The Latest Myeloma News From ASH Breaking News December 21, 2010 Sagar Lonial, M.D. Robert Orlowski, M.D. Jack Aiello Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction This year the meeting of the American Society of Hematology, or ASH, in Orlando, Florida, was very encouraging for people who are concerned about multiple myeloma. We wanted to get a wrap-up and find out what's significant for patients. It's all next on Patient Power. Hello and welcome to Patient Power. I'm Andrew Schorr. This program is supported through a grant from Onyx Pharmaceuticals. Well, I spent several days in Orlando, Florida, at the American Society of Hematology meeting, and there was a lot of news that was very encouraging for people who are concerned about myeloma. And whatever stage you are with the illness or if it's a family member, there's something to talk about, and we did on video with several experts, and that's all at patientpower.info/ash, but also we wanted to gain the perspective of another expert who we've invited for this recording and also to have a little time to think about it. You know, when you step away from it where there are so many poster sessions and so much research it can be just dizzying, if you will. And fortunately the pace of myeloma research and the options available seem to go increasing, so that's what we'll be discussing, also answering some of the questions that have been sent in to Patient Power. Helping me with all this is someone who has been living with myeloma for 16 years. Joining us from San Jose, California, is Jack Aiello. Jack, I know we got your perspective on video, but you've had a couple of weeks to think about it. Are you encouraged in what you've been saying to other patients around the country and around the world? Jack: Yes. Thanks for inviting me, Andrew, on this call. I really enjoyed attending ASH, and when I talk with other patients, as I did this weekend through our support group, we're all overwhelmed by again the number of newer treatments available, combination treatments, new drugs, discussions of maintenance, etc., so I'm looking forward to learning on this conference call as well as asking questions. 1
The Headlines Well, it's a hopeful time, and we'll get into that. One doctor we didn't get a chance to catch up with on video but he's with us now, he's been with us on Patient Power before, is Dr. Robert Orlowski. He's associate professor in the departments of lymphoma and myeloma and experimental therapeutics at the MD Anderson Cancer Center in Houston. Dr. Orlowski, let's begin with you, a headline. How do you feel about this year's ASH when it comes to what's significant for people living with the illness? Well, Andrew, thanks for inviting me to participate on this call. I think that there were a lot of exciting areas in myeloma that were presented at ASH. I thought just briefly I'd talk about a couple of things from studies that focused on patients with relapsed or refractory myeloma because this is where the new drugs are being developed which will eventually be moved up front. And a couple of developments I thought that were interesting, one was a randomized study for patients with relapsed myeloma comparing two different ways of giving bortezomib. One was the standard intravenous approach, and the other one was using the same dose and the same schedule but instead of using IV patients were given a subcutaneous injection. And it turned out that very interestingly the approach was quite similar in terms of the response rate, the survival at one year and also the time to progression, but very importantly patients who got the subcutaneous injection had fewer episodes of neuropathy and also a trend toward fewer problems with blood count drops. And overall this suggests that it's safe to give bortezomib with injections under the skin. It may get people in and out of the clinic or the office more quickly, and any time you can reduce side effects like neuropathy that's always a positive development. Another I think important study looked at using carfilzomib, and this is one of the second generation proteasome inhibitors which is irreversible, unlike bortezomib, and the data that were presented showed a nice overall response rate with 24 percent of patients having at least a partial response or better, and if you counted patients with stable disease or better the response rate was almost 70 percent. The duration of response was about 8.3 months. Progression-free survival was quite nice as well. Overall survival was one year. And hopefully these data will be used to support a filing early next year in order to try to get carfilzomib approved by the Food and Drug Administration, which hopefully would get it out there pretty quickly to patients in the community. There also was one poster presented about carfilzomib that showed if you gave it over a longer IV period of about 30 minutes patients could tolerate higher doses and maybe even have a much better response rate. 2
All right. I just want to make sure I get all that right. So first of all, related to Velcade, which of course was a breakthrough drug in myeloma, you could get a little shot rather than infusion and that seems to be as effective but fewer side effects. Did I get that one right? Yep, that's right. Okay. And you don't need to put in an IV into patients in order for them to get the bortezomib. Okay. So that's great news. And then bortezomib or Velcade being a proteasome inhibitor, now we have a second generation and that is going to be up for FDA approval, and that has encouraging data as well, maybe with reduced side effects. Yes. Did I get that one right? Yes. Okay. All right. Let's go to our other expert guest with us--besides Jack and I being experts, too, from our perspective--but Dr. Sagar Lonial is associate professor at the Winship Cancer Institute of Emory Institute in Atlanta. He's also director of translational research for the B-cell malignancy program. Dr. Lonial, we have you on video as well, but just now you've had a couple of week to think about it, for patients what do you feel is significant from ASH? Well, thank you again for having me on. It's always a pleasure to be able to interact with my friend Dr. Orlowski and try and provide new updates for patients on what was exciting at the meeting. I think that in addition to the relapsed refractory data that Dr. Orlowski touched on I think that the other big question that is starting to emerge now in myeloma is about the role of maintenance therapy. And I think we did see a number of abstracts looking at post-transplant maintenance therapy. We saw a number of abstracts also that talked about patients who had not had a transplant being on randomized to either 3
