London Comes to Little Rock - How to CURE Myeloma Patients
BY GARY PETERSEN
Dr. Gareth Morgan, the new Director of the Myeloma Program at UAMS Little Rock, was the featured speaker at the November 18th Cure Panel Broadcast and explained the Total Therapy approach to treatment and the science behind it. UAMS is one of the premiere and world class Myeloma programs internationally and has data showing they can cure 60% of low-risk patients.
What you soon recognize once you do some research is that Dr. Morgan is not just any doctor. He was the head of the Myeloma Program at the largest comprehensive cancer institute in all of Europe (his bio follows), he is the Director of the Myeloma UK which is like our IMF, is internationally known and respected, and lived in one of the most cultured and beautiful cities in the world (London). So what could possibly tear him away from such a remarkable existence, uproot himself and move to Little Rock, AK, to a program which has been such a historic HOT TOPIC, both praised and loved by patients and doctors, yet harshly criticized and questioned as well?
What you find out is Dr. Morgan is all about the patient; the patient experience, and improving outcomes. And when I asked him what drew him to UAMS he responded by saying "I feel I made the right decision!" and for the following reasons.
- He believes it is an honor to be at UAMS - UAMS is respected internationally.
- Thinking creatively, he thinks it was a good decision for himself and for the program at MIRT.
- He now has access to the large patient base, the outstanding and amazing infrastructure, and the staff who look after all elements of the patient's care from arrival. UAMS has a pastoral care approach to patients.
- UAMS will deliver game-changing treatments for patients and take the myeloma care and treatment program to the next level.
Dr. Morgan goes on to explain myeloma biology, the success of the Total Therapy program, and the UAMS survival measurement accuracy.
Within Myeloma there is more than one cancer cell or one clone. Cells have different behavior and are not homogenous. The challenge for cure is to kill every myeloma cell so there are none left to relapse. This is how the More Can Cure comes into play. He would not use the term " More Can Cure" but believes a combination of drugs with different therapeutic actions kills more of these cells and therefore cure more patients. Also, that with time, the program will phase to more targeted individualized therapy and depend less on high-dose chemotherapy and use more of the monoclonal antibodies and immunotherapies to achieve cure. However, the current program has been so successful with an average life expectancy exceeding 15 years, they will not do away with what works until they are sure of the success of the new combinations. He looks to improve the cure rate by adding monoclonal antibodies to the front line treatment with an eye to eliminating one of the transplants without reducing the cure rate. He coined the term "TTT" or Total Targeted Therapy.
Other takeaways from Dr. Morgan's presentations include:
- He has reviewed the data for the Total Therapy program and finds that it has been audited by independent outside companies as well as the National Cancer Institute and the claims of long term survival and cure are valid.
- The quality of people he inherited at UAMS are skilled and dedicated personnel, and he could not be happier with the current staff.
- Quality of life is a timing tradeoff, where during treatment there are impacts, but it is then followed by a long period without any treatment and a high probability of cure, vs. the continual treatment and relapse cycle.
- Internationally the concepts of Total Therapy with induction, two transplants, consolidation, and maintenance are accepted and used extensively, and Dr. Morgan used them in the UK. He is committed to clinical trials and is very excited about the monoclonal antibody trials.
- Another focus of the UAMS program will be in the area of high risk myeloma, where for this cohort of 15% of patients there has been little progress. Much like myeloma 15 years ago, high risk patient have a life expectancy of just two years and we must find a way to push that out and begin curing this group of patients.
- Dr. Morgan has made a commitment to get out in front of patients to spend time and energy to explain the UAMS program, its benefits, and outstanding results to the myeloma patient community. He has and will continue to let patients discover how the UAMS program is cutting edge, innovative, with a pastoral approach to patient treatment and care, uses a targeted approach to each patient's care, and is not a one size fits all program.
