This weekend, I was able to participate in TWO very satisfying events.
First, I spoke at a CME conference organized by the Karmanos Cancer Institute focusing on cancer-related bone disease. Topics covered included myeloma, prostate cancer, and breast cancer, as well as specific treatment modalities - kyphoplasty, radiopharmaceuticals, external beam radiation, etc.
|Brochure from today's symposium in Troy, MI: 130 registered attendees!|
I discussed multiple myeloma with my colleague Muneer Abidi in a debate-style format:
We discussed two questions which plague oncologists, even ones with particular expertise in myeloma:
- Should all patients with active myeloma receive zoledronic acid as part of their therapy (even in the absence of bone lesions)? Traditionally, bisphosphonates (BPs) are used to treat hypercalcemia (high calcium) and to prevent skeletal complications in myeloma patients with either osteopenia or frank lytic bone lesions. The MRC IX Trial, which randomized myeloma patients treated with one of four different anti-myeloma induction regimens to additional treatment with either clodronate or zoledronic acid, found that patients treated with the latter not only had reduced skeletal events, but also modestly improved progression free survival (by about 2 months) and overall survival (by 5.5 months). Since this benefit was seen even in the third of patients without myeloma bone disease, recent updates of the NCCN guidelines and Canadian guidelines (the Alberta Health Services myeloma guidelines) recommend zoledronic acid or pamidronate (both potent amino-containing bisphosphonates, as opposed to the non-amino type, clodronate) for all myeloma patients receiving systemic anti-myeloma therapy. I was assigned the "against" side of debate, and the best argument against universal zoledronic acid use is a Cochrane Review from 2010 which did NOT show a definitive survival advantage related to zoledronic acid or any other bisphosphonate (though a 2012 update seems to, at least partially). Additionally, I find the fact that BPs don't seem to modify the natural history of MGUS or SMM a strike against the use of these drugs in patients without bone disease. Also, there is the cost and the potential side effects like osteonecrosis of the jaw and subtrochanteric femoral fractures. Hard call.
- Should any patients with MGUS or smoldering multiple myeloma (SMM) be treated with bisphosphonates? I was assigned the "yes" side of this debate and found it somewhat easier, because I believe its actually the correct answer. There is ample evidence that people with MGUS or SMM are at increased risk for osteopenia and - more importantly - fractures. A recent analysis performed by Kristinsson, et al., compared the incidence of fractures amongst ~5000 MGUS patients and ~20,000 matched controls from a Swedish health registry. MGUS pts had an increased fracture risk (HR: 1.74 @ 5 yrs, and 1.61 @ 10 yrs, not affected by M-protein Ig type or titer). Patients with fractures were not at higher risk of a subsequent diagnosis of myeloma, which I found a bit surprising. Even though BPs do not reduce risk for progression of MGUS/SMM to frank myeloma, the risk of having lytic bone disease at the time of progression may be reduced. In my own practice, I make sure that I check bone density in MGUS and SMM patients, and - at the least - treat osteopenia/osteoporosis with BPs according to the standards for non-MGUS/SMM pts. If BPs are used, bone density needs to be tracked over time to assess efficacy of the intervention.
The second event I attended was a meeting of the Southeast Michigan Amyloidosis Support Group. This group meets face-to-face twice a year in a conference room at Karmanos. The group is one of several around the country coordinated by Muriel Finkel and Amyloidosis Support Groups, Inc. Over 20 patients and caregivers were in attendance, along with Sue Smith - the moderator - myself, and Dr. Grogan (a cardiologist from Mayo Clinic, Rochester). The meeting was about 4 hours long, with breakfast and lunch served. We saw some slides describing the ways that amyloidosis affects one's heart (see my prior post on that). As always, everyone shared their story and provided health updates since the last meeting. I always find the stories fascinating, and I learn something about amyloidosis every meeting. If I am the weekend rounder for our inpatient hematology service when our group is meeting, I will break rounds and attend the meeting with the residents. Invaluable learning experience. The list of meetings for the remainder of 2013 can be found at this link. (The amyloidosis expert(s) who will be attending each meeting also listed. I will be at the Denver CO mtg August 10th, the Detroit MI meeting Sept 21st (with the famous Dr. Robert Kyle!) and in Columbus OH Oct 19th. I also plan on attending the Familial Amyloidosis Support Grp Weekend in Chicago on Oct 25th, as a roving reporter).
Weekends like this are part of the reason I find my work deeply satisfying: ample opportunity to teach others and learn from others.