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Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT WELCOME AND INTRODUCTION Lizette Figueroa-Rivera, MA Hello everyone. On behalf of The Leukemia & Lymphoma Society (LLS), a warm welcome to all of you. Special thanks to Dr. Tomer Mark for sharing his time and expertise with us today. We have over 2,200 people participating in today's program from across the United States, Canada, and India. We would like to acknowledge and thank Bristol Myers Squibb, Genentech & Biogen, GlaxoSmithKline, and Takeda Oncology for support of this program. Before we begin, Cynthia, a myeloma patient and advocate, as well as LLS volunteer, will make some welcoming remarks. Cynthia Sims Hello, my name is Cynthia Loyal Sims, and I'd like to welcome all the patients, caregivers, and healthcare professionals attending this program today. My journey with cancer began in 2015. While on my summer vacation in Florida, I began experiencing back pain so severe that I had to be in a wheelchair for the rest of the trip. When I returned home, I immediately went to see my doctor who referred me to an oncologist. After several tests, I would receive the devastating news that I had multiple myeloma. Chemotherapy and radiation soon followed, along with the horrible side effects, sleepless nights, countless blood transfusions, but I was not going to let cancer defeat me. I recalled a quote, "Cancer is a word not a symptom," and I thought, okay, I've got this, and I felt spiritually strong. In 2016, I underwent an autologous bone marrow transplant that used my own stem cells, then immediately extended or entered into an immunotherapy clinical trial. It was an extremely difficult time, and the experience gave me a new meaning to the word sick. Updated: 11/2/20 Page 1 of 53 LLS20135a Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT When I was initially diagnosed, I was told that life expectancy for my type of cancer was only two years. Thankfully, since the transplant and the trial, I am doing much better. And as of today, I've been in remission for nearly three years. My faith has been a vital part of my physical and mental healing. I'm so grateful to my family, friends, and doctors who saved my life. I am also thankful to The Leukemia & Lymphoma Society for funding one of the treatments that helped save me and for providing a valuable support system. Now I work to help others and give them hope. I volunteer for LLS in various ways, including their Myeloma Link program that aims to create awareness and improve access to education and treatment for myeloma to the African American community. As Dr. Mark will mention in this presentation, the incidence in African Americans is almost twice as high as in Caucasians. Knowledge is so critical. So like you, I am looking forward to hearing Dr. Mark provide this update on treatment options for myeloma patients. Every day that I survive is a blessing and a victory. So, remember, if you ever feel that you've come to the end of your rope, remember to tie a knot and hang on. Lizette Figueroa-Rivera, MA Thank you so much, Cynthia, for sharing your story with us. I know many of our listeners can relate to you and your cancer journey. PRESENTATION Lizette Figueroa-Rivera, MA I'm now pleased to introduce Dr. Tomer Mark, Associate Professor of Medicine at the University of Colorado, Anschutz Medical Campus in Aurora, Colorado. On behalf of The Leukemia & Lymphoma Society, thank you for volunteering your time and expertise. Dr. Mark, I'm now privileged to turn the program over to you. Updated: 11/2/20 Page 2 of 53 LLS20135a Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT Tomer M. Mark, MD Thank you. These are my disclosures. And I first want to start off by thanking The Leukemia & Lymphoma Society for giving me the opportunity to talk to you all and help you understand multiple myeloma, what it is, the philosophy of treatment, and also things that you can do to make your myeloma journey more comfortable. I work at University of Colorado in Aurora, and I wanted to point out that at the bottom right-hand corner of the slide over here, there's a bone marrow sample taken from one of my patients that shows involvement with myeloma. Updated: 11/2/20 Page 3 of 53 LLS20135a Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT , So, here's the outline for the talk. I won't spend too much time on this, but we'll go through what is myeloma, what's the disease course, and then there are common patient and caregiver questions that I'd like to go through. So, multiple myeloma is a malignancy of a cell called the plasma cell, and the hallmarks of the disease are this protein called monoclonal immunoglobulin or M spike, anemia, renal or kidney failure, destructive bone lesions, high blood calcium, and increased risk of infection. In the upper right-hand corner, you can see a picture of a skull from a patient with myeloma, and you can see these punched out lesions that sort of look like swiss cheese that are the lytic lesions that we describe that go with this disease. And then below that is another marrow picture with an infiltration of cells that look sort of like sunny-side up eggs, and those are the myeloma cells. There are slightly Updated: 11/2/20 Page 4 of 53 LLS20135a Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT different sizes and shapes, but you can see that in most of them the nucleus, the round purple dot is moved off to one side of the cell, and that's pretty typical of a plasma cell. So, what are plasma cells? All of the elements in our bloodstream come from the bone marrow and more particularly these hematopoietic stem cells, HSCs. From these hematopoietic stem cells, you get red cells, white cells, and also platelets. And if you go on the right-hand side of this slide over here, you get this sort of family tree. And on this half of the tree over here, that's called the myeloid theories; and from there you get red cells, over here erythrocytes, megakaryocytes which leads to platelet production, and then other cells like neutrophils, eosinophils, and macrophages. On this side of the family tree, this is called the innate immune system. This is the immune system that's been present since the dawn of time. Amoeba have this kind of immunity. And I put this picture of Pacman down below because this immunity is pretty dumb. If there's something foreign in your bloodstream, some particle, or virus, bacteria, these cells will just chomp those foreign bits up like Pacman in the video game without any sort of rhyme or reason. This brings us to this part of the tree. This is the humoral immune system or adaptive immune system that comes form lymphocytes. And some of these lymphocytes are T cells over here. Others are B cells over here, and these are important in certain infections. Certainly, if you don't have T cells, that's a major manifestation of HIV. B cells can lead to lymphomas. But at the very bottom over here you can see is the plasma cell. The plasma cell's the most differentiated, the most mature type of lymphocyte, and it is the job of the plasma cell to make antibody. Antibodies are also called immunoglobulins, and these are proteins that are generated as part of our defense against foreign invaders. So, if a bug comes into our body, what happens is that the B cells and the T cells recognize that bug as foreign, they talk to each other, and they may generate these plasma cells that will produce an immunoglobulin or an antibody that is specific for that bacteria or virus. It will coat the foreign particle, and then your body will get rid of that foreign invader very efficiently. Updated: 11/2/20 Page 5 of 53 LLS20135a Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT As you can probably surmise, the innate immune system is instant. It turns on right away. It turns off right away, whereas the humoral immune system with antibodies is relatively slower because you need time to generate those antibodies. The advantage of the humoral immune system, of course, is memory, such that you don't get reinfected with the same thing over and over and over again. And this is the principle behind vaccinations. I'd like to remind you that myeloma is just one of a group of plasma cell disorders. The most common type of plasma cell disorder is MGUS (monoclonal gammopathy of undetermined significance) over here. In between MGUS and myeloma is this entity called smoldering myeloma, and then there's other more rare forms of plasma cell disorders listed below. Updated: 11/2/20 Page 6 of 53 LLS20135a Understanding Myeloma Patient Education Telephone/Web Program TRANSCRIPT It is complicated to tell between MGUS, smoldering myeloma, and active myeloma. This is a pretty frequent consult that we get in that somebody would go for a life insurance exam or go to their primary care doctor for an annual checkup, see that the protein is elevated in the blood, and all of a sudden they wind up in my office scared to death that they may have an active malignancy like myeloma when, in fact, many of them would have MGUS or smoldering myeloma which are precursor conditions.
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