maintenance versus no maintenance or different kinds of maintenance dosing, using thalidomide, using lenalidomide or using bortezomib or combinations of those drugs in the maintenance setting. I think that there are a number of themes that are emerging around which patients perhaps should receive some form of maintenance therapy versus those who perhaps can wait until their disease comes back and be retreated at that time point. So I think it's not a one-size-fits-all kind of an approach. I think that what is making this more difficult and more challenging is that if you had 10 different patients with myeloma you have at least 10 different kinds of myeloma in those 10 patients, and so trying to say that every patient should get maintenance or that no patient should get maintenance is probably a little too black and white, and there are subtleties to clinical practice that I think make a decision an individual one, one that a patient certainly participates in but one where the physician who is treating and working with that patient probably needs to take lots of different factors into account when they make a recommendation regarding maintenance therapy. Decision Regarding Maintenance Therapy Let me just follow-up on that for a second because people are listening and saying, okay, how can I work with my doctor? What tests do I need to really understand what my situation is so your growing armamentarium of myeloma treatments can come to bear for me? When do we need to change course? So how do you do that at Emory? What sort of tests do you do? Well, I think there are a couple of pieces of information that are useful to help gauge whether or not maintenance is something that I for instance will want to recommend. And again I'm sure Dr. Orlowski has his version of this as well. One of the questions that I want to know about a given patient is is their disease biologically aggressive or is it biologically indolent. And by "indolent" I mean slow growing. You know, those tend to be very steroid-sensitive tumors. You make them go away and they may stay away for a long time. Or is it the kind of disease where once you let up on it comes right back and oftentimes comes back faster that it initially had presented. So that's one of the factors we take into account. The next factor is what were the side effects or toxicities that a given patient experienced during their treatment, whether that treatment was initial therapy, a transplant or there's no transplant for that patient. What were the side effects or toxicities that that patient achieved developed their treatment? And the third is what are the patient's individual goals for treatment. There are patients who say to me, I don't psychologically want to live with the idea that I'm not always doing something to keep my disease under control. And then there are other patients who psychologically will say, I don't want to be on treatment for as long as I can go between 4
treatment approaches, and I'd rather be off of everything for a while and know that I can potentially come back and receive treatment again, as well as how good a response did I get with my initial treatment. Those are all the factors we use to try and make a decision about maintenance. Jack: Dr. Lonial, if you decide to put someone on maintenance it sounds like you would still use those factors to determine the best maintenance program, whether or not it's Revlimid or Velcade or thalidomide. Is that correct? Yeah, I think that that is correct. I mean, if I make the determination that I think maintenance is something that would benefit a patient then I try and tease through the available data to say is this somebody I'm going to treat with lenalidomide, is this somebody I'm going treat with bortezomib, is it somebody I'm going to treat with both together as maintenance. And again those are individualized patient decisions as opposed to a blanket recommendation. Dr. Orlowski, any other view from you? I certainly agree with Dr. Lonial's considerations. I would bring up three other points to consider in the maintenance setting. We know from studies of thalidomide and maintenance that that agent did not benefit patients who were in a complete remission or very good partial remission after transplantation. And there was at least a little bit of a presentation from the French study of lenalidomide that suggested that people who were in CR or VGPR did benefit from lenalidomide maintenance in progression-free survival, but I think as the quality of our complete responses improves it may be that patients will start to have such a low disease burden that maintenance will not any longer be necessary. The second question that still sticks in my mind that we don't have an answer to is if you go on for example lenalidomide maintenance at a low dose and eventually the disease progresses, will you lose the ability to get some benefit from full-dose lenalidomide, and if that's true, which we don't know yet, you may gain a year or 15 months during maintenance but you may lose that time during relapse if you have fewer options. Wow. And finally I briefly just wanted to mention that we don't know the answer to this either, but two of the post-transplant studies, the French and the CALGB or the US study, did show a small increase in second cancers among patients who got lenalidomide maintenance compared to those who did not. I think the numbers in my mind are still too 5
