Clinical Advances in Myeloma 2019 | Overview Part II

The Clinical Advances in Myeloma 2019 conference, held on 16 January 2019 at the American Square Conference Centre, London, UK, aimed to address the current management of patients with multiple myeloma (MM), with a particular focus on improving the outcomes for each patient group. An overview of the morning sessions, which focused on future clinical practice and the current and emerging treatments, has previously been published on the Multiple Myeloma Hub. This current article focuses on the afternoon sessions which included talks on practical management and improving patient outcomes in MM.

Practical Management

The third session of the day addressed the practical management of MM, with the first talk delivered by Dr. Simon Stern from Epsom and St Helier University Hospitals NHS Trust. Dr. Stern discussed the evidence-based management of monoclonal gammopathy of undetermined significance (MGUS), including the classification and risk-stratification of patients. Dr. Stern stated that as MGUS consistently precedes MM, a re-classification of MGUS from a pre-malignant to an early malignant condition may be more appropriate.¹ Dr. Stern concluded that his current practice reflects clinical guidelines with follow-up of MGUS patients based on risk stratification, where low-risk patients receive follow-up in primary care, and high-risk patients receive follow-up in hematology clinics.

Dr. Olwen Westerland from Guy’s and St Thomas’ NHS FT, presented case studies to highlight the growing importance of imaging in the diagnosis and monitoring of patients with MM. Dr. Westerland outlined the main advantages and disadvantages of the imaging techniques that are currently used in patients with MM. The current International Myeloma Working Group (IMWG) guidelines recommend whole body magnetic resonance imaging (WBMRI) in asymptomatic MM, smoldering MM and solitary plasmacytoma.² However, the most commonly used technique in current UK clinical practice is skeletal survey.³ Differences between best practice according to guidelines and the current practices in UK hospitals occur due to funding issues, regulations, and availability of treatment regimens. Dr. Westerland concluded that this disparity between the recommendations and the current practice for diagnosis and monitoring of patients with MM may have negative implications for patient diagnosis and treatment management.

Dr. Jenny Bird from University Hospitals Bristol NHS FT discussed the topic of overcoming susceptibility to infection in patients with MM. Patients with MM can be at a higher risk of infection due to immune deficits or organ dysfunction, which may be related to their disease and/or treatment. Dr. Bird concluded that MM patients require thorough infection monitoring, with the appropriate use of antibiotics, as the presentation of infection in this patient population can be masked by disease characteristics. Moreover, the clinical evidence for prophylactic immunoglobulin replacement is currently lacking in the MM patient population.⁴  

Improving Patient Outcomes

The fourth session of the conference discussed improving patient outcomes. The first talk by Julie Watson from Colchester General Hospital focused on the impact of the myeloma clinical nurse specialist (CNS) on patient care. The CNS is uniquely positioned to support patients with MM. The CNS can assess the holistic needs as well as frailty of the patient and provides practical support throughout the treatment pathway. The talk concluded that the presence of a CNS within a myeloma clinic can provide significant benefits to patient treatment and clinic management.

The final talk of the day was delivered by Professor Sam Salek from the University of Hertfordshire, who discussed the hematological malignancy-patient reported outcomes (HM-PRO) tool.  The HM-PRO tool, which was developed and validated within a heterogeneous oncology patient population, can be utilized for patients with MM. Professor Salek highlighted the relevance of measuring PROs in patients living with a hematological malignancy, in that they can provide a clinically relevant data point for a physician. HM-PRO accurately measures the impact of a treatment regimen over time, on both the effect of symptoms and quality of life, which may prove beneficial in a clinical setting.⁵

Discussion

Key discussion points arose throughout the day amongst the speakers and the attendees, including the identification of patient status and treatment of patients based on disease type. It was discussed that it is critical to adapt therapy to effectively treat to the patient’s capacity, with an emphasis on considering quality of life and toxicity of therapy, as well as efficacy endpoints of therapy.

A major challenge facing clinical practice that was identified during the day was the distinction between the currently licensed, currently available and currently funded therapies within the UK for patients with MM. Furthermore, this issue is complicated by the restrictions placed on certain therapies at a given stage of relapse, which creates additional challenges for clinicians deciding on the best therapy for their patients.

The current MM treatment landscape in the UK is diverse. When making treatment decisions, physicians have to factor in a multitude of restrictions in terms of licensing, funding, access and practical issues. The development of novel therapies has provided the potential to improve outcomes in patients with MM, however, the current restrictions in the UK will need to be overcome in order to translate this potential benefit into everyday clinical practice.