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Thanks to the development of medicine and innovative therapies, the survival time of oncological and oncohematological patients is longer, and some cancers fall into the category of chronic diseases. Such an example is, for example, immunoactivating therapies (anti-PD1, anti-CTLA-4) in melanoma.
Joanna Lewandowska: What examples of the use of innovative therapies can be found in hematology. Is multiple myeloma such an example?
dr hab. med. Artur Jurczyszyn from the Department of Hematology, Jagiellonian University Medical College: It can be said that the greatest success of hematology in recent years are tyrosine kinase inhibitors used in chronic myeloid leukemia, which is a chronic disease. In multiple myeloma, we can talk about a chronic disease in certain groups of patients, classified as the so-called standard risk. Indeed, these patients, with this state of medicine in 2017, can live up to 10 years. As it is a disease of the elderly, it is indeed a success, because even 15 years ago, people lived with this cancer for a maximum of 2-3 years. This happens thanks to modern therapies, but also bone marrow transplants, because it must not be forgotten, in patients who meet the criteria for transplantation, this method extends life and, fortunately, in our country it is an unlimited therapy. This is very good news for the sick, because there are more and more patients with myeloma. I have been dealing with this disease for the last dozen years and there is not a week without 2, 3 or even 4 new patients with this diagnosis. As the society is getting older and more patients will be added, it will become a bigger and bigger problem.
Advances in treatment include not only innovative therapies, but also an increasingly visible approach of specialists to “treating the sick, not the disease”, that is, greater emphasis on the patient’s quality of life and not only on improving medical parameters.
dr hab. med. Artur Jurczyszyn: This approach means looking not only at the disease, but also a comprehensive and holistic approach to the treatment of the patient, and it is for this reason that the Myeloma Treatment Center Foundation was established, which focuses on this. This approach means that a patient with myeloma is guided by a hematologist, but he must have a few other specialists to cooperate in order to properly guide a given patient, neurosurgical, orthopedic and radiotherapy consultations are needed. Patients require rehabilitation, sometimes consultation and nephrological care, as many myeloma patients have renal failure. Well-treated patients with this cancer are patients treated interdisciplinaryly. At the University Hospital in Krakow where I work, this interdisciplinarity is possible because we work with radiotherapists, orthopedists, neurosurgeons and nephrologists. The form in which the treatment is administered is also very important. The patient often commutes, which means that he is unable to come two, sometimes three times a week, for subcutaneous or intravenous administration. In this case, oral treatment is indeed optimal. Especially since this patient is burdened with the so-called bone disease, which means that his spine is often broken. Therefore, if he could come in once a month or once every two months, it would be optimal, and medicine now offers such opportunities thanks to modern therapies.
What is characterized by multiple myeloma? Is diagnosis of patients with this disease made early enough? What role does this play in therapeutic success?
dr hab. med. Artur Jurczyszyn: Multiple myeloma, also known as multiple myeloma or Kahler’s disease, is the result of what is known as clonal expansion of plasmocytes, leading to skeletal damage and often to anemia, renal failure, hypercalcemia and other complications. It is a disease that is not easy to recognize because patients do not see a hematologist right away at the first symptoms. Often, diagnostics are delayed by several months, and sometimes even by several years. The symptoms are very non-specific, because who does not hurt the spine at the age of 70? Does anyone feel weak at times and have frequent infections? These are the symptoms of myeloma. Here are three simple tests – I always encourage GPs to do them: ESR, urinalysis, and morphology. If any of these tests turns out to be suspicious or pathological, then the diagnosis must be extended and in this way, myeloma can be diagnosed. It is worth mentioning here that 30 percent. patients with myeloma are completely asymptomatic. The sooner the treatment is started, the better, because we cannot wait until extreme kidney failure occurs, where the patient will be dialyzed, or will have many bone defects – because that’s what myeloma is all about. The more people talk about the disease, the better, because we all know the public awareness campaigns related to cervical cancer, leukemia or transplant problems, but few people know that myeloma kills more people than cervical and liver cancer combined. It is good that there are various places, associations and foundations that are trying to talk about it more and more, and it is worth mentioning that, unfortunately, many therapies in Poland that could be available and prolong patients’ lives are not reimbursed. In 2015, 4 new therapeutic options were registered in the world. Unfortunately, none of them are reimbursed with us.
In the context of multiple myeloma, an extended survival time of patients around the world is observed. What it comes from?
dr hab. med. Artur Jurczyszyn: I think there are several reasons for this. Certainly better diagnostics and patient awareness
and the availability of various information, but also most of all modern therapies and, what I want to emphasize, the possibility of bone marrow transplantation. This is a great method for patients who qualify for such treatment, because after a bone marrow transplant – I am talking about autologous transplant – the patient often, for many years, has a period of remission, and there is no recurrence of the disease. Myeloma is such a unit that there is no other such disease, where over 10 new therapies have been registered in the last dozen or so years, it is indeed an absolute revolution, which patients benefit from and before our eyes their lives are getting longer. I dare to say that with an optimally treated patient, this extension of life will be possible thanks to the so-called maintenance therapy – it is only important that it is financed by the National Health Fund.
Does this tendency also apply to patients in Poland? And do patients in Poland have a chance for optimal treatment?
dr hab. med. Artur Jurczyszyn: Unfortunately, we’ve been such a white spot when it comes to chronic lymphocytic leukemia and access to ibrutinib for many years – that is changing now, as of September 1, ibrutinib is available for chronic lymphocytic leukemia patients, but we’re still a white spot if it is about access to carfilzomib, pomalidomide, ixazomib, daratumumab. These are breakthrough therapies where Polish patients do not have access to them, and all these substances are registered in the EU. It is very frustrating to look at the patient and be aware that there are methods that can help him and condemn the patient to palliative therapy.
What is the innovation of ixazomib, considering not only the breakthrough of this therapy, but also the approach to “treating the sick, not the disease”?
dr hab. med. Artur Jurczyszyn: It is a modern therapy characterized by very good bioavailability,
administered orally. Importantly, a treatment that also includes lenalidomide and dexamethasone is entirely oral treatment. At a recent convention in the US, there were reports that the combination of ixazomib, lenalidomide and dexamethasone is promising and patients tolerate it well. This method is also very important, especially since the patient may come to the clinic once or twice a month and does not have to come for subcutaneous administration or intravenous infusions. This allows you to function better in professional life and in the natural environment outside of work, reducing the daily awareness of the disease. Oral therapies will be the future, because patients appreciate the “quality of life” and nobody wants to queue up to see the doctor, because other activities can be done at that time. Too
this therapy will definitely displace the intravenous or subcutaneous forms.
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