small that we can say it's definitely true, this could all be due to random chance, but definitely those cases need to be followed up to get more information. One follow-up question for you about this, Dr. Orlowski, we got a question from Pat in Jackson, Mississippi, where her husband has been doing well over three years taking Revlimid or lenalidomide, and she wonders can he stop. And so I guess we don't know all these answers, right? I mean, we can't talk about his specific situation but you if you're doing well, everything seems to be in order you wonder, well, can I just stop. Yeah, it's a great question, and so far most of the studies have continued lenalidomide until disease progression, and until we have information that says it's safe to stop it if you're in complete remission, as long as he's tolerating the drug well I would probably recommend continuing that. And of course if he's been on it for a long time hopefully he has some stem cells stored away so that if he does relapse in the future he could get stem cell transplant. Transplant Let's talk about transplant for a minute. Now, Jack, you had three in the end, including an allo. Dr. Lonial and Dr. Orlowski, I want to ask you both because I do this every time I do a myeloma program. Where are we now with transplants? Dr. Lonial, your view in Atlanta. I hear the statement from other patients or community oncologists all the time, quote, I don't believe in transplant, unquote, and I think that what that does is reduce what we as physicians do to a belief system. And I'm not sure that that's necessarily the way that I approach medicine and I'm fairly certain that's not the way Dr. Orlowski approaches medicine. I think what we try and do is use available evidence to say is there evidence that certain treatments or approaches can offer benefit to patients. And I think if you look at the weight of evidence there is a significant amount of data that says that transplant is a tool that can offer significant benefit to lots of patients with myeloma. Now, does it benefit every patient with myeloma? No. But I think that the way I visualize the use of transplant is that it is not the single one treatment that we say yes or no to. It is one of the tools that we use to treat myeloma and keep myeloma under control over the life of the course of a given disease. So to say to somebody be who is young and fit, I don't believe in transplant so I'm not going to bring it up with you is like saying I'm going to build a house and I'm not--i'm going to do it without a hammer. You need different tools to build that house, and you need different options to control the disease over time, and I think transplant is one of them. 6
Dr. Orlowski, similar view from you? Yeah, I would agree. I think a lot of people now say that because we have all of these new drugs maybe we can get away without doing the transplant, but there was one presentation from a study done by the Eastern Cooperative Oncology Group that had treated patients with lenalidomide and dexamethasone and then looked later on what happened to them if they got a transplant or they didn't, and it wasn't a randomized study so it wasn't necessarily a fair comparison, but the patients who got transplant seemed to do better than the ones who didn't, and I think that still argues that even with novel drugs we still need to keep transplant in the mix. The one negative thing I would say about transplant is that there was a presentation from one large randomized study that looked at tandem autologous transplant versus an autologous followed by what's called a mini or nonmyeloablative allo transplant where the second transplant is given from stem cells from a donor like a brother or a sister. And in that study the tandem autologous transplant did as well as the other arm with less side effect, which I think really says that we should still consider allogeneic transplant or stem cells from another donor as still being experimental. And I think some people, and I'd be interested to hear what Dr. Lonial thinks, some people may say even that that approach shouldn't be considered even in a clinical trial. Any comment? Yeah, I think that Dr. Orlowski brings up a great point and that is that was very in my mind definitive data regarding at least in that trial--which was a large trial, regarding the lack of benefit for allogeneic transplant as performed in that study for patients with myeloma. And I think in my mind philosophically it breaks down into a couple of different camps. You've heard about all the great stuff that's happening, all the new drugs that are being developed, how the survival of patients with myeloma has increased markedly over the last five to 10 years, and so I think that if you break down patients into three categories, standard risk, high risk and then somewhere am the middle, where we're not exactly sure where they fit, if you take the standard or good risk patients I think that their median survival is over eight years. If you look at the high-risk patients where we've not done as well with the new drugs as we would like to do, in both of those patient subsets in the trial that Dr. Orlowski referred to there was no benefit for an allo transplant. And so I would argue that for the standard or good risk patients the risk is much, much higher in those patients without significant benefit. And in the high-risk patients, while the benefit--potential benefit may be high the time for that maneuver to really work was 7
