Dr Denis O’Keeffe is a Consultant Haematologist at Limerick Mid Western Regional Hospital. He will be presenting on “The Newly Diagnosed Patient” at the upcoming MMI Patient and Family Awareness Day.
What attracted you to haematology as a specialty?
It came about by accident really; I spent part of a rotation in haematology shortly after I became qualified. The fact that as a haematologist you got to work in the lab but also see patients was attractive to me, because it is the only specialty where you get to do both. That’s what got me interested and after that I carried on training to be a haematologist.
What aspect of managing myeloma patients’ care do you like best?
The great thing about treating myeloma is that over the last 10 years since I started out in haematology, the choices of treatment have increased hugely, and the success of that treatment has also improved hugely. It’s become more complex and more challenging but it also has become more successful. That success and the range of treatments we now have, have made it a very exciting area to work in.
Does multiple myeloma suffer from a lack of general awareness, in comparison to other cancers?
I think that is true. It is a disease that occurs more in older people, so it is becoming more common as people survive and live to a greater age. But it is not as common as bowel cancer or breast cancer, so it is a challenge for people to understand what myeloma is – many think of cancer as being local or having spread but myeloma is very different. Because it originates within the immune system and therefore the bone marrow and the blood, it means that it presents in lots of different ways, such as bone problems, kidney problems, infection etc. In that way it is difficult for people to understand it is very different from solid organ cancers.
At the upcoming study day you will be talking about the newly diagnosed patient. What is most important for them to know?
The important thing is to explain exactly where this cancer comes from, and what damage it has caused. I also set out a reasonable idea of their prognosis and what the future holds. Very important, however, is that there are increasingly many treatment options, and although we still can’t cure it, we can achieve control of it for five to 10 years or more.
Treatment is now tailored on the person, based on their own physical condition as well as factors like their social support and other co-morbidities they may have. We choose the best treatment that gives them the best chance of a response but hopefully minimises the side effects based on that person’s general health. The goal is to give them the best treatment we can so that they remain under control for longer.
What is the typical treatment pathway for a multiple myeloma patient?
Myeloma patients can typically be divided into two groups – those that are young enough and well enough to have a transplant, and those that are not. The older group can then be divided into two further groups, those that are reasonably fit and can thus have intensive treatment, and those who are very elderly and would not be considered for intensive treatment.
Transplant patients would typically received combined chemotherapy, so one of the newer agents as well as a steroid, whereas for the non-transplant patients it is similar combination but usually with less intensive doses.
Infection is a major issue. What can be done to lower the risk of infection?
This is true right from the beginning and there is a continuous risk. Multiple myeloma originates from the cell that produced a person’s antibodies and one of the immediate results is that they can’t make antibodies well. That negatively impacts their immune system and makes them especially vulnerable to infection. Depending on the intensity of the treatment, that can also have a significant impact on a person’s risk of infection.
For patients who get recurrent infections who have very low antibodies, we can give replacement antibodies or immunoglobulins but we also educate people for what to watch out for. They have to watch out for any risks, such as a high temperature or any symptoms so that they seek help or antibiotic treatment very early on. There may be the occasional person who will need continuous treatment with antibiotics, depending on their own treatment.
You say steroids are a key aspect of treatment. What can be done to mitigate the adverse effects of long-term use of steroids?
One of the standards of care for all patients receiving treatment for myeloma, would be bisphosphonate treatment. As long-term use of steroids can potentially cause osteoporosis of the bones, these protect and reduce reabsorption of the bone.
Another key issue is to monitor a person’s blood sugar, as if someone is already diabetic, steroids can make their blood glucose levels very unstable. Steroids can make sleeping difficult, as well as increasing appetite and weight gain can then be a problem. We have to educate patients on all these potential side effects.
What are the other complications of multiple myeloma?
Apart from bone damage, the other most common complication in multiple myeloma is kidney damage. At the time of presentation around 10-20 percent of patients will already have significant renal damage. Kidney function can be reduced so much that people may need dialysis. The kidneys are at significant risk from this condition from the moment it begins, throughout treatment.
Can you tell me more about recent and ongoing developments in myeloma treatment?
Research into multiple myeloma and new treatments has really exploded in the last five years. The most recent developments have been the licensing of antibodies to treat patients but the next step we are hoping for is targeted therapy of the molecular pathway. The standard of treatment has really been a combination of chemotherapy and steroids, and there are also proteasome inhibitors and immunomodulatory therapies. Now, in the last 12 months, we are moving into an era of antibodies joining those drugs in first-line treatment, and the targeted treatment of the pathways is the next step, which is hugely promising.