patient could be eligible for a kidney transplant, but now we are seeing more of it. As we've controlled myeloma for longer periods of time, patients that have kidney damage can be eligible for a transplant. Does it mean though that they're at greater risk of relapse? There probably is a little bit of an increased risk because we know when someone gets a kidney transplant, they have to go on medications to suppress their immune system so that they don't reject the kidney. And we have seen in some contexts, although it's mostly lymphoma, what we call post-transplant lymphoproliferative disease, meaning after someone had something like a kidney transplant, they're at slightly increased risk of certain malignancies. 

Myeloma can potentially be one of them, but thankfully in most of our experience, we have been able to see the myeloma return the way it normally would return and often not return for long periods of time because we select kidney transplants for patients whose disease is under very good control. 

Joanne asks, "I am going to start my fourth line of therapy soon and it'll probably be teclistamab or talquetamab. How long will I need to be hospitalized? I'm reading six to seven days or 48 hours after the first two or three treatments." Great question, Joanne. I'm sorry I can't give you a concrete answer because really the answer is it depends. Historically, we would always admit patients for teclistamab and talquetamab and typically for a week, but we are now developing more strategies to deliver these as an outpatient. Depending on where you're being treated, it may still be six to seven days, but many of us now are starting to do this with shorter admissions to hospital, one or two days, or frankly giving it all as an outpatient. I think that's going to be the future of giving bispecific antibodies. 

One of my BFFs, Oya, is asking this question, "Can you explain the overview of the delayed diagnosis for black patients in comparison to the outcomes when black patients are treated?" Oya, Great question and such an important point because we at the IMF are so committed to this issue, we've created the M-Power Initiative, mpower.myeloma.org, where we outline our commitment to improving the short and long-term outcomes of African-Americans with multiple myeloma. The facts are as follows, African-Americans have twice the risk of developing multiple myeloma, but also sadly twice the mortality. What that means is a black man or a black woman diagnosed today with myeloma is expected to live half as long as a same-aged white man or white woman. So many reasons for this. A lot of it has to do with the social determinants of health, with the delayed diagnosis of myeloma and the lack of access to therapies. 

Oya, you've pointed out number two, that delayed diagnosis that often because of lack of access to primary care, confounding diagnoses like diabetes and other factors influences that delay. Whereas most myeloma patients do have some delay in making the diagnosis of myeloma somewhere between three to six months, the average patient sees their primary care doctor three times with signs and symptoms consistent with myeloma before the diagnosis is made. We know that's probably three to six months longer in American and Latino American patients. This is something that we're committed to reduce and it's so important that we recognize this disparity so we can develop ways to reduce it. 

Dana asks, "Related to CAR T-cell therapy or bispecific antibodies, how important are specific mutations when deciding on these therapies? Will they work equally well for a high risk patient with a 17p deletion like a low risk patient, or is the level of BCMA, GPRC5D and all these other targets expression, is that more important in the decision to treat the patient?" 

Really detailed and deep question here, Dana, and the short answer is we know that these more modern therapies, bispecific antibodies, CAR T-cell therapies are even more effective than our historical therapies in all patients, both standard risk and high risk. In fact, we now even have more evidence that in so-called extra medullary disease or when myeloma lives outside of the bone marrow, that CAR T-cell therapy is particularly effective at controlling it. In some ways, we still of course have high risk myeloma that is a little less responsive to therapy and more likely to relapse quickly, but we're bridging that gap as we use these new immunotherapies. 

We won't typically say, "You have this deletion, therefore you won't get this treatment." More often than not, we look for what is the best treatment possible and provide it, be it to the high risk or the standard risk patient. 

That's all I have time for questions today. Thank you for asking these great questions. And remember, you can always ask us questions using the #AskTheIMF at any of our social media channels, and also if your question is of a more personal nature, feel free to reach out to us at the info line and be more than happy to talk to you and help you through your journey with multiple myeloma.