Several of the Cure Panel myeloma patient hosts had excellent questions for Dr. Morgan:
- Pat Killingsworth asked what kinds of treatments are available for relapse and refractory patients. Dr. Morgan believes the antibodies are a great option alone and in combination. He mentioned the use of T cells as another approach to treatment. He identified a Ras mutation which has been found and the use of a Ras inhibitor show response with heavily treated patients. These developments will be put into a formal program in near future. CLICK HERE to read a blog post by Pat on this subject.
- Nick asked about the implications of the improved survival of the TT4 standard arm, which was much better than that of the TT4lite arm. Dr. Morgan said these results highlighted that any reduction in the alkylating agents should be done with caution because the only difference between the two arms was the standard arm used more melphalan. They may be able to do so in the future with the use of new antibodies and immunotherapies, but not at the cost of outcomes.
- Cindy asked if his recent article on the use of cyclical treatments would be getting into the treatment mix. She thought due to the heterogeneity of the disease this might make a lot of sense. Dr. Morgan said he thought so in the maintenance phase of treatment where different combinations of drugs used in maintenance would be cycled.
Other topics he covered include:
- With smoldering patients, they should be treated before organ damage. With a MGUS condition, there is no need for treatment, however with smoldering patients, he uses gene array to see who will progress in 1 to 2 years. They use a 4 gene signature, which will predict early onset of active disease. He would use an anti-CD38 antibody for these patients.
- On the subject of awareness and delayed diagnosis, he believes the fact that it takes 3 to 6 months and more often 6 months from first symptoms to diagnosis is a bit of a scandal. To make real inroads in the myeloma we need to get it diagnosed early before we have organ involvement. We need to make family doctors and family practitioners more aware of the disease. They should do M-spike and light chain tests on patients. This makes a lot of sense to Dr. Morgan. It is really tragic when patients develop renal failure when awareness of myeloma by a General Practitioner might have allowed the patient to get a consult or treatment from a myeloma specialist. A myeloma specialist is critical to a patient's long term care and survival. It is a disease that does not come on over night but takes years in the making. Patient organizations can make a difference. Like with Smoldering, there might be a non-toxic and safe treatment for MGUS which would be a chemo prevention program. He believe the future of Myeloma will be to get earlier diagnosis, safe treatments, chemo prevention strategy, regulate screening for para protein, and early intervention. This is the future but should be what we are striving to achieve.
- There is much more good information, so I would recommend you take the time to listen to the entire program. You will learn so much and understand the current UAMS program, and how it will change under Dr. Morgan's leadership.
Gareth Morgan, MD, PhD, FRCP, FRCPath
Dr. Gareth Morgan is professor of medicine and pathology and director of the Myeloma Institute for Research and Therapy at the University of Arkansas for Medical Sciences (UAMS). He is also the deputy director of the Winthrop P. Rockefeller Cancer Institute at UAMS. He is an internationally recognized scientist and clinician in the field of the molecular genetics in blood cell cancers, in particular, multiple myeloma. He came to UAMS from The Royal Marsden Institute NHS Foundation Trust and the Institute of Cancer Research in London, Europe’s largest comprehensive cancer institute, where he was a professor of hematology and director of the Centre for Myeloma Research.
Dr. Morgan received his doctorate on the genetics of leukemia from the University of London in 1991 and his MD in 1981 from the Welsh National School of Medicine. He is a director of Myeloma UK, a respected UK patient organization, as well as a member of the Scientific Board of the International Myeloma Foundation. He is the founding director of the European Myeloma Network.
Dr. Morgan is doing influential work in characterizing the myeloma genome, defining specific subsets of the disease that have prognostic importance, and developing personalized therapeutic strategies targeted to each subtype. He also is engaged in advanced research in molecular diagnostics, drug development and clinical trials. Dr. Morgan has authored more than 450 articles appearing in leading peer-reviewed journals, including New England Journal of Medicine, Blood, Journal of Clinical Oncology, Leukemia, Lancet-Oncology, and Clinical Cancer Research.
He is a member of the British Society of Haematology, the American Society of Hematology, the American Association for Cancer Research, the Royal College of Physicians, UK, and the Royal College of Pathologists, UK.