simply not there because the disease grows too fast. And so for both of those I would say I don't think allografting offers much of an advantage for them. It's the people in the middle that I think we're debating about oftentimes and again I think you really--the burden is on the trials to show the benefit rather than saying we should keep doing it. Vaccines Hmm. Let's go on. So people want to know about other things that are in development. Just want to bring up vaccines. So there is now a vaccine used to fight the cancer in men with very advanced prostate cancer. That was I think the first vaccine of its kind approved. I interviewed a lymphoma specialist who is trying to work on one in lymphoma, and there is research going on in myeloma. Any comment on that, Dr. Orlowski? Are you familiar with that? Any comment on whether your own immune system could be managed that way with a vaccine to fight the myeloma? Well, I think this is part of a more general issue which is how do we harness the immune system in patients to try to help fight off myeloma because most of the approaches that we've been using so far probably don't use that, but we are making progress. First, although this isn't a vaccine, we have a number of antibodies that are now being used in the clinic in trials that target proteins on the surface of the myeloma cells, and some of these studies have been actually done by Dr. Lonial, so there is an antibody called elotuzumab, where the data look I think quite promising. And there was another antibody presented at the meeting called lorvotuzumab, mertansine, which also seems quite attractive, and maybe some of your listeners will have hopefully access to the trials with those drugs. I do think that vaccine approaches are important as well, and there are a number of trials being prepared with different types of vaccines. One of the studies that the Dana-Farber people are going to be doing is using peptide vaccines against proteins that are important to the growth of myeloma cells in order to try to raise immunity and maybe prevent people who have early-stage asymptomatic myeloma from progressing to symptomatic myeloma. And then we have a trial coming at M. D. Anderson which will using a personalized vaccine which will be developed against the M protein, or monoclonal protein, that myeloma cells make, and that will be added onto stem cell transplantation to try to boost the immune system after transplant to get rid of any leftover myeloma cells. And I think if we combine chemotherapies and transplant and these vaccine approaches that will get us closer to a cure. 8
Research and Clinical Trials Wow. So, Dr. Lonial, just for our audience that could be anywhere in the world but certainly across the US, this whole idea of trials. As their research is accelerating should that be a discussion that you think that a patient should often have with their doctor, bring it up, and say are there trials we should be talking about. Yeah, I think that that is probably--especially in a disease that is as--i won't say rare, but is not as common as lung cancer or breast cancer, I think trials are of critical importance for us to move the field forward, and I think it's through participation in trials that we got drugs like lenalidomide and bortezomib and thalidomide. It's through trials that we hope to get drugs like carfilzomib and pomalidomide and elotuzumab and all the other new drugs that are currently in phase I and phase II testing. When a patient is referred to me for a clinical trial the doctor often wants them to go on the study and will say, you know, I really want you to go see so-and-so to find out whether a trial is an option, and I think the patient often thinks of the trial as a last-line option for them. But there are trials for patients at every stage of disease. There are trials for newly diagnosed, there are trials for smoldering, there are transplant trials, there's maintenance trials, there's early relapse, there's late relapse trials. I think we've got trials at our center, and I know Dr. Orlowski does as well, where a patient can come in at any stage of their disease and we've got something that we can offer them in the setting of a clinical trial. And I think it doesn't just mean just access to new drugs, but it almost always means a higher standard of care because there are more eyes watching what's going on when a patient is on a trial than when they're not on a clinical trial, and that almost always results in better clinical care. Jack, I know you were in a trial with thalidomide, right? Jack: Yeah, I've actually been in a couple of trials, one being thalidomide. And I was just going to echo what Dr. Lonial said and that is that you are watched very carefully by all sets of eyes monitoring your myeloma markers and such and questioning, deciding, figuring out whether or not your response to this trial and your treatment. Right. Jack: I mean, I always tell patients to consider trials that might be available to them. 9
Right. And some people know I'm a leukemia survivor, CLL, and I was in a phase II trial. I liked the attention. Not only am I doing well, but I certainly liked the attention. Dr. Lonial, quick question for you. So people say, okay, all the drugs and all this. What did can I do myself? And they ask, and I'm sure you get asked all the time when people see you about nutrition, what can I be doing that might help me related to my fight against myeloma. And also some people have some concern, they may have other things going on with them and they're concerned about insulin as well. Could you comment on that? Well, I think when patients ask me what supplements and things and what can they do to try and make their myeloma go away or to try and help the treatment, I think that one important point I would make is that everything in moderation is probably incredibly important whether or not you have myeloma. And so what I tell people to do is to stay very active and to stay as physically strong as they're able to because, you know, how physically well you are translates into how aggressive a treatment can be or how much treatment you can tolerate. And so I want people to be as physically fit as they are able to be. That doesn't mean going to the gym for six hours a day. That means walking, being mobile, getting up and doing more than just sitting on the sofa and watching TV. I think the second part that of that for me is a well-balanced diet. There are all sorts of patients that I've seen where their spouse has put them on diet fad X or diet fad Y, and oftentimes those are no sugar or low sugar diets because of this myth floating out there that sugar feeds cancer, and patients are miserable during that kind of a diet. And if you're not happy it doesn't matter whether the treatment is ultimately working because you just feel miserable. So I think it's important that you not go off the deep end in terms of picking really restrictive diets or really unusual fad diets. You know, patients are often looking on the web for ideas, and what can I do here and what can I do there, and there are all these people out there that propose to make your immune system stronger or make your cancer go away simply by paying X dollars to this one supplement, and there really is not a lot of data supporting that and they're taking your money. And so I would suggest that people are just well, that they've used common sense, eat well, are physically active and try and do the best they can to stay strong. When to Start Treatment Great, great comment. Dr. Orlowski, one area I wanted to ask you about, and we got many questions on this, is when to start treatment. Some people had this diagnosis of MGUS. They're feeling good but it's showing up in their blood, and their family is saying, you've got to start, you've got to start. What's the latest thinking both in that, or somebody is diagnosed with myeloma is when to start treatment and how hard to hit it. 10
Well, I can imagine that as the patient the worse thing after being told that you have a diagnose of cancer is hearing that your doctor doesn't want to treat you for it although they're going to watch you really closely, but actually for many patients with diseases in this category that is the best approach. For example with MGUS, or monoclonal gammopathy of undetermined significance, there are a variety of types of patients who get MGUS, some of whom have a very low risk of progression to frank myeloma, and some who are even at, quote/unquote, higher risk, still have a low risk overall. On average it's about 1 percent to 1.5 percent per year, and it's not cumulative, and the vast majority of those people will never have a problem from their myeloma, which provides little rationale for starting treatment. There are some folks that have what we used to call smoldering myeloma. Now we call it asymptomatic myeloma. These are people that have more disease burden, but still many of those will not necessarily need treatment for years to come, and the benefit of waiting is that first of all it gives us time as investigators to learn more about myeloma biology and develop better drugs so that probably a year from now or two or three years from now our treatments will be more effective than they are now. And second of all, no matter how benign the drugs are there are some side effects and by waiting if you don't have any symptoms you spare yourself those effects. There are some clinical trials now with various drugs that are targeting those people with smoldering myeloma, and again that's an area where patients should try to get as much information as possible, although in that case you do have to weigh the possibility that you may never need therapy for your disease against the risks of going on some kind of novel drug that may or may not work for you. Side Effects I just want to cover one other area before we wrap up. Dr. Lonial, we got a lot of questions in about side effects, and we talked about new ways of giving bortezomib or Velcade, subcu, for example, or maybe a newer generation proteasome inhibitor, carfilzomib, that might have fewer side effects. It's very much on the minds of people. Jack, I know you're happy to be with us 16 years after being diagnosed, but had side effects for sure. Dr. Lonial, what do you tell people on how we can try to help them fight their myeloma but improve their quality of life and not be debilitated with side effects? Yeah, I think that that's a really important point. And, you know, when we were dealing with a disease that had a very limited number of treatment options and the median survival was shorter, you know, 10 or 15 years ago, I think that whatever drugs you did have you used them until--the main focus was disease response, how patients felt during treatment was not as important because you just didn't have that much that you could do. 11
When we think about myeloma patients now we think about a 10- to 15-year course for many of them, and so I think it is important that we minimize the number of long-term side effects they have. And one way to do that is to, even for instance if you're receiving a drug like bortezomib or Velcade, if in the middle of the cycle you start having trouble with a numbness in your fingers or on your hands or something along those lines it's okay to let the nurse know that early on so that dose adjustments or modifications can at least be considered. And that doesn't mean that you want to do that or that you have to do that, it just means that it's something that should be actively thought about. And the same for drugs like thalidomide or Revlimid. If there are side effects or things that are occurring let your doctor or the nurse know about them so that we can try and minimize long-term complications because long-term complications are going to be what keeps coming up over and over again, and ultimately may limit your ability to receive new drugs in trials. If you've got bad neuropathy you're not eligible for many clinical trials anymore, and that doesn't mean that you can't get treated with these new drugs, but not only does it impact your quality of life but it ultimately may impact your life if you can't get some of these new lifesaving agents. So I would say pay attention to these side effects. Let your doctor and the nursing team know about it so that we can prevent them or minimize them from limiting quality and quantity of life. The Future of Treatment Dr. Orlowski, as we wrap up, you mentioned this word along the way, "cure," and obviously anyone with myeloma wants to know is there any glimmer of study, data, anything under the microscope that shows any sign towards that? So looking in your crystal ball and what you know of science now where are we with that, with the hope for a cure? I think it's a very exciting time in myeloma because the studies that have been done recently looking back at outcomes years ago compared with outcomes now are showing that survival in myeloma has improved anywhere from 50 to 100 percent depending on what groups of patients you look at. And Dr. Lonial mentioned about patients with good-risk myeloma, I do think that especially in those groups we're probably within the next five to 10 years going to get to the point where those people really are going to be cured with some combination of chemotherapy, transplant, and some kind of maintenance therapy which could be, as we mentioned, something in the vaccine category. There still will be folks with higher risk disease for whom we need to find new options, and that does support thinking about clinical trials because clinical trials, as we talked about earlier also, are where you get the most exciting and newest therapies available to you. And I should also mention that our laboratory models of myeloma are now so much better that we can much better predict which drugs and which combinations will work than we used to. So no trial is 100 percent guaranteed to work, but their success rate is 12
improving. And even with standard therapy, unfortunately, you're not 100 percent guaranteed that that standard option will work. So really any treatment that you go on, whether it's with standard therapy or on a protocol, really is a trial to some extent, and you may as well get the trial with the most active drugs as possible. You're upbeat at this point. I am. I think there's every reason to think that within the next few years we will be curing at least some people with myeloma, and I think that that number will continue to increase with time. Wow. Well, I hope it works out that way. All the best to you. And, Dr. Lonial, a final comment from you? I know you've told us on video and I get the sense here that you have more options, you're feeling good about where things are going. Yeah. I mean, I absolutely agree with Dr. Orlowski's summary. I think there are will clearly be a subset of patients that I think we can say their disease is nondetectable and they'll have very long-lasting remissions, and whether we call that a cure operationally or functionally I think that that's a debatable point, but ultimately for the patient the outcomes will be quite good either way. I think that one of our challenges now is what do we do with that other set of myeloma patients, the ones with very poor-risk or high-risk disease, and that's where I think a lot of us are focusing our attention because that's a patient population that so far has not benefitted as much from the new therapies. They have benefitted some. They are doing better now than they did 10 years ago, but we still have a long ways to go with those patients, and I think that that remains an important focus. Whether that includes debates about stem cells and all those other issues related to myeloma, ultimately we have to understand the biology well enough to tailor our treatments to control all of the myelomas, not just the good or the intermediate ones. Well, thank you so much for what you do. Jack, I'm going to give you the last word. When you hear all this, though, you know, there's a responsibility for everyone in the myeloma community to say how can we partner with myeloma specialists, researchers like this to help gain more knowledge, both for us and everyone else. It would seem like ASH next year may be yet more exciting, Jack. 13
Jack: Well, I'm looking forward to it. I know that we always recommend to patient that they get second opinions from myeloma experts, and that's awfully important. I know when I was diagnosed 16 years ago there were only two treatment paths. There was melphalan-prednisone or a stem cell transplant. And now there are so many more options, which is really the good news for patients, and yet sometimes patients will say I'm frustrated. I don't know the best solution. And that's where--and it's not necessarily known, but that's where getting second and third opinions can really benefit a patient. Wow. Thank you so much, Jack. Let's go to ASH together next year. We'll both be feeling well. That's my hope, okay? Jack: I agree. All right. Well, I want to thank Jack Aiello for helping me out and joining us all through the whole ASH learning process. And, Jack, all the best to you in San Jose. Dr. Sagar Lonial from Winship Cancer Institute in Emory, all the best. We'll have you again. Dr. Lonial, thank you for taking time out of your schedule. And, Dr. Robert Orlowski from MD Anderson Cancer Center in Houston, gentlemen, thank you both. Thank you, Andrew. And best holiday wishes to all the audience. Yes, thank you. Yeah, happy holidays. And we hope this has been helpful. We always welcome your feedback. Just send them to comments@patientpower.info. And thank you so much for the grant we received from Onyx Pharmaceuticals that helps make this possible. In Seattle I'm Andrew Schorr reminding you that knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 14